The purpose of this paper is to present a conceptual framework that would enable the effective application of time based competition (TBC) and work in process (WIP) concepts in the design and management of effective and efficient patient processes.
This paper discusses the applicability of time-based competition and work-in-progress concepts to the design and management of healthcare service production processes. A conceptual framework is derived from the analysis of both existing research and empirical case studies.
The paper finds that a patient episode is analogous to a customer order-to-delivery chain in industry. The effective application of TBC and WIP can be achieved by focusing on through put time of a patient episode by reducing the non-value adding time components and by minimizing time categories that are main cost drivers for all stakeholders involved in the patient episode.
The paper shows that an application of TBC in managing patient processes can be limited if there is no consensus about optimal care episode in the medical community.
In the paper it is shown that managing patient processes based on time and cost analysis enables one to allocate the optimal amount of resources, which would allow a healthcare system to minimize the total cost of specific episodes of illness. Analysing the total cost of patient episodes can provide useful information in the allocation of limited resources among multiple patient processes.
This paper introduces a framework for health care managers and researchers to analyze the effect of reducing through put time to the total cost of patient episodes.
The purpose of this paper is to explore the variety of mechanisms applied since 1991 to engage English and Welsh general practitioners (GPs) in local health services planning and implementation.
Three qualitative case studies.
The paper identifies three types of mechanism: separation, alliance and integration. "Separation" characterises the relationship between most GPs and health authorities during the 1990s; alliance refers to the cooperative arrangements between groups of GPs and health authorities such as GP commissioning pilots, total purchasing, primary care groups and local health groups; integration refers to the integration of most health authority functions with primary care organisations (primary care trusts--PCTs and local health boards). Alliance models appear to have been most successful in promoting GP engagement in local planning and implementation; the necessarily bureaucratic nature of PCTs an local health board has alienated many.
As yet, the National Health Service (NHS) lacks organisational arrangements which permit GPs a primarily clinical focus while ensuring that their knowledge and advice is available to those carrying out administrative functions. Practice-based commissioning may provide a means of improving such arrangements.
The paper combines a number of features in health services and policy research. Few studies of primary health care organisations in the mid-2000s have been undertaken; the Welsh NHS is very under-researched; organisational analysis of the NHS is more often based on analysis from the outside rather than grounded in the felt experience of NHS personnel; and the historical perspective is often neglected.
The World Health Organization (WHO) is a global organization that nowadays has integrated gender issues into its policy, programmes and budget. How then is the state of affairs in the area of gender equity at the ultimate governing bodies of the modern WHO? This study aims to assess the representation of women and men and their promotion within the supreme decision-making bodies of the WHO during the year 2000. Information sources used are the official and confirmed protocols of the 53rd World Health Assembly (WHA) in 2000 and of the two Executive Board (EB) meetings of the corresponding year. A descriptive quantitative content analysis approach is used exclusively. The present study demonstrates strikingly skewed gender distribution, with men substantially at an advantage numerically in the prominent positions at the WHA 2000. Additionally, men also hold an advantage in terms of being promoted to leading positions within the bodies examined, notably all upgraded chairs of the EB during 2000. However, the formerly male-dominated supervisory positions of the WHO are, these days, challenged by women having been elected at the very top of the WHO. The present study stresses the need to elaborate a qualitative research design to advance the understanding of the social construction of gender in supreme governing positions of the modern WHO.
A vehicle to reduce health inequalities and improve public health has been provided by programmes at a neighbourhood level. The purpose of this paper is to analyse the development processes in four municipalities for achieving sustainable structures in area-based development programmes during and after a formal partnership period.
A case-study database was compiled based on the strategic and local work of four municipalities and four municipal housing companies who cooperated in the Partnership for Sustainable Welfare Development 2003-2009. The case-study database includes nine in-depth studies with interviews (n = 68), participant observations (n = 125), a survey (n = 1,160), and documents. The data are analysed using three theoretical concepts: political support, alliances, and citizen participation.
Political support, alliances, and citizen participation are important building blocks in neighbourhood development work. However, when the partnership ended there was little left that could function as a sustainable structure. Political support seems to be a means to reach the target, including ensuring a consistent approach and allocation of resources. However, the support must continue also after the intervention period, when the formal partnership collaboration ends, otherwise the established structure will soon decompose. Citizen participation is another precondition for a sustainable structure able to continue despite reduced municipal support. Alliances have the best chance of forming sustainable structures when they involve both the strategic and the operational level.
Even though many evaluations have been conducted to capture the process of interventions, little attention has been given to the challenges facing the outcomes of the intervention when it comes to making permanent the activities for reducing health inequalities. This paper is an attempt to deal with these challenges.
The purpose of this article is to provide answers to two questions: what has been the impact of nGMS on practice organisation and teamwork; and how do general practice staff perceive the impact?
The article is based on comparative in-depth case studies of four UK practices.
There was a discrepancy between changes observed and the way practice staff described the impact of the contract. Similar patterns of organisational change were apparent in all practices. Decision-making became concentrated in fewer hands. Formally or informally constituted "elite" multidisciplinary groups monitored and controlled colleagues' behaviour for maximum performance and remuneration. This convergence of organisational form was not reflected in the dominant "story" each practice constructed about its unique ethos and style. The "stories" also failed to detect negative consequences to the practice flowing from its adaptation to the contract.
The paper highlights how collective "sensemaking" in practices may fail to detect and address key organisational consequences from the nGMS.
The purpose of this paper is to integrate Greenberg's perspective on the connection between injustice and stress in order to clarify the role of organisational justice, burnout and organisational commitment in the understanding of absenteeism.
The study was carried out among 457 workers of a large healthcare establishment in the Canadian public healthcare sector. The model was tested using structural equation methods.
The results reveal that procedural and interactional justices have an indirect effect on exhaustion through distributive injustice. Moreover, it was found that distributive injustice is indirectly linked to short-term absences through exhaustion. By contrast, the relationship between distributive injustice and long-term absence can be explained by two mediating variables, namely, exhaustion and psychosomatic complaints.
In spite of the non-longitudinal nature of this study, the results suggest that the stress model and the medical model best explain the relationship between organisational injustice and absenteeism, while the withdrawal model via organisational commitment is not associated in this study with absenteeism.
