Dissertations / Theses on the topic 'Public healthcare management'

Healthcare is recognised as a complex high risk industry that demands effective management of the risks presented. A total of 260 NHS Trusts were surveyed to identify the risk management arrangements in place. The results were analysed alongside three different sources of nationally published data (CQC, Monitor and NHSLA) to determine if certain organisational or system characteristics existed that would either predetermine risk performance or predispose the Trust to a higher or lower level of performance. The results successfully dispelled a number of preconceptions relating to the size and status of the Trust in determining the performance achieved. However what was evident was the influence that the Trust’s culture and commitment to risk has on the safety and quality of services delivered. A second finding was the significant influence of central policy in the arrangements that organisations had in place from the presentation and content of risk strategy documents, criteria considered and executive leadership. The constraints of a national policy applied locally potentially limits the effectiveness of the processes in managing risk. It was concluded that whilst central policy may help in standardising how risk is managed current arrangements focus arrangements to narrowly. As a result the role of central policy makers should be to set principles that draw on and translate best practice from other high risk industries and encourage local health leaders to flex the approach to reflect local needs and priorities. This local flex should aim to integrate with other corporate programmes to ensure that risk is embedded in all decision making and the risk of the safety and quality of patients is considered alongside risks that may be perceived to be a higher priority such as operational targets and financial balance.

Healthcare utilization is a factor that directs quality and cost of health services. The cost of healthcare, income level, and demographics affect the frequency and circumstances, in which patients seek medical attention. One of the main goals of public assistance programs in this study is to facilitate the access to medical services for vulnerable groups of children. This study analyzes the impact of enrollment in various different public assistance programs and the access patterns to healthcare services. The study found that children who are enrolled in public assistance programs are more likely to visit an emergency room but less likely to visit a doctor at least 7 times a year (high utilization) compared to children who are also eligible for public programs but are not enrolled. This difference in patterns has a significant impact on cost of health services for public assistance programs' beneficiaries. A causal multifactorial link is observed, and therefore further research is needed.

The disparities in healthcare and the challenges of healthcare leaders in achieving positive health outcomes are a priority in America. Much discourse and policy is currently evolving in the legislative and executive branches of government. The United States has the highest health expenditures in the world and is classified as one of the unhealthiest countries. Many factors contribute to the disparities. These factors include socioeconomic, cultural competency, social determinants, policy, and health leadership. The challenge for health leaders is to identify strategies to improve the trends and e the status of health quality and well-being for all Americans. This study employed qualitative research using a phenomenological approach; surveying healthcare leaders in the United States. Data collection employed in-depth interviews of healthcare leaders with at least two years of experience in their current role. This qualitative study identified challenges of leaders in health care, best practices of successful healthcare leaders to improve patient access, narrow the gap of health-related disparities, and evaluated techniques and methods to improve health outcomes across racial and ethnic groups.

The purpose of this study was to collaborate with one of the New England VA Healthcare Systems to conduct research to evaluate the current leadership competencies at the Department of Veterans Affairs (VA) to identified competencies essential for leadership by the VA. The researcher also assessed how VA front-line staff, first-line supervisors, mid-level managers, and senior/executive leadership rate their performance and that of their supervisors. Lastly, the researcher evaluated how these leaders are trained to assume their important roles at the VA and how much of a role are executive coaching and mentoring play in this training process. The research is a quantitative research study, and the competencies and specific behavior indicators were assessed using a web-based survey via a self-administered competency instrument designated to determine employee’s perceptions. The data collected comprised data from four different surveys/questionnaires for each position level within the organization including the demographic data. A total of 143 VA employees participated in the research study and completed surveys to measure the frequency of behaviors on a 10-point scale to answer the research questions. The results answered the key research questions asked in this study to measure leaders and emerging leader competence.

This thesis focuses on quality improvement in local NHS services in response to national legislation. The preparatory literature search of healthcare, change and quality theories identified the common theme of participation for success as well as a distinct gap in quality management models suitable for healthcare. Action research was used to develop, implement and evaluate such a model, combining qualitative and quantitative methods, enabling ownership of the model by participating stakeholders, and facilitating change by reflection and action. The thesis is organised into three main parts from which key themes emerge. The first section establishes health and its care as the most basic of human needs. Healthcare delivered through public provision has a medically dominated hierarchy of stakeholders with different expectations: users pursue a social model of care, managers a business model, and providers a scientific model. The lack of evidence on which to base provision has resulted in autonomous clinical practice which, without reference to guidelines, is difficult to assure. In a culture of professional awareness, autonomy can provide an opportunity for service improvement The second section describes the development of the Quality Synthesis Model through participant involvement. Recent experiences of change in the NHS provided direction through: the need for clarity and agreement over quality issues, vision and values; a strategic approach; and capacity and empowerment to respond. In addition, these followed generic best practice of a conducive culture, communication, commitment and measures of progress. Finally, in the third section, the empirical chapters describe implementation and analyses of the model in the sample semi-profession service of chiropody with older people. Quantitative and qualitative data was collected through records, repeat surveys and sub sample telephone interview. Evaluation of the model was against: • operational criteria requirements • compatibility with commissioning • sound methodology • changes in stakeholder culture. The results suggest that the Quality Synthesis Model is a cost-effective answer to local quality management in a culture of professional awareness, respecting the influence of the ultimate power of medicine. Together with the principles of change management, and particularly the lessons learned from the implementation of previous initiatives, local NHS units could successfully move towards a sustained responsive culture through the use of the model.

This study explores how managers are coping within a changing public healthcare service context and how the role of service managers and the nature of Management Development are being transformed. With the public healthcare sector in the UK facing complex challenges including financial constraint and increasing service demand, it is inevitable that collaborative partnership working and service integration are viewed as a means of addressing such challenges. Using the views and experiences of service managers from Scottish Community Health Care Partnership cases, the study highlights the experiences of managers in relation to partnership working and service integration and explores the potential implications of this for managerial learning, training and development. The research evidence establishes the importance of changing roles, responsibilities and relationships for managers in a changing healthcare service environment and takes on board a Service-Dominant approach and propositions from New Public Governance theory to explain these and to address attendant issues. Specifically, the challenges surrounding the learning, training and development of managers in an increasingly integrated services environment are explored and reconceptualised through a Services-as-Systems approach. The outcomes of this study allow for a better understanding of the changing nature of work that managers do and attempts to reframe Management Development in such a context for the future.

The constant evolution of medical technology has increased the demand for managing medical devices to ensure safety and effectiveness. In this paper I will investigate how biomedical engineering has addressed the issue of equipment management and identifies strategies to successfully maintain an inventory of medical devices. Through research, on-the-job experience, and in-depth discussions with various biomedical engineering managers, I have been able to document possible equipment strategies and best practices for managing medical devices. There is really no "one size fits all" to medical equipment management due to the various clinical environments, but there are many aspects that remain necessary to ensure proper equipment safety and function while meeting or exceeding various regulatory requirements.

Thesis: S.M. in Management Studies, Massachusetts Institute of Technology, Sloan School of Management, 2016.
Cataloged from PDF version of thesis.
Includes bibliographical references (pages 83-86).
Over the past decade, Public-Private Partnerships (PPPs) have increasingly found their application in the sector of health infrastructure. The objective of this paper is to determine whether PPPs are a viable option for health infrastructure projects in developing countries. For this purpose, the author discusses and describes PPPs in general and specifies features of PPPs, which may be relevant for the healthcare sector and developing countries. In a next step, the author extensively analyses the Lesotho New Hospital PPIP case study and establishes key learnings from the undertaking. The combined evidence suggests that the PPP model for health infrastructure projects in developing countries is not recommended as a result of its high complexity and wide spectrum of underlying obstacles. Therefore, the author suggests developing countries' governments to engage in smaller and less demanding PPP projects in order to acquire the skills and expertise that are required for large-scale health infrastructure PPP projects. Keywords: Public-Private Partnership, PPP, 3P, integrated, PPIP, healthcare, infrastructure, finance, new hospital, Queen 'Mamohato Hospital, Queen Elizabeth II Hospital, developing countries, emerging markets, World Bank Group, International Finance Corporation, IFC, Oxfam, Tsepong, Netcare, Maseru, Lesotho, Bloemfontein, South Africa.
by Andreas Michael Lang.
S.M. in Management Studies

Healthcare priority setting is a major concern in most countries because healthcare represents a large and increasing public expenditure. Yet, there is not well established procedure that is consistently used to support those responsible for priority setting decisions. This dissertation consists of a review of the literature and five independent essays on healthcare priority setting, focusing on the value of formal analysis to support local healthcare planners in allocating a fixed budget. This dissertation makes both an intellectual and a practical contribution. The intellectual contribution is a synthesis of both economics and decision analysis insights. The review of the literature shows that tools grounded in health economics currently fail to contribute to local healthcare priority setting decisions because they are not practical. At the same time, tools grounded in (multi-criteria) decision analysis fail to incorporate the methodological advances of health economics and are hence theoretically weak. My thesis contributes to closing this gap. The practical contribution is that I design, and test the value of, a process and of particular value functions that can be used by local healthcare planners within their limited resources.

The capstone project reports the risk factors causing unplanned hospital readmission of vascular patients as well as the effects on healthcare cost. The methods for determining the risk factors include clinical indicators for risk prediction process, and the STAAR (State Action on Avoidable Rehospitalization) initiatives, which can be used as healthcare improvement projects to facilitate the cross-continuum team. The findings indicate a relationship between the patient’s engagement in the lower extremity vascular procedure, and effectiveness of follow-up after surgery in the reduction of hospital readmission and healthcare cost. Potential strategies to prevent the risk factors for readmission of vascular patients and to reduce the healthcare cost are discussed. Presenting unplanned readmission for vascular patients and reducing the cost associated with readmission is important for senior leaders and policy makers to improve health care outcome.