Healthcare managers should consider the possibility of better involving employees in the decision-making process in order to increase their perception of procedural and interactional justice, and indirectly reduce exhaustion and absenteeism through a greater perception of distributive justice. SOCIAL IMPLICATIONS: For the healthcare sector, the need to reduce absenteeism is particularly urgent because of budget restrictions and the shortage of labour around the world.
This is one of the first studies to provide a complete model that analyses the stress process in terms of how organisational justice affects short- and long-term absences, in a bid to understand the specific process and factors that lead to shorter and longer episodes of absence.
A comprehensive "health promoting schools" (HPS) approach is advocated by the World Health Organization to foster the health of students. To date, few studies have evaluated schools' capacity to implement it in an optimal way. The purpose of this paper is to present a conceptual framework that identifies core features likely to facilitate the incorporation of innovation, such as HPS, into school functioning.
The framework was built by combining dimensions derived from two major strands of literature, i.e. management and HPS. It has taken root in Zahra and George's model of organisation absorptive capacity (AC) for new knowledge but has been adapted to better explore AC in a school context. The contrasting cases of two secondary schools that adopted a HPS approach in Quebec, Canada, for at least three years were used to illustrate the value of the framework.
The framework proposed is a multidimensional model that considers components such as modulators, antecedents, integration mechanisms and strategic levers as potential determinants of AC, i.e. acquisition, assimilation, transformation and exploitation. The conceptual framework helped to qualify and compare AC regarding HPS in the two cases and holds promise to appreciate mechanisms having the greatest influence on it.
The framework can serve as a conceptual guide to facilitate the absorption of innovation in schools and to design future empirical research to better understand the underlying process by which schools strengthen their capacities to become settings conducive to the health of youth.
This paper describes managed care, competition and high health care costs and reductions in funding as the major market forces that affect US academic health centers. As academic health centers continue to preserve their missions of providing patient care, educating and training health professionals and conducting research, they are negatively impacted by these market changes, thus, resulting in increased expenses and lowered revenue. A key component to surviving in difficult times is market-focused management. This paper develops a model to show the path of senior level management teams in their decision making. Through the performance of essential managerial roles, senior level managers are responsible for strategies that result in the long-term viability and growth of academic health centers.
A recurrent theme in medical sociology has been the juxtaposition of emotion with scientific rationality in the delivery of health care services. However, apart from addressing this juxtaposition very little is said about the complex intertwinement of "emotional" and "rational" practices which makes up professionals' own day-to-day work experiences - and how these experiences are influenced by present ways of organising health care. This paper aims to explore the ways that hospital doctors relate emotions to their understanding of professional medical work and how they respond to recent organisational changes within the field.
Drawing upon a small series of semi-structured interviews (n = 14) with doctors from a public teaching hospital in Denmark, the paper adopts a constructivist framework to analyse personal biographies of health professionals' working lives.
The doctors represented rich accounts of professional medical work, which includes an understanding of what a doctor should feel and how he/she should make him/herself emotionally available to others. However, the impetus for making this appearance was not left unaffected by recent new public management reforms and attempts to accelerate the delivery of services.
The organisation of cancer services into a work system, which consists of a set of tasks broken down into narrow jobs, underestimates the emotional components of patient-doctor encounters. This makes the creation and maintenance of a genuine patient-doctor relationship difficult and the result is feelings of a failed encounter on behalf of the doctor.
The paper suggests that recent rearrangements of cancer services complicate doctors' ability to incorporate emotion into a stream of medical care in a "rational" way. This is shown to challenge their professional ethos and the forms emotional engagement takes in medical practice.
The optimum response to the different stages of a major burns incident is still not established. The fire in a café in Volendam on New Year's Eve 2000 was the worst incident in recent Dutch history and resulted in mass burn casualties. The fire has been the subject of several investigations concerned with organisational and medical aspects. Based on the findings in these investigations, a multidisciplinary research group started a consensus study. The aim of this study was to further identify areas of improvement in the care after mass burns incidents.
The consensus process comprised three postal rounds (Delphi Method) and a consensus conference (modified nominal group technique). The multidisciplinary panel consisted of 26 Dutch-speaking experts, working in influential positions within the sphere of disaster management and healthcare.
In response to the postal questionnaires, consensus was reached for 66 per cent of the statements. Six topics were subsequently discussed during the consensus conference; three topics were discussed within the plenary session and three during subgroup meetings. During the conference, consensus was reached for seven statements (one subject generated two statements). In total, the panel agreed on 21 statements. These covered the following topics: registration and evaluation of disaster care, capacity planning for disasters, pre hospital care of victims of burns disasters, treatment and transportation priorities, distribution of casualties (including interhospital transports), diagnosis and treatment and education and training.
In disaster medicine, the paper shows how a consensus process is a suitable tool to identify areas of improvement of care after mass burns incidents.
It is commonplace to talk of the UK's National Health Service (NHS) as having its inception in 1948 in an Act of Parliament which brought together many hundreds of widely dispersed organisations into one, new organisation, "the" NHS. This paper aims to challenge the concept of "a" National Health Service and to argue that the (seeming) accomplishment of this "organisation" is the daily task of health managers.
The paper develops a theoretically-based analysis of how an "organisation" is accomplished through ongoing processes of construction. First, critiques of the ontological status of this thing called "organisation" are considered. Then Laclau and Mouffe's discourse theory of political action, inspired by Derrida and Gramsci is used, to try to understand this apparent "thing" and the work of those charged with its management.
There has been little application of this theoretical perspective to understanding management in general and health management in particular but, given the highly politicised nature of health management, their theoretical perspective seems more than apposite. Application of Laclau and Mouffe's theory to the NHS leads to the conclusion that there is no such "thing" as the NHS. There is, rather, a presumption of the thingness of the NHS and one of the major tasks of managers working "within" this organisation is to achieve this sense of thingness.
This is "work in progress"--these ideas continue to evolve, but feedback from readers is necessary.
This is the first time that Laclau and Mouffe's work has been used to analyse health organizations. The value of the paper is mostly for people working to develop critically-informed understandings of how organizations work.
This study seeks to explore what young women want from their school-based sex education.
Qualitative methods were used to explore the perspectives of two groups of young women from Uganda and Scotland.
Of particular importance to all the young women were: a diverse sex education curriculum appropriate to the ages of the students, being taught by an outside female facilitator, single-sex classes and access to a female teacher. Furthermore, they proposed that discussion between small groups of friends is very useful. The Scottish group said that having a young teacher, teaching about emotions and relationships and being guided through their own decision making is also important. The Ugandan group emphasized the importance of being taught by female family members and having written materials provided on sex education.