Without exception, healthcare systems in the Sub-Saharan Africa, including Ghana, face many challenges. Difficulties in Ghana’s healthcare system stem from many factors, but the most notable one is professional migration, which has crippled the former British colony since 1980. Statistical data demonstrate the yearly migration of healthcare workers from Ghana and its impact on healthcare services (the doctor/nurse population ratio). This study used a quantitative multiple regression research method to examine and empirically analyze the relationship between healthcare workers, technological innovations, and changes in healthcare services in Ghana from 1990 to 2010. The main result was that technological innovations had a significant impact on healthcare services in Ghana during the observed period. Also, regional disparities in the number of medical doctors and nurses were largely explained by the degree of urbanization and economic development. Therefore, the pooled regression analysis from the panel data consistently showed that technological innovations significantly impacted the healthcare system in Ghana during the observed period. However, the numerical impact of the technological innovation coefficients was relatively lower in Ghana during the observed period.

Bakgrund: Sedan 1980-talet har en uppsättning organisatoriska idéer och teorier lånade från näringslivet under namnet New Public Management tagit sig in i den offentliga sektorn och sjukvården. I takt med att medvetenheten om dessa idéer och teorier ökat hos allmänheten har en levande debatt om New Public Management inom sjukvården tagit fart. Från politiskt håll har nu en önskan om att utveckla nya styrmodeller för offentlig sektor bortom New Public Management lagts fram. Därför är det av intresse att studera New Public Management-diskursen kring svensk sjukvård. Syfte: Denna studie avser studera den rådande New Public Management-diskursen kring svensk sjukvård. Utifrån ett kritiskt analytiskt perspektiv är syftet med studien också att undersöka hur denna diskurs kan kopplas till de strukturella relationer som manifesteras av språket. Metod: Kritisk diskursanalys Teorier: New Public Management, Revisions- och mätbarhet, Kvalitetsbegreppet, Diskursanalys, Kritisk diskursanalys Empiri: Sekundärdata bestående av debattartiklar om svensk sjukvård. Slutsats: Denna studie har identifierat en strukturell maktrelation i den diskursiva praktiken som manifesteras i språket.
Background: Since the 1980s, a collection of organizational ideas and theories borrowed from the private sector and under the name of New Public Management have entered the public sector and healthcare. As the public awareness of these ideas and theories has increased, a vivid debate about New Public Management within the healthcare has gained momentum. Politically, a wish for a development of new models of management beyond New Public Management in the public sector have been introduced. Thus, it is of interest to study the discourse of New Public Management surrounding Swedish healthcare. Objective: This thesis aims to study the current discourse of New Public Management surrounding Swedish healthcare. By using a critical analytical perspective the objective of the thesis is also to study how this discourse can be linked to the structural relations that manifest themselves through language. Method: Critical discourse analysis Theories: New Public Management, Auditability, Concept of quality, Discourse analysis, Critical discourse analysis Empiric: Secondary data consisting of debate articles about Swedish healthcare Conclusion: This thesis have identified a structural relation of power in the discoursive dimension which manifest itself through language.

Access to primary medical care and prevention services in Nigeria is limited, especially in rural areas, despite national and international efforts to improve health service delivery. Using a conceptual framework developed by Penchansky and Thomas, this case study explored the perceptions of community residents and healthcare providers regarding residents' access to primary healthcare services in the rural area of Isu. Using a community-based research approach, semistructured interviews and focus groups were conducted with 27 participants, including government healthcare administrators, nurses and midwives, traditional healers, and residents. Data were analyzed using Colaizzi's 7-step method for qualitative data analysis. Key findings included that (a) healthcare is focused on children and pregnant women; (b) healthcare is largely ineffective because of insufficient funding, misguided leadership, poor system infrastructure, and facility neglect; (c) residents lack knowledge of and confidence in available primary healthcare services; (d) residents regularly use traditional healers even though these healers are not recognized by local government administrators; and (e) residents can be valuable participants in community-based research. The potential for positive social change includes improved communication between local government, residents, and traditional healers, and improved access to healthcare for residents.

Thesis (MPA (School of Public Management and Planning))--University of Stellenbosch, 2009.
This study examines the key success factors in the Public Private Partnerships (PPP) field in the Healthcare Sector in South Africa. It gives health departments insight into the factors which should be considered when using PPP procurement and when looking at possible PPP opportunities. The development of PPP’s around the world has urged governments to look at alternative service delivery methods because of increased pressures on government budgets. Public Private Partnerships presents governments with a means of generating private funds for health service delivery whilst government manages the relationship via a negotiated PPP agreement to monitor the quality of services rendered. Different PPP models are applied all over the world depending on the specific needs of countries. Different factors impact on the success of these partnerships and it is essential that government share knowledge and best practices. The study showed that in order for PPP’s to be successful the public institution must do its homework thoroughly and that the legal framework should be conducive for private sector involvement in service delivery. The study showed that the government of a country plays a pivotal role in the PPP process by giving the necessary political support to ensure the trust of foreign investors. The legislative framework is a critical factor in the advancement of PPP procurement and the allocation of risk as an important consideration when pursuing this type of procurement. The study examined three concluded PPP Health Sector agreements in South Africa and looked at lessons learnt, mistakes which were made and what should be avoided in the future. The three PPP’s in South Africa in this study were the first though there are other health sector PPP agreements concluded. The other PPP’s are still in the commencement stage and it is too early to make an assessment at this stage. However, the three case studies conducted give departments a clear picture of the process, the lessons learnt and the impediments in the PPP process. The uniqueness of the South African Health sector also prompted the Government to look at a model which will be best suited to the local market. Best practices from other countries provide useful information and lessons learnt from other countries are also important in a developing PPP environment.

The study sought to investigate the management of medical records for healthcare service at the Victoria Public Hospital in the Eastern Cape Province. The objectives of the study were to describe the present records management practices in Victoria Hospital; find out the existing infrastructure for the management of patient medical records at the Victoria Hospital; determine the compliance of patient medical records management in Victoria Hospital with relevant national legislative and regulatory framework; find out the security of patient medical records at the Victoria Hospital. Quantitative and qualitative approaches were employed. The sample was drawn from the service providers and from the healthcare service users. Questionnaires, interviews and observation were used to collect data. The findings showed that Victoria Hospital uses manual records management system in the creation, maintenance and usage of records. In the findings, there were challenges related to misfiling and missing patient folders which sometimes lead to the creation of new patient folders. Also, the study discovered that the time spent in the retrieval of patient folders could negatively affect the timely delivery of healthcare services. The study recommended the adoption of electronic records management system as most public healthcare institutions in the country are rapidly shifting to electronic records management system. The use of electronic records management system is believed to be efficiently and effectively promoting easy accessibility, retrieval of patient medical records and allows easy communication amongst the healthcare service institutions and healthcare practitioners.

The purpose of this study is to establish a relationship between responsiveness of hospital staff to a patient's call for help and the hospital fall rate. Patient falls are a very serious matter so data that furthers understanding in this area may be of help for hospitals trying to raise patient satisfaction scores, improve patient outcomes, and improve financial impact. The data utilized in this project are datasets downloaded from the Centers for Medicare and Medicaid Services (CMS) website.

Two hypotheses were tested from each extreme end of the responsiveness spectrum. The final conclusion is that the hospital fall rate is strongly associated with the high ("Always") but not the lower end ("Sometimes or Never").

Further research in this area is recommended to account for casual factors. The limitations of the study may be the collection and manipulation of the data by CMS.

In the last decade, the reach of New Public Management (NPM) has stretched well beyond its Western origins as modernising African governments and their global health partners have sought to import new approaches. Public health systems in Africa are entirely different to those of the West however, and this sort of application introduces a number of contextually-specific questions that are not considered by the majority of the NPM literature. The few studies that do investigate NPM in Africa are evaluative in content, seeking to understand whether reforms work and to identify barriers to success. Invariably, whether they find in favour of public management reform or not, the same issues are highlighted: lack of capacity, weak institutions, and improper implementation. This thesis will build a theory of NPM reform that is particular to the African context. I develop this theoretical extension through an intensive ethnographic case study of one of the most important on-going public health reform efforts in Africa—the transformation of the entire Ethiopian hospital system to an NPM-style administrative regime. I develop a constructionist theory of African NPM through thick description of the hospitals under reform. I detail the various ways in which the reforms are indigenised as they meet up with local understandings, institutions, and market contexts, and the inevitable unintended consequences as managers seek to ‘make do’ in environments radically different to those of NPM’s origins. I then conduct a detailed consumer analysis to describe the strategies employed by patients seeking care. Patients from different class positions use very different strategies to get health services and I demonstrate that the reform has very different consequences for Ethiopians across classes. Many patients are not recognisable as the ‘customers’ described in the reform documents, and so the hospitals do not organise their reform efforts to serve them.

A growing body of evidence now exist, which suggests that Healthcare Associated Infections (HAI) are a major cause of morbidity and mortality. There is, however, a paucity of empirical knowledge and evidence-base of the role of Facilities Management (FM) in the control of HAI. Therefore, the main aim of this research was to investigate the role of FM in the control of HAI. The focus of the study is on domestic services. The research methodology of the study employed both qualitative and quantitative approaches. Altogether, 81 interviews were carried out involving experts in the areas of FM and HAI in the National Health Service (NHS). The qualitative data collected was analysed using content analysis. The qualitative data sets were then augmented by 412 completed questionnaires. The quantitative data sets obtained were subjected to rigorous statistical analyses. The study concluded that FM has a major role to play in the control of HAI, mainly in terms of cleaning, catering, waste management and laundry and linen services. However, FM is yet to feature prominently in the ‘control of HAI agenda’ in the NHS. There is evidence and lack of clarity on the roles and clear lines of communication between the major players in the control of HAI in FM services. There is a relatively low level of integration between the clinical teams and FM teams in the control of HAI. The roles and benefits of knowledge management and performance management are yet to be fully exploited in FM services in the control of HAI. A Performance Management Framework (PMF) for the control of HAI in FM services (particularly in domestic services) have been developed, tested and validated. The study recommends, inter alia, that FM should be made integral to the core services in hospitals for effective control of HAI. A national training and education framework for FM teams should be developed in order to enable them to carry out their work to the highest standards. There is also a need to adhere to a Performance Management Framework (PMF), which allows FM services to monitor and measure the performances in the control of HAI. The research methodology employed in this study could be replicated in different countries, including developing countries. There is also scope to research the key motivational constructs associated with effective knowledge sharing between the domestics and ICT teams in the control of HAI.