The study showed that young women from different backgrounds have strong opinions about sex education, and are an important resource for policy makers.
Understanding the incentives of stakeholders and employing effective management practices with various stakeholder groups is essential for program sustainability. This paper offers a conceptual model that depicts four different types of stakeholder interests that are relevant to health service organizations. The study identified the major stakeholders of telehealth programs, compared the influence of stakeholders by organizational ownership and investigated the practices used to manage these stakeholders. Quantitative and qualitative analyses demonstrated empirical support for the stakeholder model. The paper suggests that the model can be used as a stakeholder management tool in healthcare organizations and offers an assessment of the utility of the stakeholder framework in organizational research
The purpose of this paper is to introduce the new US health organizations called accountable care organizations (ACOs) which are expected to improve the quality and reduce the cost of healthcare for Medicare enrolees. It assesses the importance of ACOs, defining and articulating the values that will underpin their strategic and clinical decision making.
This paper uses a social values framework developed by Clark and Weale to consider the values relevant to ACOs.
It is likely that social values could be made more explicit in a US setting than they have ever been before, via the new ACOs. Social values could start to form part of a local health economy's marketing strategy.
ACOs are very new. This paper identifies that they will need to be very explicit about the values relevant to them. The development of ACOs and the articulation of social values therein may even form the basis of a meaningful dialogue on the importance of assessing value for money or cost-effectiveness in the wider US health policy environment.
The purpose of this paper is to investigate the impact of accounting on clinical practices.
This paper reviews existing studies of clinical budgeting, analyses publicly available data on cost-effectiveness recommendations for the NHS; analyses publicly available data on the influence of accounting in medical dilemmas.
The paper finds that there is limited evidence of clinical budgeting dominating clinical decisions, but there is some evidence of central agency directions on appropriateness of treatments, but this is on a cost-effectiveness basis. Numerous examples of adverse medical outcomes are cited in this paper--but with limited influence of accounting in these decisions.
The paper shows that the combination of accounting and medical data in a topical matter makes this an original and distinctive study.
The purpose of this paper is to draw on scientific models in conceptualising the evolutionary bases of contemporary behaviours, and make cross-species comparisons, to account for male managerial activities in situ in health organizations.
In the animal world, males of many species display in order to induce females to mate. Such lekking behaviour involves inter alia, strutting, puffing out, catching attention via the use of ornamental physical characteristics, exhibiting gaudily-coloured body parts, singing or splashing, and other courting and wooing strategies. The paper applies these behavioural repertoires as an explanatory device for male-dominant organizational lekking in a set of contemporary settings. It draws on six studies of managerial talk, appearance and behaviour in order to do so.
Within the organizational lek male managers display mainly by power dressing, positioning, and exercising power and influence via verbal and behavioural means. Social and religious mores prohibit overt sexual coupling in organizations but lekking for other rewards is nevertheless pursued by male managers. The paper explores this managerial patterning, compares it to the lekking behaviour of other species, and discusses points of comparison and departure. It shows how male managers display within various sub-habitats, and discusses the central issues of appearance, tasks and work assignment, physical interaction structure, and talk and physiognomy.
Understanding what makes people tick via deep explanations than are customarily rendered is a vital contribution of scholarship to the practical world of management.
The evolutionary bases of contemporary behaviours, and cross-species accounts, may prove useful paradigms for other theorists and empiricists in organizational studies, and could encourage the development of a new field that might be labeled evolutionary organizational behaviour.
Inquiries into healthcare organisations have highlighted organisational or system failure, attributed to poor responses to early warning signs. One response, and challenge, is for professionals and academics to build capacity for quality and safety research to provide evidence for improved systems. However, such collaborations and capacity building do not occur easily as there are many stakeholders. Leadership is necessary to unite differences into a common goal. The lessons learned and principles arising from the experience of providing distributed leadership to mobilise capacity for quality and safety research when researching health care accreditation in Australia are presented.
A case study structured by temporal bracketing that presents a narrative account of multi-stakeholder perspectives. Data are collected using in-depth informal interviews with key informants and ethno-document analysis.
Distributed leadership enabled a collaborative research partnership to be realised. The leadership harnessed the relative strengths of partners and accounted for, and balanced, the interests of stakeholder participants involved. Across three phases, leadership and the research partnership was enacted: identifying partnerships, bottom-up engagement and enacting the research collaboration.
Two principles to maximise opportunities to mobilise capacity for quality and safety research have been identified. First, successful collaborations, particularly multi-faceted inter-related partnerships, require distributed leadership. Second, the leadership-stakeholder enactment can promote reciprocity so that the collaboration becomes mutually reinforcing and beneficial to partners.
The paper addresses the need to understand the practice and challenges of distributed leadership and how to replicate positive practices to implement patient safety research.
Costing health care services has become a major requirement due to an increase in demand for health care and technological advances. Several studies have been published describing the computation of the costs of hospital wards. The objective of this article is to examine the methodologies utilised to try to describe the basic components of a standardised method, which could be applied throughout Europe. Cost measurement however is a complex matter and a lack of clarity exists in the terminology and the cost concepts utilised. The methods discussed in this review make it evident that there is a lack of standardized methodologies for the determination of accurate costs of hospital wards. A standardized costing methodology would facilitate comparisons, encourage economic evaluation within the ward and hence assist in the decision-making process with regard to the efficient allocation of resources.
Personal medical services pilots were introduced in England in 1998 to provide increased flexibility to general practitioners practising in deprived areas, to improve service provision and reduce inequalities. The aim of this study was to identify health authority perspectives of the achievements of their pilots. Less than half of the health authorities agreed that their pilots' original objectives had been completely achieved. Support, commitment and enthusiasm from within and outside the pilots, and the ability to be flexible, were helpful in promoting change management. Obstacles were financial difficulties and a lack of understanding of personal medical services. The opinion was that personal medical services had made a highly regarded contribution to the local health economy, especially in the provision of new services and the promotion of new staff roles. The results provide lessons for primary care organisations in England and elsewhere in terms of the factors required to successfully implement change.
Many approaches on the economic aspect of hospital acquired infections (HAIs) have two major limitations: first, the lack of distinction between resources attributable to the management of HAI and resources absorbed by the main clinical problem for which the patient was hospitalized, and second, the lack of an adequate method for calculating the relative costs. These assume that the resources used by HAI can be determined by measuring the extra days of length of days (LOS) of infected patients versus non-infected patients and attribute to extra-LOS a value to the mean total cost. The aim of the article is to test a cost-modelling method that could overcome these limitations by applying the appropriateness evaluation protocol to the medical charts of patients with hospital-acquired symptomatic urinary tract infection (UTI) or sepsis, and by using cost-centre accounting.
The paper explains and tests a model for calculating costs of HAIs.
The data analysis showed that it is not always true that infections protract LOS: five out of 25 sepsis cases have extra-LOS and eight out of 25 UTI cases have extra-LOS, while the cases of sepsis that arose in surgery ward and intensive care units and urinary tract infections in ICU are without prolongation of LOS. The data analysis also showed that, using the mean total cost, the three cases of sepsis in the general surgery and the six in the ICU did not incur costs, nor did the two cases of UTI in ICU, so that they appear to be infections at zero cost. Moreover, the weight of the cost for the bed, or for the diagnostic services, or for the pharmacological treatment, varied widely depending on the site of the HAI and the ward where the patient was hospitalized.
The method can be applied in any hospital.
The purpose of the paper is to investigate the inter- and intra-organisational relationships in the commissioning of secondary care by primary care trusts in England, using a principal-agent framework.
The methodology is a qualitative study of three case studies. A total of 13 commissioning-related meetings were observed. In total, 21 managers and six consultant surgeons were interviewed.
There are a number of different levels at which contractual and managerial control take place. Different strengths of control at one level can affect willingness to comply with agreements at other levels. Agreements at one level do not necessarily result in appropriate or expected action at another.
The system for commissioning in the National Health Service (NHS) has changed with the introduction of payment by results and practice-based commissioning. However, the dynamics of the inter- and intra-organisational relationships studied remain.
Incentives within organisations are as important as those between organisations. Within a chain of principal-agent relations, it is important that a strong link in the chain does not result in the exploitation of weaknesses in other links. If government targets and frameworks are to be met through commissioning, it may be advantageous to concentrate efforts on developing incentives that align clinician with NHS trust objectives as well as NHS trust with primary care trust (PCT) and government objectives.
This paper is based on original empirical work. It uses a principal-agent framework to understand the relationships between PCTs and NHS trusts and highlights the importance of internal NHS trust governance systems in the fulfilment of commissioning agreements.
The aim of this paper is to illustrate and discuss how healthcare organisations can act as institutional entrepreneurs in a context of change.
The authors conducted an in-depth longitudinal case study (2005-2008) of a healthcare organisation in the province of Quebec, Canada. Data collection consisted of real-time observations of senior managers (n = 87), interviews (n = 24) with decision-makers and secondary data analysis of documents.
The paper reports on the extent to which entrepreneurial healthcare organisations can be a driving force in the creation of a new practice. The authors analyse the development of a diabetes reference centre by a healthcare organisation acting as an institutional entrepreneur that illustrates the conceptualisation of an innovation and the mobilisation of resources to implement it and to influence other actors in the field. The authors discuss the case in reference to three stages of change: emergence, implementation and diffusion. The results illustrate the different strategies used by managers to advance their proposed projects.
This study helps to better understand the dynamics of mandated change in a mature field such as healthcare and the roles played by organisations in this process. By adopting a proactive strategy, a healthcare organisation can play an active role and strongly influence the evolution of its field.
This paper is one of only a few to analyse strategies used by healthcare organisations in the context of mandated change.
To put forward the, to date, unidentified viewpoint that organisational action research and project management have many shared properties--making it a useful exercise to compare and contrast them in relation to organisational management structures and strategies.
A conceptual exploration, drawing on a wide range of supporting literature, is used here.
Project management represents a mainstay strategy for much of the organisational research seen in health care management--and has done for many years. More recently, the exploratory literature on project management has identified many limitations--especially when matched against "traditional" examples. Many health services have witnessed a more recent organisational management drive to seek out alternative strategies that incorporate less hierarchical and more participatory research methods. Action research certainly fits this bill and, on further examination, can be incorporated into a project management ethos and vice versa.
The views expressed here are of a theoretical construct and have not been implemented, as they are presented in this paper, in practice. The intention, however, is to do so in some of the author's future studies.
If the management of health service organisations are to evolve to incorporate desirable structures that promote consumer-oriented empowerment and participation (where the consumers also include the workforce), then having a wider array of research tools at one's disposal is one way of facilitating this. Incorporating action research principles into project management approaches, or the other way round, or marrying them both to form a "hybrid" research strategy--it is argued here--represents an appropriate and representative way forward for future organisational management studies.
In terms of originality, this represents a conceptual piece of work that puts forward constructs that have, to date, not featured in the health care literature. Its value lies in suggesting further options for organisational-oriented health care research.
The purpose of this paper is to identify ways for organizationally complex, community-based health improvement initiatives to avoid "failures" with regard to client outcomes.
Organizational research on errors, failures and high reliability organizations led Weick and Sutcliffe to articulate five strategies for organizational mindfulness: preoccupation with failure, reluctance to simplify, sensitivity to operations, commitment to resilience, and deference to expertise. Using this framework, one US federally funded health initiative to reduce infant mortality and pre-term birth and a corresponding locally implemented program are analyzed. Experience with both over a five year period is the basis for this case study.
Mindlessness actions were found to occur at both the federal and local levels, despite the possibility of enacting mindfulness strategies at federal and local levels.
To create health care initiatives and programs in ways that prevent disastrous outcomes, such as infant death and preterm births, can be achieved through application of the mindfulness strategies.
The evidence-based approach of organizational mindfulness previously has not been applied to health programs. Yet, this analysis demonstrates its usefulness in identifying ways in which these semi-autonomous organizations could avoid "failures" for their program clients.
The purpose of this paper is to examine organizational leadership and its relationship to regional health authority actions to promote health.
Through use of four previously developed measures of Perceived Organizational Leadership for Health Promotion, this paper focused on leadership as a distributed entity within regional health authority (RHA) jurisdictions mandated to address the health of the population in the province of Alberta, Canada.