Thesis (MTech (Public Relations Management ))--Cape Peninsula University of Technology, 2010
The aim of this study is to examine the relationship of public relations and marketing and how these two functions can fuse their work without encroaching on each others fields. The strategic corporate function of stakeholder management is used as the platform to illustrate this proposed mutually beneficial relationship. The theoretical approach to the study is directed at exploring the three different fields of public relations, marketing and stakeholder management by outlining the general theory of excellence in corporate communication; marketing management theory; and stakeholder management theory. The public relations and marketing role within the Life Healthcare hospitals in the Eastern region are explored through a quantitative study aimed at gaining the incumbents' (in the public relations/marketing positions) view on their outputs within their function mapped against the outputs needed as viewed by the dominant coalition of the various hospitals. The incumbents' contribution to; and the dominant coalition's view of stakeholder management is also explored through the same dual view approach. Differentiating the roles' (public relations and marketing) contribution to stakeholder management (as subset against the theoretical background of what these roles should entail) are the outcomes of this quantitative study in the Life Healthcare group - Eastern region. This will then provide the platform for creating a framework of synthesis where public relations and marketing can collaborate in stakeholder management. Therefore, the outcome of this study, firstly, is a framework for the collaboration of public relations and marketing in stakeholder management within the Life Healthcare Group Eastern region. The framework creates a synthesis of the two corporate functions so that both can effectively contribute to the hospitals' strategic relationship building process in their own right as is necessary in excellent organisations. Secondly, it highlights insights gained (through the quantitative study and exploration of theory) into the public relations and marketing function within the region, and outlines problem areas that should be tackled by the dominant coalition if they are to elevate public relations and marketing to a function which can contribute to the broader organisational strategy.

Healthcare reforms and restructuring have been a global phenomenon since the early 1980s. The major structural reforms in the healthcare system in New South Wales (NSW) including the introduction and implementation of the area health management model (1986), the senior executive service (1989) and performance agreements (1990), heralded a new era in management responsibility and accountability. It is believed that the reforms, the process of the reforms, and the instability brought about by the reforms may have not only resulted in the change of senior healthcare management practices, but also in the change of competencies required for senior healthcare managers in meeting the challenges in the new era. However, limited studies have been conducted which examined how health reforms affected its senior health executive workforce and the above changes. Moreover, no study on senior healthcare managers has focused specifically on NSW after the major reforms were implemented. The purpose of this research was to examine how reforms in the NSW Health public sector affected its senior health executive workforce between 1990 and 1999 in terms of their roles and responsibilities, the competencies required, and the challenges they faced. This study, from a broad perspective, aimed to provide an overview of the NSW reforms, the forces behind the reforms and the effects the reforms may have had on senior health managers as predicted by the national and international literature. This study also explored the changes to the senior health executive workforce in the public sector during the period of rapid change in the 1990s and has provided indications of the managerial educational needs for future senior healthcare managers. Both quantitative and qualitative data have been collected by this study using triangulated methods including scientific document review and analyses, a postal questionnaire survey, and in-depth telephone interviews. The findings from the two quantitative methods informed and guided the development of the open-ended questions and overall focus of the telephone interviews. This study found differences in the characteristics and employment-related aspects between this study and previous studies in the 1980s and 1990s, and identified four major tasks, twelve key roles and seven core competencies required by senior health executives in the NSW Health public sector between 1990 and 1999. The study concludes that the demographic characteristics and the roles and responsibilities of the NSW Health senior executive workforce since the reforms of the 1980s have changed. This study also identified seven major obstacles and difficulties experienced by senior health executives and suggested that during the introduction and implementation of major healthcare reforms in NSW since 1986, barriers created by the ‘system’ prevented the achievement of its full potential benefits. Although this study did not focus on detailed strategies on how to minimise the negative impact of the health reforms on the senior health executives or maximise the chance of success in introducing new changes to the system, some suggestions are proposed. Most significantly, the study has developed a clear analytical framework for understanding the pyramidal relationships between tasks, roles and competencies and has developed and piloted a new competency assessment approach for assessing the core competencies required by senior health managers. These significant findings indicate the need for a replication of the study on an Australia-wide scale in order to extend the generalisability of the results and test the reliability and validity of the new competency assessment approach at various management levels in a range of healthcare sectors. This is the first study acknowledging the impact of the introduction of the area health management model, the senior executive service and performance agreements in the NSW public health system through an original insight into the personal experiences of the senior health executives of the reforms and examination of the major tasks that senior health executives performed and relevant essential competencies required to perform these tasks. The possible solutions identified in this study can guide the development of strategies in providing better support to senior healthcare managers when large-scale organisational changes are proposed in the future.

Introducing technological change to an organization’s normal processes can potentially bring about positive or negative results, depending mostly on the manner in which the change was facilitated and integrated into the organization. However, very little research has been done on information technology (IT) investment among hospitals, its effect on the personnel, as well as how it influences patient care and financial performance. Consequently, little is known about users’ resistance to new technologies and the precedents of technology rejection in healthcare. Therefore, this study seeks to fill the gap of understanding South African hospital staffs’ perceptions towards change, caused by introducing an information system into one of the hospital’s daily processes. Where resistance towards change is identified, the study aims to understand the reasons behind such resistance. Finally, it aims to find appropriate intervention strategies to deal with and minimize resistance. In doing so, the study seeks to contribute to the body of research regarding change resistance to information systems in public South African hospitals. By adopting a descriptive and exploratory interpretivist paradigm, in conjunction with an inductive approach, the study aims to get a better understanding of hospital staffs’ perceptions through shared meaning. The study adopted a case study research strategy, as it affords the researcher the opportunity to participate in the study, and as such contributes to the subjective interpretation of the findings. Data was collected using a mixed method approach, and was used to describe the difference between the current and proposed process. In addition, it was used to explore the reasons for change resistance to information system-supported change, and to explore methods of successfully introducing change to tertiary public hospitals in South Africa. Fourteen participants (7 medical interns and 7 ward clerks) who were directly involved in the process being studied, were interviewed. Two other participants (the head of the pharmacy and the patient flow manager), who were indirectly involved in the process, were interviewed, to verify the observed and mapped process. Interview data was analyzed qualitatively, firstly through coding techniques before using sentiment and thematic analysis. While the mapped process followed Business Process Modelling Notation conventions. In addition to a mapped proposed process, a change resistance conceptual model was developed from a conjunction of the findings and extensive review of literature. The conceptual model asserts that five main factors contribute to change resistance: unclearly defined duties; fear of job security and technology usage; years of service; resource availability and resource mismatch; as well as insufficient training resulting from the lack of a learning culture. These factors can be moderated by: the existing state of affairs referred to as status quo; management involvement; and communication. The conceptual model can be used to better understand the causes of change resistance, as well as how to minimize change resistance and successfully introduce change into a health organization. Change agents should aim to understand the status quo that exists in the organization and find ways of incorporating that into the change process. Furthermore, management should aim to involve and communicate with all affected stakeholders during a change process. This research has provided a better understanding of hospital staffs’ reactions to change, their reasons for resistance, and ways to minimize change resistance while successfully introducing change into a health organization.

Thesis (MPhil)--Stellenbosch University, 2010.
ENGLISH ABSTRACT: The purpose of this study was to identify possible viable future healthcare models for South Africa, using the techniques and methodologies advocated in the field of future studies by futurists and erudite academics such as Ackoff, Drucker, De Jouvenel, Slaughter, Dostal and Roux. This topic necessitated a problem-orientated approach to future studies based on the complexities inherent thereto. A great deal of emphasis was therefore placed on the tools of rational analysis, which are supported by unregarded worldview assumptions about the ability of humans to regulate and control the world and therefore the framing of new laws, rules and regulations. The forward view was generated by using the appropriate methodologies such as environmental scanning and the analysis of trends and outcomes. Enrichment to the foresight work, beyond the respective models, was furthermore achieved by acknowledging the cultural and social-political arena wherein the current healthcare models in South Africa operate. The focused scan of salient and credible material and publications was extended to include research into healthcare outcomes achieved in countries with comparable economic and demographic profiles to South Africa. Supplementary research was also conducted into comprehensive aspects such as ethics and health economics in conjunction with recognised international healthcare models. The drivers of quality healthcare at primary and secondary healthcare levels and therefore also representing the constraining factors in the South African milieu being available healthcare practitioners, training, physical infrastructure, technology, access to facilities and the affordability of healthcare were explored to ensure the viability of the futures healthcare models contemplated. The identification of probable futures was accomplished by means of scenario development which focussed on the critical uncertainties of healthcare funding models and nationalisation as opposed to free market models competing for available resources in a semi-regulated environment. Thereafter Delphi techniques were used to acquire consensus from specialists currently working in the field of public and private healthcare along with stakeholders such as leaders of enterprise, healthcare funders and regulators as regards the identification of preferred future healthcare models that will meet, in a sustainable manner, the constitutional right to basic healthcare and enhance the quality of life and life expectancy of all South Africans. The relevance and credibility of the consensus opinions of the selected experts who participated in the research was again tested against the futures discourse publicised in the press to ensure that personal, cultural and organisational factors were not disregarded in the process. The study concluded on the fact that additional research and debate are required to ensure that the societal, organisational and individual aspects of the system wherein healthcare operates are comprehensively addressed by all relevant stakeholders in a manner that void of the neuroses caused by anxiety when thinking of the future.
AFRIKAANSE OPSOMMING: Die doel van die studie was om moontlike volhoubare toekomstige gesondheidsorgmodelle vir Suid-Afrika te identifiseer deur gebruik te maak van tegnieke en metodologieë soos voorgehou deur deskundiges en hoogs belese akademici in die veld van toekomstudies, soos Ackoff, Drucker, De Jouvenel, Dostal en Roux. Die studie het, as gevolg van die kompleksiteit daarvan, ´n probleem-gerigte benadering tot toekomstudies verlang. Gevolglik is baie klem geplaas op rasionele analise-tegnieke, wat ondersteun word deur wêreldsiening-aannames aangaande die mens se vermoeë om die wêreld te reguleer en te beheer deur middel van nuwe wetgewing, reëls en regulasies. Die toekomsgerigte siening is gegenereer deur die gebruik van toepaslike metodologieë, soos byvoorbeeld omgewingskandering en die analise van tendense en uitkomste. Die toekomsgerigte werk is aangevul deur erkenning te gee aan die kulturele en sosio-politiese milieu waarbinne die huidige gesondheidsorgmodelle in Suid Afrika funksioneer. Die gefokusde skandering van kredietwaardige bronne en publikasies is uitgebrei ten einde navorsing oor gesondheidsorguitkomste, soos behaal in lande met vergelykbare ekonomiese en demografiese profiele, soos Suid Afrika, in te sluit. Aanvullende navorsing is verder onderneem en was gerig op omvattende aspekte soos etiek en gesondheidsekonomie, tesame met erkende internasionale gesordheidsorgmodelle. Die kernbepalers van kwaliteit-gesondheidsorg op primêre en sekondêre gesondheidsorgvlak, wat dus ook die beperkende faktore in die Suid-Afrikaanse milieu verteenwoordig, naamlik beskikbaarheid van mediese praktisyns, opleiding, fisiese infrastruktuur, tegnologie, toegang tot fasiliteite en die bekostigbaarheid van gesondheidsorg, is ondersoek ten einde die volhoubaarheid van die toekomsgesondheidsmodelle te verseker. Die identifiserings van waarskynlike toekomste is bereik deur scenario-ontwikkeling wat gefokus het op die kritiese onsekerhede van gesondheidsorgbefondsing en nationalisering, teenoor ´n vryemarkstelsel wat meeding om beskikbare hulpbronne in ´n deels-gereguleerde omgewing. Daarna is Delphi-metodieke gebruik om konsensus te verkry onder kenners wat tans in die veld van openbare en privaat gesondheidsorg werksaam is, asook belanghebbendes soos leiers in besighede, gesondheidsorgbefondsers en reguleerders, ten opsigte van voorkeur-toekomsgesondheidsorgmodelle wat op ´n volhoubare wyse die grondwetlike regte tot basiese gesondheidsorg en die verbetering van die kwaliteit van lewe en lewensverwagting van alle Suid-Afrikaners sal bevorder. Die toepaslikheid en geloofwaardigheid van die konsensusmenings van die gekose kenners wat deelgeneem het aan die navorsing is weer getoets teen toekomsgesprekke soos gepubliseer in die media ten einde te verseker dat persoonlike, kulturele en organisatoriese faktore nie in die proses misken is nie. Die studie het tot die slotsom gekom dat verdere navorsing en debat nodig is ten einde te verseker dat die sosiale, organisatoriese en individuele aspekte van die stelsel waarbinne gesondheidsorg funksioneer omvattend aangespreek word deur alle belanghebbendes, en op ´n wyse wat enige neurose wat tot angstigheid oor toekomsdenke kan lei, die hok slaan.