First, examination of differentials between organizational levels (i.e. board members, n = 30; middle/senior management, n = 58; and service providers, n = 56) on ratings of the four leadership measures revealed significant differences. That is, board members tended to rate leadership components significantly higher than service providers and middle/senior managers: from across all 17 RHAs; and in low health promotion capacity and high health promotion capacity RHAs. Second, regression analyses identified that the leadership measures "Practices for Organizational Learning" and "Wellness Planning" were positively associated with health authority actions on improving population heart health (heart health promotion). The presence of a "Champion for Heart Health Promotion" and the leadership measures "Workplace Milieu" and "Organization Member Development" were also positively associated with health authority actions for health promotion. A subsidiary aim revealed low to moderate positive relationships of the dimensions of Leadership, Infrastructure and Will to Act with one another, as proposed by the Alberta Model on "Organizational Capacity Building for Health Promotion."
This paper, conducted on the baseline dataset (n = 144) of the "Alberta Heart Health Project's Dissemination Phase", represents a rare effort to examine leadership at a collective organizational level.
This paper aims to report on the approach to change used in the development of a tool to assess patient status six months after stroke (the Greater Manchester Stroke Assessment Tool: GM-SAT).
The overall approach to change is based on the Promoting Action on Research Implementation in Health Services (PARiHS) Framework, which involves extensive stakeholder engagement before implementation. A key feature was the use of a facilitator without previous clinical experience.
The active process of change involved a range of stakeholders--commissioners, patients and professionals--as well as review of published research evidence. The result of this process was the creation of the GM-SAT.
The details of the decision processes within the tool included a range of perspectives; the process of localisation led commissioners to identify gaps in care provision as well as learning from others in terms of how services might be provided and organised. The facilitator role was key at all stages in bringing together the wide range of perspectives; the relatively neutral perceived status of the facilitator enabled resistance to change to be minimised.
The output of this project, the GM-SAT, has the potential to significantly improve patients' physical, psychological and social outcomes and optimise their quality of life. This will be explored further in future phases of work.
A structured process of change which included multiple stakeholder involvement throughout, localisation of approaches and a dedicated independent facilitator role was effective in achieving the development of a useful tool (GM-SAT).
A Swedish framework law has enabled integration between public agencies in vocational rehabilitation. With the support of this law, coordination associations can be formed to fund and organize joint activities. The purpose of this study is to describe and analyze how the law has been interpreted and translated into local coordination associations and how local institutional logics have developed to guide the organization of these associations.
Data was collected through observations of meetings within two coordination associations and supplemented with documents. The material was analyzed by compilation and examination of data from field notes, whereupon the most important aspects were crystallized and framed with institutional organization theory.
Two different translations of the law were seen in the associations studied: the association as an independent actor, and as an arena for its member organizations. Two subsequent institutional logics have developed, influencing decisions on autonomy, objectives and rationality for initiating and organizing in the two associations and their activities. The institutional logics are circular, further enhancing the different translations creating different forms of integration. RESEARCH IMPLICATIONS/LIMITATIONS: Both forms of integration are legitimate, but the different translations have created integration with different degrees of autonomy in relation to the member organizations. Only a long-term analysis can show whether one form of integration is more functional than the other.
This article is based on an extensive material providing insights into a form of interorganizational integration which has been scarcely researched. The findings show how different translations can influence the integration of welfare services.
The national tariff system for clinical processes and procedures aims to put a discrete unit cost on clinical activity. Calculating such costs can be subject to a great deal of local variation and interpretation. Given the rising costs of diabetes the purpose of this paper is to ask the question what does a diabetes outpatient appointment in the UK NHS actually cost? This is important in a time of financial austerity and healthcare rationing because it can be difficult to decipher the attribution of costs within the acute hospital setting.
Exploring this question, the author considers the present cost model and analyse in terms of the language of unit model cost; the basic tariff system and how it works in diabetes and looking at internal cost information the author attempts to unbundle the cost to provide a more accurate value for the cost object.
One major finding is that costs and overheads are divided arbitrarily as opposed to being distributed on the basis of measured relative consumption. Alternative costing methods are appraised to demonstrate that a patient level episodic costing approach such as patient level information and costing system (PLICS) which incorporates aspects of activity-based costing (ABC) would be far more appropriate. Using time driven ABC (TDABC), a new patient appointment costs £162 for 30 minutes and a follow-up appointment costs £81 for 15 minutes.
PLICS has the added benefit of greater financial and clinical transparency and this goes some way towards the holy grail of greater engagement with the doctors delivering clinical care.
It would appear that there are different purposes of different costing systems. One can argue that a costing system is there to both contain costs and divide overheads and demonstrate activity. Depending on how data are interpreted costing information can be an agent of enlightenment and behavioural modification for healthcare professionals to show them their direct and indirect costs, their capacity and productivity.
Clinicians and health service managers can see from this practical example how the distribution of costs and resources are unfair and can impede the delivery of a service. By using alternative costing methodologies such as ABC not only do the author gets a better reflection of the true cost of the finished consultant episode but is also able to engage clinicians in understanding how costs are generated.
The purpose of this paper is to report the findings from an evaluation project conducted to investigate the impact of two staff engagement programmes introduced to four National Health Service (NHS) hospital Trusts in England. It seeks to examine this development in the context of current policy initiatives aimed at increasing the level of staff involvement in decision-making, and the related literature.
A mixed-methods approach incorporating document analysis, interviews, a survey and appreciative inquiry, informed by the principles of impact evaluation design, was used.
The main finding to emerge was that leadership was crucial if widespread staff engagement was to be achieved. Indeed, in some of the trusts the staff engagement programmes were seen as mechanisms for developing leadership capability. The programmes had greater impact when they were "championed" by the Chief Executive. Effective communication throughout the organisations was reported to be a prerequisite for staff engagement. Problems were identified at the level of middle management where the lack of confidence in engaging with staff was a barrier to implementation.
The nature of the particular organisational context is crucial to the success of efforts to increase levels of staff engagement. The measures that were found to work in the trusts would need to be adapted and applied to best meet the needs of other organisations.
Many health care organisations in England will need to harness the efforts of their workforce if they are to meet the significant challenges of dealing with financial restraint and increasing patient demand. This paper provides some insights on how this can be done.
This paper aims to assess administrative and clinical manager stances on health system reform. Understanding these stances will help to identify cultural differences and competing agendas between these two key health service stakeholders and contribute to developing strategies to improve organisational performance.
A qualitative methodology was used comprising in-depth open-ended interviews conducted in 2007 with 26 administrative and clinical managers who managed clinical units.
This paper provides empirical insights into the ways that administrative and clinical mangers conceive of their managerial roles in relation to health care reform and performance improvement in health services. The findings suggest that developing a hybrid clinical manager culture as a means to bridge the gap between administrative and clinical manager stances on reform objectives, while possible, is not yet being realised.
The research has relevance for health services that are experiencing organisational transformation. However, its location in one health service limits the generalisability of findings to other sites. Further research is needed to assess the opportunities for a hybrid culture to emerge as well as its effect.
While attention is predominantly directed to clinician groups as a key stakeholder in implementing health reform policies, this paper has implications for how administrative managers also structure their roles and responsibilities to create an organisational climate conducive to change. This will include strategies to support clinical managers to make the transition from a predominantly clinical, to a clinical managerial, orientation.
This paper addresses a significant problem in health service governance, namely the divide between the value stances of dual hierarchies. This problem is only now gaining prominence as a significant barrier to health reform.
Hong Kong was particularly affected by the 2003 outbreak of Severe Acute Respiratory Syndrome (SARS). During the epidemic, it seemed as if the Hong Kong government and health system were barely coping, leading to calls of mismanagement and governance incapacity. In the wake of the SARS outbreak, two inquiries were conducted. The purpose of this article is to review the Hong Kong's response to SARS from the perspective of two inquiries.
An historical analysis of the institutional arrangements for health care delivery in Hong Kong is undertaken, followed by a chronology of developments in the SARS outbreak. The article then reviews outbreak management and the findings of the two inquiries. Finally, it considers whether the Hong Kong health system can be reformed to manage any future infectious disease epidemic better.
Both leadership and coherency were lacking in Hong Kong's response to SARS. These are age-old problems in the Hong Kong health sector. The prospects for mending the health system appear limited, given that leadership and coherency have been consistently absent features of post-1997 governance in Hong Kong.
This article reviews events in the immediate period following the SARS outbreak. A future follow-up study of the Hong Kong government and health system's capacity to respond to infectious disease outbreaks would be useful.
This article provides a review that will be useful to policymakers and researchers.
No other article reviews the Hong Kong health system's SARS response.
This study seeks to explore the perspectives of young women in Uganda with the aim of better informing re HIV prevention.
Group discussions and interviews were used to explore issues relating to HIV prevention. An inductive content analysis identified emerging themes and patterns in the participants' conversations.
The study revealed that, although young women were informed and motivated to prevent HIV, poverty and inequality were significant barriers, limiting their power to protect themselves.
The research adds evidence to the current argument that failure to address the disempowering effects of poverty and gender inequality limits the effectiveness of current HIV prevention for young women. HIV prevention must now address poverty and gender vulnerabilities, promoting a protective environment, rather than focusing on influencing individual sexual behaviour.
This study seeks to undertake a systematic review to consolidate existing empirical evidence on the impact of financial and non-financial incentives on motivation and retention of health workers in Ghana's district hospitals.
The study employed a purely quantitative design with a sample of 285 health workers from ten district hospitals in four regions of Ghana. A stepwise regression model was used in the analysis.
The study found that financial incentives significantly influence motivation and intention to remain in the district hospital. Further, of the four factor model of the non-financial incentives, only three (leadership skill and supervision, opportunities for continuing professional development and availability of infrastructure and resources) were predictors of motivation and retention.
A major limitation of the study is that the sample of health workers was biased towards nurses (n = 160; 56.1 percent). This is explained by their large presence in remote districts in Ghana. A qualitative approach could enrich the findings by bringing out the many complex views of health workers regarding issues of motivation and retention, since quantitative studies are better applied to establish causal relationships.
The findings suggest that appropriate legislations backing salary supplements, commitment-based bonus payments with a set of internal regulations and leadership with sound managerial qualities are required to pursue workforce retention in district hospitals.
Risk-adjustment is designed to predict healthcare costs to align capitated payments with an individual's expected healthcare costs. This can have the consequence of reducing overpayments and incentives to under treat or reject high cost individuals. This paper seeks to review recent studies presenting risk-adjustment models.
This paper presents a brief discussion of two commonly reported statistics used for evaluating the accuracy of risk adjustment models and concludes with recommendations for increasing the predictive accuracy and usefulness of risk-adjustment models in the context of predicting future healthcare costs.
Over the last decade, many advances in risk-adjustment methodology have been made. There has been a focus on the part of researchers to transition away from including only demographic data in their risk-adjustment models to incorporating patient data that are more predictive of healthcare costs. This transition has resulted in more accurate risk-adjustment models and models that can better identify high cost patients with chronic medical conditions.
The paper shows that the transition has resulted in more accurate risk-adjustment models and models that can better identify high cost patients with chronic medical conditions.
The purpose of this paper is to explore employee perceptions of communication in psychologically safe and unsafe clinical care environments.
Clinical providers at the USA Veterans Health Administration were interviewed as part of planning organizational interventions. They discussed strengths, weaknesses, and desired changes in their workplaces. A subset of respondents also discussed workplace psychological safety (i.e. employee perceptions of being able to speak up or report errors without retaliation or ostracism--Edmondson, 1999). Two trained coders analysed the interview data using a grounded theory-based method. They excerpted passages that discussed job-related communication and summarized specific themes. Subsequent analyses compared frequencies of themes across workgroups defined as having psychologically safe vs unsafe climate based upon an independently administered employee survey.
Perceptions of work-related communication differed across clinical provider groups with high vs low psychological safety. The differences in frequencies of communication-related themes across the compared groups matched the expected pattern of problem-laden communication characterizing psychologically unsafe workplaces.
Previous research implied the existence of a connection between communication and psychological safety whereas this study offers substantive evidence of it. The paper summarized the differences in perceptions of communication in high vs low psychological safety environments drawing from qualitative data that reflected clinical providers' direct experience on the job. The paper also illustrated the conclusions with multiple specific examples. The findings are informative to health care providers seeking to improve communication within care delivery teams.
This paper aims to examine empirically the ways in which workforce knowledge and organisational factors of an implementing agency affected the implementation of health sector administration decentralisation in Ghana with insights from the Nkwanta district health administration.
This is a qualitative study using data from individual and group interviews through purposive selection of health officials, who were directly involved in the work of actual implementation of the programme. Specifically, participants included senior management, middle management and junior workers, who had worked at least for the past three months in the district.