Implementation of protocols and guidelines is an important strategy used by hospitals in their fight against healthcare-associated infections (Pratt et al., 2007), yet their use remains a challenge (Boaz et al., 2011; Grimshaw et al., 2001). This thesis addresses the topic of behavioural change through exploring how protocols and guidelines are used on hospital wards to manage the risk from Clostridium difficile infection, the difficulties ward staff faced with their use and what happened in practice as difficulties were experienced. A qualitative study was conducted using a single case study methodology (Yin, 2009) with one acute NHS hospital in the UK. Methods used included nonparticipant observation (184 hours), informal conversation, interviews (49) and document review. An adapted version of the topic guide developed by Michie et al. (2005) based on their theoretical framework of behavioural change was used in the interviews. Data collected was analysed inductively using NVivo 8 and compared against Michie et al’s (2005) framework. The findings illustrate that nurses and doctors were detached from protocols and guidelines. Instead they relied heavily on informal sources of knowledge to guide their practice. Examples include experiential knowledge, common sense, intuition, ‘‘rules of thumb’’ and “mind lines’’ (Gabbay and le May, 2004, 2011). They also took account of preferences, their perceptions of risk, social norms and other contextual issues. Four emergent themes illustrate the complexity of factors hindering and assisting the use of protocols and guidelines into practice. These are ambiguity, organisational issues, professional frustrations and perceptions of contamination. Variations in practice were widespread as protocols and guidelines were ‘worked around’ and improvisations were made as ward staff struggled against a tide of organisational constraints, unrealistic conflicting priorities and difficulties with protocol ambiguity. The way that difficulties were being solved on the ward means that the underlying causes were not being addressed as concerns were not brought to the surface. Professional frustrations such as feeling overwhelmed and powerless acted as barriers to nurses’ reflection. The study has empirically expanded Michie et al’s (2005) behavioural framework whilst exploring the dynamics and complexity of categories influencing the use of protocols and guidelines through a ‘thick’ description of the study findings. This study has made a conceptual contribution to the literature by identifying that Michie et al’s (2005) framework does not seem to take into account tacit and experiential knowledge, professional knowledge, how sense is made of information from the local context or the process of reflection as part of learning. Recommendations are made to address the findings from this study.

Bakgrund

Svensk sjukvård har idag bland de bästa behandlingsresultaten i Europa, men trots det förs diskussionen om sjukvården ofta i negativa ordalag. I ett försök att förbättra synen på verksamheten och bli mer effektiva har sjukvården i Sverige ofta använt sig av kommersiella

modeller, modellerna har dock behövt anpassas för att fungera i sjukvårdens miljö. En av de senaste kommersiella modellerna som nu införs i den svenska sjukvården är Lean Healthcare,som är sjukvårdens version av Toyotas produktionsfilosofi Lean Production. En stor del av

tidigare forskning på området har behandlat Lean Production men lite finns att tillgå som handlar om Lean Healthcare. Den här studien är ett bidrag till att utöka kunskapen om Lean Healthcare i Sverige.

Syfte

Syftet med den här studien är att beskriva hur Lean-filosofin fungerar i den svenska sjukvården samt att göra en jämförelse mellan Lean Production och andra kommersiella modeller som tidigare har införts i den svenska sjukvården.

Genomförande

Med hjälp av intervjuer på tre svenska sjukvårdsenheter har en fallstudie med fokus på Lean Production och Lean Healthcare genomförts.

Resultat

Resultatet av studien visar att Lean Healthcare, i likhet med tidigare modeller, har krävt anpassningar för att fungera i sjukvårdens kontext. Det har bland annat visat sig i att de undersökta enheterna endast har infört vissa delar av filosofin.

Background

Swedish healthcare has today among the best treatment results in Europe, despite that the discussion about healthcare in Sweden is often pursued in negative terms. In an attempt to enhance the opinion about the organization and try to become more efficient, Swedish

healthcare has often used commercial models, however, the models has needed adjustments to function in the healthcare environment. One of the latest models that now are implemented in Swedish healthcare is Lean Healthcare which is the healthcare version of Toyota´s production

philosophy Lean Production. Much of the previous research has focused on Lean Production but little is to be found about Lean Healthcare. This study is a contribution to extend the knowledge about Lean Healthcare in Sweden.

Aim

The aim with this study is to describe how the Lean philosophy functions in Swedish healthcare and to compare Lean Production with other commercial models that earlier have been implemented in Swedish healthcare.

Completion

Through interviews on three healthcare units in Sweden a case study has been conducted with focus on Lean Production and Lean Healthcare.

Findings

The findings of this study show that Lean Healthcare, in resemblance with earlier commercial models, has needed adjustments to function in the healthcare context. It has also shown that the examined units only have implemented some of the parts of the philosophy.

Vården i Sverige har sedan länge kännetecknas av långa vårdköer och bristande resurser. Allt fler sjukhus och vårdcentraler däribland Brahehälsan, Hälsocentralen Akka, Akutmottagningen på Länssjukhuset i Kalmar samt Diagnostiskt centrum på Länssjukhuset i Kalmar väljer att möta dessa problem med hjälp av ”Lean Healthcare”. Denna nya modell och den filosofi den bygger på bidrar till ett nytt arbetssätt som är tänkt att medföra effektivisering av sjukvården. Är effektivisering av sjukvården det verkliga motivet eller finns det bakomliggande motiv för att införa ”Lean Healthcare”? Vid allt förändringsarbete är det viktigt att ha med sig medarbetarna. Deras motivation och acceptans för förändring av organisationen i samband med implementeringen av ”Lean Healthcare” är avgörande för slutresultatet. Hur har denna samverkan skötts och hur har arbetet gått till med att ta fram ett fungerande koncept för respektive sjukvårdsinrättning, d v s hur är deras förankrings- och implementeringsprocess. Har man uppmärksammat någon skillnad när det kommer till effektivitet och kvalité under arbetets gång vid de respektive sjukhusen och vårdcentralerna. Syftet med denna studie är att undersöka ovan frågeställningar samt se om det föreligger någon skillnad mellan privata och landstingsdrivna sjukvårdsinrättningar. Arbetet ämnar medverka till ökad kunskap om varför Lean implementeras inom sjukvården och om resultaten svarar mot förväntningarna. Syftet med studien åstadkoms genom en fallstudie på två vårdcentraler och två avdelningar på ett sjukhus samt en djupintervju med Prof. Håkan Aronsson. Studien bygger sin datainsamlingsmetod huvudsakligen på kvalitativa intervjuer med personer ifrån respektive sjukhus och vårdcentraler. Analys av empirin är gjord mot teorier om Lean, Kaizen, organisationsförändring, New Public Management (NPM) samt motivation.  I analysen går det att utläsa att vissa faktorer har legat till grund för motivet att införa Lean samt påverkat förankrings- & implementeringsprocessen. Dessa motiv ger utslag på det slutliga resultatet av implementeringen. Att valet föll på ”Lean Healthcare” beror till stor del på att det ligger i tiden. Förankringsprocessen har skett genom kommunikation och utbildning. Vi har inte kunnat finna belägg för några större skillnader när det gäller huvudmannafrågan förutom ett mer grundligt tillvägagångssätt vid implementeringen vid den privata vårdcentralen. En faktor som arbetet med ”Lean Healthcare” har bidragit med är medarbetarnas möjlighet till identifiering av förändring samt genomförande av förändringsarbetet. Genom att möjliggöra detta genomför medarbetarna förändringar som leder till en mindre stressad arbetsmiljö. Alltså kan ”Lean Healthcare” ge upphov till högre effektivisering samt minskad stress på arbetet. ”Lean Healthcare” har visat sig ge goda resultat i de implementerade verksamheterna och förutsättningarna för framgång inom sjukvården finns. Men arbetet har nyss börjat och för att hela verksamheten ska anses genomsyrad av ”Lean”-filosofin krävs ett fortsatt långsiktigt arbete och förändringsvilja.
The Care in Sweden has long been characterized by long waiting lists and lack of resources. More and more hospitals and medical centers including Brahehälsan, the medical centre of Akka, Emergency room at the county hospital in Kalmar and Diagnostic Centre at the County Hospital in Kalmar choose to address these problems by using Lean Healthcare. This new model and the philosophy it is based on contributes to a new approach that is intended to result in more efficient care. Is the efficiency of health care the real reason or are there ulterior motives for introducing Lean Healthcare? In all change processes it is important to involve and have abroad its employees. Their motivation and acceptance of change by the organization in conjunction with the implementation of Lean Healthcare is critical to the outcome. How has this interaction been handled and how has this work gone to develop a working concept for each medical institution, that is, how is their anchoring- and implementation process. Have one noticed any difference when it comes to efficiency and quality during the work at respective hospitals and health care centers. The purpose of this study is to investigate the above issues and see if there is any difference between private and governmental health care facilities. The work intends to contribute to a better understanding of why Lean is implemented in health care and if the results meet expectations. The purpose of this study is accomplished through a case study in two health centers and two departments in a hospital and an interview with Prof. Håkan Aronsson. The studys data collection methodology is mainly based on qualitative interviews with people from respective hospitals and health centers. Analysis of empirical data is made towards theories of Lean, Kaizen, organizational change, new public management and motivation. In the analysis it is possible to deduce that some factors have been the basis reason to introduce lean and also affected the anchor- & implementation process. These motives affect the final result of the implementation. The choice of Lean Healthcare is mainly due to that it is in fashion. The anchoring process has taken place through communication and education. We have not been able to find evidence of any major differences in the Principals of the question except for a more thorough approach to the implementation at the private clinic. One factor that works with Lean Healthcare has helped with the employees' ability to identify change and implementing change. By enabling the implementation of staff changes has lead to a less stressful working environment. Consequently, Lean Healthcare results in higher efficiency and reduced stress at work. Lean Healthcare has shown to give good results in the implemented activities and the conditions for success in health care. But the work has just begun and for the entire operation to be considered to be steeped in "Lean" philosophy it is required a continued long-term effort and will to change.