The study found that most of the interviewees involved in the implementation process are knowledgeable of the objectives of the decentralisation process. Also, major factors that are militating against effective decentralisation in the district include inadequate funds, lack of qualified personnel, inadequate logistics and equipment, poor interpersonal relationships, lack of transparency and a good operational system, lack of incentives to motivate the staff, political interference, poor infrastructure and high rate of illiteracy.
The findings of this study will help improve the implementation of decentralisation within the health sector in Ghana. The paper provides recommendations, which, if considered for implementation, will help improve the decentralisation process.
The purpose of this paper is to examine anger associated with types of negative work events experienced by health administrators and to examine the impact of anger on intent to leave.
Textual data analysis is used to measure anger in open-ended survey responses from administrative staff of a Canadian hospital. Multivariate regression is applied to predict anger from event type, on the one hand, and turnover intentions from anger, on the other.
Person-related negative events contributed to administrator anger more than policy-related events. Anger from events predicted turnover intentions after adjusting for numerous potential confounds.
Future studies using larger samples across multiple sites are needed to test the generalizability of results.
Results provide useful information for retention strategies through codifying respect and fairness in interactions and policies. Health organizations stand to gain efficiencies by helping administrators handle anger effectively, leading to more stable staffing levels and more pleasurable, productive work environments.
This paper addresses gaps in knowledge about determinants of turnover in this population by examining the impact of administrator anger on intent to leave and the work events which give rise to anger. Given the strategic importance of health administration work and the high costs to health organizations when administrators leave, results hold particular promise for health human resources.
This paper aims to show that identification of expectations and software functional requirements via consultation with potential users is an integral component of the development of an emergency department patient admissions prediction tool.
Thematic analysis of semi-structured interviews with 14 key health staff delivered rich data regarding existing practice and future needs. Participants included emergency department staff, bed managers, nurse unit managers, directors of nursing, and personnel from health administration.
Participants contributed contextual insights on the current system of admissions, revealing a culture of crisis, imbued with misplayed communication. Their expectations and requirements of a potential predictive tool provided strategic data that moderated the development of the Emergency Department Patient Admissions Prediction Tool, based on their insistence that it feature availability, reliability and relevance. In order to deliver these stipulations, participants stressed that it should be incorporated, validated, defined and timely.
Participants were envisaging a concept and use of a tool that was somewhat hypothetical. However, further research will evaluate the tool in practice.
Participants' unsolicited recommendations regarding implementation will not only inform a subsequent phase of the tool evaluation, but are eminently applicable to any process of implementation in a healthcare setting.
The consultative process engaged clinicians and the paper delivers an insider view of an overburdened system, rather than an outsider's observations.
The purpose of the study is to test the utility of a taxonomy of innovation based on perceived characteristics in the context of healthcare by exploring the extent to which discrete innovation types could be distinguished from each other in terms of process antecedents.
A qualitative approach was adopted to explore the process antecedents of nine exemplar cases of "challenging", "under-cover" and "readily-adopted" healthcare innovations. Data were collected by semi-structured interview and from secondary sources, and content analysed according to a theoretically informed framework of innovation process. Cluster analysis was applied to determine whether innovation types could be distinguished on the basis of process characteristics.
The findings provide moderate support for the proposition that innovations differentiated on the basis of the way they are perceived by potential users exhibit different process characteristics. Innovations exhibiting characteristics previously believed negatively to impact adoption may be successfully adopted but by a different configuration of processes than by innovations exhibiting a different set of characteristics.
The findings must be treated with caution because the sample consists of self-selected cases of successful innovation and is limited by sample size. Nevertheless, the study sheds new light on important process differences in healthcare innovation.
The paper offers a heuristic device to aid clinicians and managers to better understand the relatively novel task of promoting and managing innovation in healthcare. The paper advances the argument that there is under-exploited opportunity for cross-disciplinary organisational learning for innovation management in the NHS. If efficiency and quality improvement targets are to be met through a strategy of encouraging innovation, it may be advantageous for clinicians and managers to reflect on what this study found mostly to be absent from the processes of the innovations studied, notably management commitment in the form of norms, resource allocation and top management support.
This paper is based on original empirical work. It extends previous adoption related studies by applying a configurational approach to innovation attributes to offer new insights on healthcare innovation and highlight the importance of attention to process.
When introducing new health technologies, decision makers must integrate research evidence with local operational management information to guide decisions about whether and under what conditions the technology will be used. Multi-criteria decision analysis can support the adoption or prioritization of health interventions by using criteria to explicitly articulate the health organization's needs, limitations, and values in addition to evaluating evidence for safety and effectiveness. This paper seeks to describe the development of a framework to create agreed-upon criteria and decision tools to enhance a pre-existing local health technology assessment (HTA) decision support program.
The authors compiled a list of published criteria from the literature, consulted with experts to refine the criteria list, and used a modified Delphi process with a group of key stakeholders to review, modify, and validate each criterion. In a workshop setting, the criteria were used to create decision tools.
A set of user-validated criteria for new health technology evaluation and adoption was developed and integrated into the local HTA decision support program. Technology evaluation and decision guideline tools were created using these criteria to ensure that the decision process is systematic, consistent, and transparent.
This framework can be used by others to develop decision-making criteria and tools to enhance similar technology adoption programs.
The development of clear, user-validated criteria for evaluating new technologies adds a critical element to improve decision-making on technology adoption, and the decision tools ensure consistency, transparency, and real-world relevance.
Absorptive capacity has been defined as an organization's ability to recognize the value of new information, assimilate it, and apply it to productive ends. This study aims to examine the type of organization culture that influences the capacity of hospital organizations to innovate by absorbing new technology and the importance of this absorptive capacity in information technology (IT) implementation success.
Based on previous research, this study proposes a measure of absorptive capacity that includes managerial IT knowledge and communication channels and tests its relationship to the level of success implementing new systems. A sample of 192 hospital administrators shared their opinions about their organizations culture, ability to absorb new technology, and the extent to which their latest IT implementation operational for at least one year has been a success.
The results show the importance of organization culture as an important factor in developing absorptive capacity, and the latter's influence in the implementation of new technologies.
The study provides insights into the types of activities that management should undertake in order to enhance absorptive hospital capacity.
In the light of public concern and of strong policy emphasis on quality and safety in the nursing care of patients in hospital settings, this paper aims to focus on the factors affecting the adoption of innovative quality assurance technologies.