Non-communicable diseases are on the increase worldwide, causing more than 36 million deaths each year. Evidence of the link between the role of nutrition and reducing non-communicable diseases is predominant in the literature. The factors influencing intervention strategies/policies and activities, however, need attention. AIM: The study aims to examine the factors that influence nutrition interventions within the United Arab Emirates’ healthcare system. METHOD: This research adapts an interdisciplinary approach where a triangulation mixed methodology is applied. Both qualitative and quantitative methods are used, through the analysis of ten interviews with policy makers, four case studies and 161 questionnaires. Furthermore, the research framework, which emerged from the literature search and qualitative analysis, is tested and validated by rigorous quantitative analysis using SPSS. The statistical analysis, using factor analysis, MANCOVA and ranking analysis aims to provide solid support for the resulting factors. MAIN FINDING: The study identifies five factors that influence nutrition interventions in a healthcare system, and could enhance the effectiveness of nutrition interventions. The factors are 1) quality and processes, 2) training and use of technology, 3) senior management involvement and responsibility, 4) patient diversity, and 5) multidisciplinary teams. CONCLUSION: This study contributes to the emerging literature on management in nutrition interventions and the theory and importance of preventative measures in relation to nutrition. This study provides a roadmap for policy makers to adopt in order to enhance the role of nutrition interventions in healthcare settings.
Culture Department of the Emirates’ Embassy and Ministry of Higher Education (UAE)

The management of healthcare has changed dramatically over the past two decades. Such change has not just been in the way medicine is practiced, but also in the way the health dollar is spent. Hospitals have found themselves under constant and increasing pressure to not only reduce costs in relative terms, but also at the same time, provide new and expanded services. These pressures caused hospitals worldwide to closely examine the means by which they met the demands that were placed upon them (Royal Perth Hospital, 1994a; Asay and Maciariello, 1991). One common response was to embrace New Public Management strategies, such as devolved management. That is, to place the responsibility for managing diminishing health care resources, into the hands of those who use them the most - doctors (Chantler, 1993). To achieve this many hospitals adopted organisational structures known as clinical directorates (Chantler, 1993). Following international trends, the clinical directorate model was adopted by all of Western Australia’s public teaching hospitals in the mid 1990s. The belief was that by devolving hospital management to doctors, the clinical knowledge they possess will lead to improved clinical outcomes through the better allocation of resources. From the perceptions of Clinical Directors, Chief Executives, Nurse Managers, Business Managers and Department Heads, this research has developed a model, termed the Clinical Director Efficiency and Effectiveness (CD2E) model, that describes the dimensions of efficiency and effectiveness of Clinical Directors in the Western Australian public teaching hospital context.
The model proposes that there are three perceived dimensions of efficient and effective clinical directorship. They are: those that are brought to the role by doctors and governed by the health environment in which they develop (Domain Knowledge and Skills), those that are learned (Business Skills) and those that are innate (Personal Attributes). The three perceived dimensions consist of nine components. ‘Domain Knowledge and Skills’ comprise clinical expertise, peer influence, political expertise and environment knowledge. ‘Business Skills’ comprise financial management, strategic management and human resource management. ‘Personal Attributes’ comprise commitment and participation, and communication. The CD2E model not only describes the perceived dimensions of efficiency and effectiveness, it also outlines those dimensions that are brought to the role of a Clinical Director by the medical profession and those areas where there are perceived deficiencies. Whilst the final CD2E model can be used to assist in developing and selecting future Clinical Directors who are more appropriately equipped to improve healthcare delivery within Western Australia, the literature suggests that the model also has features which are common and applicable to other health environments.

Objectives: This research identified the potential predictors of medication adherence and studied the impact of medication adherence on healthcare utilization and costs among elderly with diabetes who were enrolled in a State Pharmaceutical Assistance Program (SPAP).

Methods: Pharmaceutical Assistance Contract for Elderly (PACE) programs’ database was used to identify study population and estimate medication adherence as proportion of days covered (PDC) for 12-months post-index observation period (adherent: PDC ≥ 80%; nonadherent: PDC < 80%). Healthcare utilization and costs for the study period were estimated using Pennsylvania Health Care Cost Containment Council’s hospital inpatient discharge records. Healthcare utilization measures included all-cause, diabetes-specific, diabetes-related and diabetes-specific & related number of inpatient hospital admissions and length of stay (LOS). Multiple regression analyzes were performed to determine the predictors of medication adherence and to assess the association of medication adherence with risk of hospitalization, hospital service utilization and costs.

Results: Among 9,497 elderly PACE enrollees with diabetes, 81% were adherent and 21% were hospitalized. Race, marital status, number of unique medications and out-of-pocket payment were the significant predictors of medication adherence. The odds of being hospitalized were higher for nonadherent patients by the factor 2.030 than adherent patients (95% CI: 1.784–2.310). After controlling for covariates, non-adherent patients had significantly a greater number of all-cause (IRR 1.2727; 95% CI 1.1937–1.3569), more diabetes-related (IRR 1.2210; 95% CI 1.0492–1.4210) and more combined diabetes-specific & related (IRR 1.2106; 95% CI 1.0495–1.3965) hospital visits than adherent patients. After adjusting for covariates, LOS for non-adherent patients was longer for all-cause (IRR 1.2388; 95% CI 1.1706–1.3111), diabetes-related (IRR 1.1341; 95% CI 1.0415–1.2349) and for diabetes-specific & related (IRR 1.1271; 95% CI 1.0357–1.2267) hospitalization than adherent patients. GLM models showed that medication nonadherence was associated with significant increase in all-cause hospitalization costs ($22,670 vs $16,383; p < 0.0001) and diabetes-related hospitalization costs ($13,518 vs $12,634; p = 0.0003).

Conclusions: Medication nonadherence was associated with an increased risk of hospitalization, greater number of hospital visits, longer hospital LOS and substantial hospitalization costs among elderly SPAP beneficiaries with diabetes. Utilization of our findings to develop interventions or policies to improve medication adherence would significantly impact the US healthcare system particularly while allocating limited healthcare resources.

The objective of this dissertation was to examine the association between patients' race and receipt of National Comprehensive Cancer Network guideline-adherent and timely colorectal cancer (CRC) and non-small cell lung cancer (NSCLC) care in the Veterans Affairs (VA) healthcare system. Data were from the External Peer Review Program (EPRP) Special Study on CRC and NSCLC, originally purposed for performance monitoring, examined in an observational, retrospective study design. The sample consisted of African American (AA) and Caucasian patients diagnosed with CRC between 2003 and 2006 or NSCLC between 2006 and 2007 at VA hospitals nationwide. Statistical analysis approaches included multivariate logistic regression and survival analysis methods.

Our first analysis used multivariable logistic regression to examine associations between race and receipt of guideline-concordant care (computed tomography scan, preoperative carcinoembryonic antigen, clear surgical margins, medical oncology referral for Stages II-III; fluorouracil-based adjuvant chemotherapy for Stage III; surveillance colonoscopy for Stages I-III). There were no significant racial differences in receipt of guideline-concordant CRC care. Our second analysis examined associations between race and CRC care timeliness. There were no racial differences in time to chemotherapy initiation (HR 0.82, p=0.61) or surgery to death (HR 0.94, p=0.0.49). Caucasian race was protective for shorter time to first surveillance colonoscopy (HR 0.63, p=0.02). On average, the difference in time to colonoscopy was sixteen days. Our third analysis examined associations between race and NSCLC care timeliness. There were no racial differences in time to initiation of treatment (72 days for AA versus 65 days for Caucasian patients, HR 1.03, p=0.80) or palliative care or hospice referral (129 versus 116 days, HR 1.10, p=0.34). However, the adjusted model found longer survival for African American compared to Caucasian patients (133 versus 117 days, HR 1.31, p=0.00).

In these data there were minimal statistically significant racial differences. We identified no clinically meaningful racial differences in cancer care quality, timeliness, or patient outcomes. This suggests that VA may be a leader in providing equitable cancer care. Future studies could examine causal pathways for the VA's equal, quality care and ways to translate the VA's success into other hospital systems.

Lung cancer is the leading cause of cancer death in the United States and survival rates of American Indian and Alaska Native (AIAN) patients are worse than those of non-Hispanic White (NHW) patients. A contributing factor to the worse outcomes may be lower healthcare utilization of AIAN patients. But improving healthcare utilization of AIAN to levels used comparable to those of NHW might increase costs of their care to amounts comparable to those of NHW. Objectives: 1) To examine differences in total healthcare costs and healthcare utilization 12 months following lung cancer diagnosis between AIAN patients and NHW patients, 2) To examine differences in total healthcare costs and healthcare utilization during the end-of-life period (last 6 months of life) between AIAN patients and NHW patients who died from lung cancer or any cause, and 3) To compare the incidence of depression disorder 60 months after cancer diagnosis and determine depression treatment utilization among those with a depression disorder. Methods: The Surveillance, Epidemiology, and End Results (SEER)-Medicare dataset was used. Patients included in the study were those age 65 years and older, diagnosed with lung cancer between 2000 and 2011, Part A coverage, Part B coverage and no managed care plan before. Diagnosis and procedure codes were used to identify costs, utilization, and depression diagnoses. The propensity score matching method was used to balance groups. A generalized linear model (GLM) was used for costs analysis and the negative binomial regression model was used to analyze healthcare utilization. A Cox proportional hazards regression model was used to identify risk factors for new diagnosis of depression. Results: Being AIAN was associated with lower total healthcare costs 12 months following lung cancer diagnosis. In contrast, being AIAN was not associated with total healthcare costs six months before date of death among patients diagnosed with lung cancer and ≤ 6 month survival time. The incidence of diagnosis of depression disorder 60 months after lung cancer diagnosis was 3.67% for AIAN patients and 6.16% for NHW patients. The mean number of depression treatment visits suggests higher utilization among AIAN patients compared with NHW patients. AIAN patients were not at increased risk for depression after cancer diagnosis. Conclusions: The healthcare utilization of AIAN patients with lung cancer could be improved while keeping costs of care no higher than those of NHW patients. But any improvements of health care use would need to take account of the variability among AIAN patients receiving health care 12 months following cancer diagnosis, in the last six months of life, and after depression disorder diagnosis.

Non-communicable diseases are on the increase worldwide, causing more than 36 million deaths each year. Evidence of the link between the role of nutrition and reducing non-communicable diseases is predominant in the literature. The factors influencing intervention strategies/policies and activities, however, need attention. AIM: The study aims to examine the factors that influence nutrition interventions within the United Arab Emirates’ healthcare system. METHOD: This research adapts an interdisciplinary approach where a triangulation mixed methodology is applied. Both qualitative and quantitative methods are used, through the analysis of ten interviews with policy makers, four case studies and 161 questionnaires. Furthermore, the research framework, which emerged from the literature search and qualitative analysis, is tested and validated by rigorous quantitative analysis using SPSS. The statistical analysis, using factor analysis, MANCOVA and ranking analysis aims to provide solid support for the resulting factors. MAIN FINDING: The study identifies five factors that influence nutrition interventions in a healthcare system, and could enhance the effectiveness of nutrition interventions. The factors are 1) quality and processes, 2) training and use of technology, 3) senior management involvement and responsibility, 4) patient diversity, and 5) multidisciplinary teams. CONCLUSION: This study contributes to the emerging literature on management in nutrition interventions and the theory and importance of preventative measures in relation to nutrition. This study provides a roadmap for policy makers to adopt in order to enhance the role of nutrition interventions in healthcare settings.

Thesis (MBA)--Stellenbosch University, 2004.
ENGLISH ABSTRACT: This study set out to identify the key success factors of Public Private Partnerships (PPPs) in the healthcare sector to be considered by Netcare when exploring possible PPP opportunities. Public Private Partnerships (PPP) presents a means of mobilising private funds for delivering of public services whilst government manages the relationship via a negotiated PPP agreement to ascertain the quality of services rendered. A literature study was performed in order to conceptualize the potential of the application of PPP in the healthcare industry and the factors impacting on the success thereof. PPPs around the world did not develop in unison nor are they uniform in nature. It is this variation in development that led to the formation of a wide variety of different PPP models that define these partnerships. The different PPP models currently applied by Netcare in the UK are similar in their basic characteristics to some of the models described in literature. One of the biggest challenges facing the healthcare industry in South Africa is the unequal split between public and private healthcare sectors. This is not only in terms of number of people serviced but also includes allocation of the available resources. Very limited information is available on application of PPP in the healthcare sector. The private hospital groups primarily involved in PPP in the healthcare industry in SA are Netcare and Medi-Clinic. Netcare has successfully positioned itself not only as the biggest private hospital group in South Africa, but also as the leader in PPP involvement in the healthcare sector in South Africa. The PPP projects undertaken, though still very early days, have been very successful, but do not yield very high returns. The rationale to Netcare for partaking in these extends beyond financial returns. It is mainly strategic in terms of its position in the local market and its potential involvement in the anticipated NHS (National Health System). It is essential that Netcare maintains credibility and goodwill and continues to demonstrate its commitment to address the healthcare industry needs of all in SA. Responding to the limited growth opportunities presented by the local market, Netcare expanded its operations to include international contracts, in particular in the UK, with negotiations under way for contracts in Portugal. The experienced gained through the PPPs in the UK, the country regarded as the leader in PPPs in the healthcare sector, is invaluable to their future participation in PPPs. Governments all over the world want to improve healthcare service delivery and curb healthcare inflation. This presents opportunities to Netcare that could arguably be in the form of a PPP. The ability to evaluate the key success factors that will impact on these PPPs is therefore of great importance to Netcare. The study showed that the actual process involved in forming a PPP depends on various key factors that impact on the outcome thereof. The role of government is essential and it includes the creation of the infrastructure and the legal environment for PPP, to demonstrating competence in managing PPPs, providing the political support and achieving investor confidence. An extensive list of key success factors was identified, but applying these factors to two possible PPP opportunities revealed their shortcomings. It was concluded that the list of factors cannot be applied as the ultimate checklist to pre-determine the outcome of a PPP. This is because various factors will only be revealed in the later stages of the PPP project life. It was also concluded that PPP participation by the company is a priority strategic decision. The strengths and weaknesses of the company relative to the opportunities and threats presented then needs to be evaluated. The list of key success factors provides an important guideline in terms of considering the specific opportunities and threats associated with PPPs. These factors should be considered during the various stages of the project development.
AFRIKAANSE OPSOMMING: Die doelwat van die studie is die identifisering van die faktore wat die sukses van Staat Privaat Vennootskappe (SPV) binne die gesondheidsorg industrie sal bepaal, en wat deur Netcare in ag geneem moet word wanneer sodanige vennootskappe oorweeg word. Hierdie vennootskappe bied 'n geleentheid vir die mobilisering van privaat fondse vir publieke dienslewering terwyl die regering deur middel van die onderhandelde PPP ooreenkoms die verhouding bestuur en die kwaliteit van dienslewering monitor. Die literatuurstudie het ondermeer die potensiaal van sodanige vennootskappe in die gesondheidsorg industrie, sowel as die faktore wat die suksesvolle uitkoms daarvan bepaal, ondersoek. Verskeie SPV modelle en tipes vennootskappe bestaan weens die uiteenlopende ontwikkeling van SPVs in die onderskeie lande. Die modelle tans toegepas deur Netcare in Engeland reflekteer die eienskappe van modelle beskryf in literatuur. Een van die gesondheidsorg indrustrie in Suid Afrika (SA) se grootste uitdagings is die oneweredige verdeling tussen publieke en privaat gesondheidsorg, beide in terme van populasie verteenwoordiging en aanwending van die beskikbare hulpbronne. Inligting aangaande die aanwending van SPV in die gesondheidsorg industrie is baie beperk. In die Suid Afrikaanse konteks is Netcare en Medi-Clinic die dominante rolspelers in SPVs in die industrie. Netcare is tans nie net die grootste privaat hospitaalgroep in SA nie, maar ook die leier op SPV betrokkenheid in die gesondheidsorgsektor in SA. Hoewel die huidige SPV's relatief onlangs tot stand gekom het, is daar reeds heelwat sukses behaal. Die opbrengs gerealiseer is egter nie fenominaal nie. Die motivering vir Netcare se betrokkenheid in hierdie vennootskappe strek egter verder as bloot die finansiële opbrengste. Gegewe die potensiële nasionale gesondheidstelsel en die posisionering in die plaaslike mark, is dit noodsaaklik vir Netcare om gesien te word as toegewyd aan 'n oplossing vir die gesondheidsorg uitdaging in Suid Afrika. Netcare se internasionale uitbreiding kan deels toegeskryf word aan die beperkte groei geleenthede in SA. Hulle internasionale kontrakte sluit in Engeland met onderhandeling in Portugal tans onderweg. Die ondervinding opgedoen met die SPV's in Engeland is van onskatbare waarde gegewe Engeland se posisie as leier op die gebied van SPV in die gesondheidsorg industrie. Verskeie lande poog tans om hulle gesondheidsorg dienslewering te verbeter en mediese inflasie te beperk. Dit skep potensiële SPV geleenthede vir Netcare. Die vermoë om die kritiese sukses faktore wat die uitkoms van hierdie SPVs sal bepaal, te kan evalueer, is dus van kardinale belang vir Netcare. Dit blyk uit die studie dat die proses van die ontwikkeling van SPV deur verskeie faktore beinvloed word. Die regering van 'n land speel 'n belangrike rol in die daarstelling van die infrastruktuur, die regsaspektelike omgewing, hulle bevoegdheid in terme van die bestuur van SPV, hulle vermoë om politiese ondersteuning te verleen en hulle vermoë om beleggers se vertrou te wen. 'n Omvattende lys van faktore wat impakteer op die sukses van SPV is identifiseer. Tydens die toepassing daarvan op twee voorbeelde het dit duidelik geblyk dat die lys nie as allesomvattend beskou kan word en aangewend kan word om vooraf die uitkoms van 'n SPV te voorspel nie. Verskeie faktore wat krities is in die sukses van SPV kan eers bepaal word tydens later stadiums van die SPV. Daar is ook tot die slotsom gekom dat die firma strategie die primêre oorweging tydens die evaluering van SPV behoort te wees. Die sterk en swak punte van die firma relatief tot die geleentheide en bedreigings wat die SPV inhou moet evalueer word. Die lys van faktore krities tot die sukses van SPV dien as 'n belangrike riglyn vir die oorwerging van geleenthede en bedreigings geassosieerd met SPV. Hierdie faktore behoort tydens die verskeie stadia van SPV projek ontwikkeling in ag geneem te word.