Two sets of complementary literature were mined for key themes. Next, new empirical insights were sought. Data gathering was conducted in three phases. The first involved contact with NHS Technology Hubs and other institutions which had insights into leading centres in quality assurance technologies. The second phase was a series of telephone interviews with lead nurses in those hospitals which were identified in the first phase as comprising the leading centres. The third phase comprised a series of face to face interviews with innovators and adopters of healthcare quality assurance technologies in five hospital trusts.
There were three main sets of findings. First, despite the strong policy push and the templates established at national level, there were significant variations in the nature and robustness of the quality assurance toolkits that were developed, adapted and adopted. Second, in most of the adopting cases there were important obstacles to the full adoption of the toolkits that were designed. Third, the extent and nature of the ambition of the developers varied dramatically - some wished to see their work impacting widely across the health service; others had a number of different reasons for wanting to restrict the impact of their work.
The general concerns about front-line care and the various inquiries into care quality failures emphasise the need for improved and consistent care quality assurance methodologies and practice. The technology adoption literature gives only partial insight into the nature of the challenges; this paper offers specific insights into the factors inhibiting the full adoption of quality assurance technologies in ward-based care.
This study aims to explore the use of specific innovations in primary care practices. The research seeks to examine whether a relationship exists between environmental factors and organizational characteristics and the level of innovation in primary care practices in Virginia.
The study utilized multiple secondary data sets and an organizational survey of primary care practices to define the external environment and the level of innovation. Institutional theory was used to explain the connection between innovations in primary care practices and institutional forces within the environment. Resource dependency theory was used to explain motivators for change based on a dependence on scarce financial, human, and information resources.
Results show a positive association between organizational size, organizational relationships, and stakeholder expectations on the level of innovation. A negative association was found between competition and the level of innovation. No relationship was found between degree of Medicare and managed care penetration and innovation, nor between knowledge of, and difficulty complying with, payer organization requirements and innovation.
Primary care physician practices exist in a market-driven environment characterized by high pressure from regulatory sources, decreasing reimbursement levels, increasing rate of change in technologies, and increasing patient and community expectations. This study contributes new information on the relationship between organizational characteristics, the external environment and specific innovations in primary care practices. Information on the contributing factors to innovation in primary care is important for improving delivery of health care services and the ability of these practices to survive.
The purpose of this study is to explore the influence of hospitals' organisational characteristics on telehealth adoption by health-care centres involved in the extended telehealth network of Quebec (French acronym RQTE) DESIGN/METHODOLOGY/APPROACH: The article is based on a review of the literature and a questionnaire, which was administered via telephone interviews to the 32 hospitals involved in the Extended Telehealth Network of Quebec. Contingency analyses were performed to determine which organisational factors have influenced telehealth adoption. Subsequently, a multiple case study was conducted among nine hospitals representative of different categories of telehealth adopters. In-depth interviews with various actors involved in telehealth activities have permitted a deepening of one's understanding of the impact of clinical and administrative contexts on telehealth adoption.
The results from both the questionnaire and interviews support the observation made by Whitten and Adams in 2003 that telehealth programs are not isolated, but located within larger health organisations. Moreover, health-care organisations are also positioned in a larger geographical, economical and socio-political environment. Therefore, it is important to investigate the context in which telehealth projects are taking place prior to experimentation.
This study has highlighted the relevance of considering the characteristics and the dynamics of health-care organisations at each stage of telehealth implementation in order to take their specific needs into account.
This study proposes to examine whether tales from childhood influence the psyche and self of the adult in their professional role as a leader in a large organization. It is positioned within a social constructionist and postmodernist framework.
The methodology development was challenging; to capture the level of abstraction within which it was positioned. Using narrative inquiry allowed for a less rigid methodology, data collection and analysis. The data were collected using a non-structured single interview with a known subject, the data analysed using an initial thematic analysis followed by an in-depth analysis of the themes against the background of an Enid Blyton novel.
This research project has shown how all are products of their whole life experiences to date; thus the tales from childhood must also impact on adult lives. This project identified links between the adult professional self and the characters in the tales, which were read as children. Leadership can be read as an adventure story or fairy tale, a myth born out of the narratives and language often used to describe it, reflecting tales of quest and achievement.
The interpretations on offer are only one version; another reader or teller would experience a different interpretation; finding her own story, while constructing herself as a researcher, was unexpected and surprising. There are at least two stories running throughout predominantly: the subjects' story and the story of the research.
The creation of the Patient Advice and Liaison Service (PALS) was part of a range of measures to make the NHS more patient-centred. The purpose of this paper is to present a critical analysis of PALS through examining the impact on major stakeholder groups.
The paper starts by examining the drivers for reform and the significance of PALS in the wider policy context. Key issues for implementation are then discussed including access to information, independence, cultural change in the health service and relationships with the voluntary sector. Research literature on the provision of advice in health care settings is drawn on.
Taking a critical perspective, the paper argues that the current model of PALS can never succeed in bridging the gap between users and the health service and will end up merely defending service interests. It concludes by arguing for an alternative model of development based on fostering strong partnerships with the community and voluntary sector.
This paper highlights critical issues for service development and delivery, including examining the impact on service users and the voluntary sector.
PALS is a very significant development in the health care provision, operating at the interface between the service and the public and yet its development has attracted little critical comment. This paper provides a comprehensive analysis of the new service and proposes an alternative model of development.
The purpose of the paper is to explore the insights of experienced nurses regarding initiatives they believe would effectively retain nurses like themselves in the nursing profession.
As part of a qualitative investigation into the perceptions of nurses regarding issues affecting their profession, experienced nurses were asked to describe what retention strategies they would recommend to policy-makers. A total of 16 semi-structured interviews were conducted with long-term nurses in a health region in western Canada.
The paper found that seven retention strategies were commonly mentioned by the participants. The qualitative mode of inquiry allowed the nurses to convey the context, attitudes and feelings behind their recommendations.
The work environments and accompanying retention policies experienced by nurses vary widely according to the specific employment context As is typical with qualitative research, the findings of this study cannot be considered as generalizable to all nurses in all health care settings.
The results of this paper provide a deeper understanding of the attitudes, emotions and contextual issues behind the nurse retention strategies seen as most appropriate by the target audience of long-term nurses.
While there is much literature advocating the implementation of nurse retention strategies, very little evidence has been presented from a qualitative lens. It is necessary to directly listen to the voices of those impacted by policies in order to better appreciate how such policies are perceived from a bottom-up perspective.