The Accountable Care Organization (ACO) has been introduced in the US as a health system reform initiative with potential to achieve the immediate and long-term goals of improving population health, improving quality and producing greater value for the healthcare dollars spent. Over the past half-century, a number of health system reforms have been designed and implemented with these goals as the intended outcomes. These efforts have produced, at best, incremental learning, variable improvements in performance outcomes, and modest cost-savings. Early evaluations of the health, quality and cost outcomes from ACO sites suggest that the long-term effectiveness of the ACO care model faces obstacles similar to those that have impeded the long-term success of past health system reform efforts. The fundamental question of how to transform the existing construct of care delivery towards one of open collaboration, team-based care and active management of health and patient populations remains elusive (Institute of Medicine, 2012).

It is under these conditions that three independent but thematically linked investigations were conducted. The first investigation, a comparative policy analysis of US-based health system reform efforts found that transforming the construct of care delivery—how care is organized and how care is delivered are fundamentally social and relational processes that impact the outcomes of reform. These processes have been underexplored alongside other change levers in the health services research and practice communities to the detriment of healthcare organizations confronted by the need to transform the construct of care delivery as the healthcare environment transitions towards accountable care.

The second and third investigations were focused at the level of the healthcare organization and its members. The instrumental case of a large integrated delivery system transforming its disease management program for diabetes towards an ACO model was used to further examine the social and relational dynamics of health system reform. The second investigation, a qualitative analysis of the social-psychological dimensions of the change process, found that ACO characterization, Uncertainty, conceptual perceptions of the notion of accountability, and Electronic Health Record implementation influenced how the network of providers made sense of transformation towards accountable care and their perception of system readiness to engage in change and be successful.

The third investigation, an applied example, demonstrated how relational coordination and social network analysis can be used as complementary tools to inform the design and implementation of interventions intended to transform the construct of care delivery in support of the goals of health system reform. Measurement of the quality of team performance found weak relational coordination ties across each network and among the roles treating and managing diabetes in a network. Social Network Analysis (SNA) of relational coordination found differential pathways for leveraging roles structures within a network in support of change efforts.

Collectively, these investigations suggest that if ACOs are to achieve the short- and long-term goals of health system reform, the social and relational dynamics of change are important to incorporate and consider alongside of other health system reform change levers.

I samband med en omorganisation av hälso- och sjukvården i Region Gävleborg där bland annat fyra divisioner bildades infördes det balanserade styrkortet som styrverktyg i verksamheten. Styrkortet var ett intressant verktyg för hälso- och sjukvården då det inkluderar såväl finansiella som icke-finansiella aspekter. Syftet med studien är att öka förståelsen för hur det balanserade styrkortet anpassas inom offentliga hälso- och sjukvårdsorganisationer med avseende på om det bidrar till ett gemensamt språk och en helhetsbild av verksamheten.   Denna undersökning gjordes utifrån en kvalitativ fallstudiedesign inom Region Gävleborgs hälso- och sjukvårdsorganisationer. Undersökningen utfördes med hjälp av semistrukturerade intervjuer där fokus legat på chefer och ansvariga personer inom den berörda verksamheten. Den teoretiska referensramen inleddes med allmän forskning kring styrkortet för att sedan smalas av till en mer anpassad bild av styrkortet inom studiens valda bransch.   Resultatet visade att styrkortet medförde ett gemensamt språk samt att kommunikationen mellan de tre organisatoriska nivåerna spelade en central roll för en fungerande verksamhet. Det framgick även ur resultatet att styrkortet kunde medföra en helhetsbild över verksamheten med förutsättning att man vet hur styrkortet ska tillämpas och mätas. Det kan även konstateras att det finansiella perspektivet inte utesluts, utan att det istället utmärker sig som en summa av de övriga perspektivens resultat.   Eftersom studien bygger på en deduktiv ansats avslutas den med en analys där teorin kopplas ihop med det insamlade empiriska materialet för att på så sätt kunna urskilja huruvida dessa stämmer överrens med varandra.   Studien avslutas med en slutsats där innehållet summeras ihop och utformar studiens bidrag samt svarar på syftet.

Detailed holistic patient data is critical for healthcare organizations to better serve their patient populations. This information allows healthcare organizations to create a detailed and holistic record of a patient’s health. However, this large aggregation of personally identifiable patient data raises serious privacy and security concerns amongst patients. For this reason, patient concerns around the privacy and security of information retained by healthcare organizations must be addressed through the development of effective public policy. This research, therefore argues that any decision making process aimed at developing public policy dealing with patient data privacy and security concerns should not only address regulatory concerns, but also patient-centric values. To accomplish this task, multi-objective decision analytic techniques, with Nissenbaum’s (2004) contextual integrity as a normative framework are used. This is done to elicit patient-centric preferences to assist organizations and governmental institutions alike in dealing with their privacy and security concerns around patient data stored by Healthcare Systems.

Inom den svenska offentliga sjukvården har det under en längre tid implementerats ett antal olika styrmedel som i grunden är skapade för den privata industrin. Dessa styrmedel går under samlingsnamnet New Public Management (NPM) och riktar in sig på att rationalisera bort icke värdeskapande aktiviteter i verksamheten. Under de senaste åren är det framförallt Lean som har varit det populäraste NPM-styrmedlet inom svensk sjukvård. Det finns idag forskning kring Lean Healthcare ur ett globalt perspektiv, främst från USA och England, men relativt lite forskning finns kring hur Lean Healthcare har påverkat den svenska offentliga sjukvården. Vi har i denna studie valt att genom en fallstudie på Region Västerbotten undersöka hur implementeringen av Lean Healthcare har påverkat organisationen, och hur denna process har upplevts av tjänstemän i organisationen. Åtta personer med koppling till Region Västerbotten har genom semi-strukturerade intervjuer fått redogöra för hur de upplever att deras vardag påverkats av implementeringen av Lean, samt om de upplever att arbetet med Lean hittills kan anses ha varit framgångsrikt. Dessa åtta intervjupersoner är tjänstemän i chefsställning inom Region Västerbotten som på olika sätt har varit en del av processen från det att beslutet om att en implementering ska ske, till att nu idag kunna följa det dagliga arbetet med Lean på ett flertal avdelningar inom Region Västerbotten. Det visade sig under arbetets gång att intervjupersonerna är eniga om att implementeringen av Lean har haft en positiv inverkan på arbetet inom kärnverksamheten. Här nämns framför allt att det är positivt att nya tankar och idéer kring hur vården ska bedrivas är av godo, och på så vis undvika att hämma utvecklingen av vårdarbetet. Den kritik som riktats mot Lean menar de medverkande intervjupersoner främst brukar framkomma initialt i implementeringsprocessen för att sedan avta i takt med att Lean etablerats inom verksamheten. Den kritik som idag ännu finns inom organisationen är vanligast på de avdelningar som ännu inte helt har kommit ur implementeringsfasen.

Patient compliance and health care communication are impacted by health literacy. Poor health choices, frequent hospital visits, noncompliance with health regimens, and higher health costs are all associated with low health literacy. The purpose of this cross-sectional study was to determine whether there was an association between health literacy as measured by primary language spoken in the home (Creole vs. English) and hypertension self-management as measured by regular use of medication and cutting down on foods high in salt, and whether there was an association between Haitian men, women, their education level, or level of poverty in relation to health literacy as measured by the primary language spoken at home (English or Creole) and hypertension self-management as measured by regular use of medication and cutting down on foods high in salt. The conceptual framework used for the study was the second language acquisition theory. Strategic sampling was used to identify 318 Haitian participants; however, only 36 respondents qualified as Haitian immigrants with a relatively high propensity of hypertension. Logistic regression was used to analyze the data. The results showed no statistically significant relationship between language spoken at home and hypertensive medical compliance within the New York Haitian immigrant community. The other variables age and household income proved to be statistically significant, however gender and education did not appear to have as much of an influence on hypertensive medical compliance observed in the participants. The social change implications include the need for health care staff to be aware of the roles that age, gender, income, language, culture, and education may play in regard to health literacy and hypertension medical compliance.

The overarching aim of this thesis is to critically evaluate the implementation of Lean in NHS Lothian, a National Health Service (NHS) Health Board in Scotland. Against challenging financial times, Lean has been endorsed for adoption in the provision of healthcare by The Scottish Government and NHS Scotland and so the objectives are to understand how Lean is implemented in healthcare, the impact on the organisation and what role(s) are held by front-line staff including medical staff, in this implementation. This is an exploratory and descriptive interpretivist case study incorporating content analysis, observational and interview data which is based on a qualitative and inductive approach. The interpretative and inductive nature of the research is used to identify emergent themes and to afford greater insight into the implementation process, outcomes and the role of healthcare staff. The sociology of professions is used to evaluate the role of the medical professional within Lean from the emergent data, with the focus being on behaviours expected and demonstrated in Lean implementations. The findings provide a mapping of the process for implementing Lean. It is also demonstrated that although medical professionals are expected to hold a crucial role in Lean implementations, their identity as a professional with corresponding power and autonomy provides challenges for implementing Lean in hierarchical areas such as healthcare. This professional identity also impacts on project initiation and sustainability as other stakeholders recognise hierarchical constraints. However, evidence grounded in the data illustrates that Lean breaks down hierarchies and has resulted in improved working in services. The implementation of Lean has been programmatic in line with best-practice case examples and has been driven by strategy and target pressures faced by services. This research provides a contribution to knowledge in three key areas: firstly through mapping the approach to Lean implementation which is a contribution to Programme Theory. Secondly medical professionals are explored through the lens of professionalism which has received limited attention to date within Lean; and finally a set of propositions are generated as a framework for Lean implementation in healthcare.

The first chapter of this dissertation explores how the regulatory approval process affects innovation incentives in medical technologies. While prior studies of medical innovation under regulation have found an early mover regulatory advantage for drugs, I find the opposite to be true for medical devices. Using detailed data on over three decades of high-risk medical device approval times in the United States, I show pioneer entrants spend approximately 34 percent (7.2 months) longer in the approval process than the first follow-on innovator. Back-of-the-envelope calculations suggest that the opportunity cost of capital of a delay of this length is upwards of 7 percent of the total cost of bringing a new device to market. I consider how different types of regulatory uncertainty affect approval times and find that a product's technological novelty is largely unrelated to time spent under review. In contrast, uncertainty about application content and format appears to play a large role: when objective guidelines for evaluation are published, approval times quicken for subsequent entrants. Finally, I consider how the regulatory process affects firms’ market entry strategies and find that financially constrained firms are less likely to enter new device markets as pioneers.

Hälso- och sjukvården har genomgått stora förändringar genom åren och är idag en central del av vårt välfärdssamhälle. Utvecklingen går mot en mer primärvårdscentrerad vård vilket gör att hälso- och sjukvården står inför nya utmaningar gällande bland annat resursfördelning och prioriteringar. Idag styrs hälso- och sjukvården i allt större utsträckning av ekonomiska incitament där kopplingen till ersättning utgår från bland annat måluppfyllelse, prestation och resursinsatser. Hur ersättningsmodellerna utformas skiljer sig åt mellan olika huvudmän och varje huvudman utformar sin vårdvalsmodell efter sina prioriteringar av primärvårdsmålen.   Syftet med studien är att analysera om de olika ersättningsmodellerna i primärvården understödjer de mål man arbetar mot samt vilka erfarenheter aktörerna inom hälso- och sjukvården, dvs. politiker, administrativ ledning och profession, har av ersättningsmodellernas effekter.   För att studera hur ersättningsmodellen understödjer verksamhetsmålen i primärvården har två fallorganisationer valts ut, Landstinget Blekinge och Region Jönköpings län, där en komparativ forskningsdesign tillämpats. Data för den teoretiska referensramen utgår från publicerade artiklar, böcker och övrigt informationsmaterial från myndigheter. Primärdata har inhämtats från sex kvalitativa, semistrukturerade intervjuer. Sekundärdata för studien består av insamlad data från respektive region/landsting.   Att använda en ersättningsmodell för resursfördelning i primärvården anses vara ett bra styrmedel då monetära ersättningar motiverar. Målen tillgänglighet, jämlik vård, hög kvalité, personcentrerad vård, patientsäkerhet tillsammans med kostnadseffektiv vård kan ibland motverka varandra. God kostnadskontroll prioriteras ofta i styrningen samtidigt ger uppföljning och kontroll behov av mycket administration, vilket motverkar målet kostnadseffektiv vård.   Att styra primärvården med ersättningsmodeller är effektivt då monetär ersättning är inblandad men modellen används inte i första hand att styra mot mål utan för kostnadskontroll. Erfarenheterna av ersättningsmodellens effekter är att de ibland motverkar målen för hälso-och sjukvården och får oönskade effekter såsom manipulation av data och fokus på att det man utför genererar högre ersättning. Uppföljningen av ersättningsmodellerna kräver också mycket administration.
The health care system has undergone major changes over the years and is today a central part of our welfare society. The trend is to direct citizens towards the Primary Health Care sector, making the health care system face new challenges.  The primary challenges are related to the allocation of resources and guiding priorities for this. Today, health care is increasingly controlled by economic incentives, where the link to compensation is based on, compensation models. How the compensation model is designed varies between different principal stakeholders whom are designing their care choice model after its own priorities of primary health care objectives.   The aim of the current study is to analyse whether the different compensation models in primary care supports the goal to work towards and what experience the different operators, politicians, administrative management and profession, have of compensation models ' effects.   To study how the compensation model supports business goals in primary care two organizations has been selected, County Council of Jönköping and Blekinge on which a comparative research design has been applied. Data for the theoretical frame of reference is based on published articles, books and other information material from the authorities. Primary data has been gathered from six qualitative, semi-structured interviews. Secondary data for the study consists of data collected from each region/County Councils.   To use a compensation model for the allocation of resources in primary health care is considered to be a good instrument in which monetary remuneration justifies. Objectives as availability, equal treatment, high quality care, person-centred care, patient safety, along with cost-effective care can sometimes counteract with each other. Good cost control is often a priority when governing health care operations, monitoring and control the business needs much administration, thus undermining the objective of cost effective care.   Compensation model is effective way to control primary health care since monetary compensation is involved but the model is not used primarily to steer towards the target but for cost control. The experience of the effects of the compensation model is that they sometimes act counterproductive towards goal for the health care system and you might receiving unwanted effects as manipulation of data and focus what you can do to generate more compensation.  A vast amount of administration is needed to follow up compensation models.

Federal support and funding for human embryonic stem cell (hESC) research in the United States lags behind stem cell programs in many countries because of the divisive debate over hESC research and the continually evolving federal policies that have hindered research efforts. The purpose of this phenomenological study was to explore the perceptions of stem cell researchers, stakeholders, and investors in the United States about the effects of the current federal stem cell policy on stem cell research in the United States, the moral disagreement with stem cell research, and their recommendations to improve stem cell research policy in the United States. Rogers's diffusion of innovation theory and Kingdon's agenda-setting theory served as the theoretical frameworks for this study. Data were collected through telephonic semistructured interviews with a snowball sample of 21 participants. Data were analyzed using Attride-Stirling's 6 steps of thematic coding. Findings indicated the need to educate laypersons and legislators, involve the public in the stem cell research policy debate, increase federal funding, and exclude religious considerations from political discussions. The implications for positive social change are directed at stem cell policymakers to focus attention and resources on creating a cohesive federal hESC funding policy to ensure that stem cell research improves in the United States with the goal of developing treatments for conditions that are currently untreatable.

Darbo tikslas. Ištirti Lietuvos daugiaprofilinės ligoninės N skyriaus darbuotojų nuomonę apie konfliktų valdymą. Uždaviniai. 1. Įvertinti Lietuvos daugiaprofilinės ligoninės N skyriaus darbuotojų požiūrį į konfliktus darbe ir jų priežastis; 2. Atskleisti vyraujančias konfliktų valdymo strategijas tarp Lietuvos daugiaprofilinės ligoninės N skyriaus darbuotojų; 3. Įvertinti Lietuvos daugiaprofilinės ligoninės N skyriaus darbuotojų ketinimus gilinti žinias konfliktų valdymo srityje. Tyrimo metodika. Tyrime objektas – darbuotojai, dirbantys Lietuvos daugiaprofilinės ligoninės N klinikoje. Tyrimui atlikti buvo pasirinkta anketinė apklausa. Naudotas T. Killman konflikto būdo instrumentas. Kokybinių požymių tarpusavio priklausomumui vertinti taikytas chi kvadrato (χ2) kriterijus. Priklausomai nuo imčių dydžio, buvo taikytas tikslus Fisher's arba Monte Carlo (mažoms imtims) ir asimptominis χ2 kriterijus. Tyrimo kintamųjų struktūrai tirti panaudotas faktorinės analizės metodas. Rezultatai. Daugiau nei pusė respondentų (67,4 proc.) konfliktus įvertino visiškai neigiamai, visiškai teigiamai konfliktus vertina tik 7,2 proc. darbuotojų. Pseudokonfliktus, kaip dažniausiai vykstančius, įvardino 34,9 proc., tarpasmeninius – 31,0 proc. darbuotojų. Pusė respondentų (50,0 proc.), esant konfliktinei situacijai, naudoja vengimo strategiją, 27 proc. apklaustųjų bando ieškoti kompromiso ir tik 2 proc. bendradarbiauja. Didžioji dalis respondentų 76,9 proc. norėtų gilinti savo žinias šioje srityje... [toliau žr. visą tekstą]
Aim of the study. To reveal employees opinion on conflict management in N division of Lithuania multi-division hospital. Objectives. 1. Rate employees opinion on conflict at the workplace and conflict management in N division in Lithuanian multi-division hospital; 2. Reveal prevailing conflict management strategies among employees; 3. Reveal employees intention to deepen their knowledge of conflict management. Methods. Study object – employees of N division of Lithuanian multi-division hospital. Study questionnaire along with T. Killman conflict mode instrument was used. For qualitative assessment of interdependence of variables the chi-square (χ2) test was used. Depending on the size of the sample, Fisher or Monte Carlo (for small samples) and asymptomatic χ2 criterion were used. Factor analysis was used to investigate the structure of study variables. Results. More than half of the respondents (67.4 %) evaluated conflicts as a completely negative object and only 7.2 % of employees see it as a positive object. Pseudo conflicts, as usually occurring in the workplace, were named by 34.9 %, interpersonal – 31.0 % and structural – 22.9 % of employees. In a conflict situation half of the respondents (50.0 %) are using avoidance strategies, 27 % - are trying to find a compromise and only 2 % of employees cooperate. The majority of the respondents (76.9 %) would like to deepen their knowledge in this area. Most acceptable conflict management knowledge and skill development... [to full text]

Depuis ces trois dernières décennies, la modernisation du secteur hospitalier implique un nouveau mode d'organisation de l'activité et une nouvelle répartition des pouvoirs à l'hôpital. De nouveaux modes de management ont été transposés du secteur privé pour perfectionner et moderniser l'action du secteur public. Cependant, les objectifs de ces deux secteurs ne sont pas les mêmes : satisfaction de l'intérêt général pour l'un et rentabilité pour l'autre. Cette différence peut être enrichissante (exemples : émulation liée à la compétition, réalisation d'économies substantielles), mais aussi source de résistances et de stress. Cette nouvelle gestion publique déstabilise les différents acteurs des établissements qui doivent, à la fois, répondre aux grands principes du service public et à des logiques économiques de performance. Dans un tel contexte, des tensions de rôle peuvent-elles se développer chez le personnel soignant ? Ce travail de recherche s'intéresse tout particulièrement aux différentes stratégies d'ajustement utilisées par les cadres de santé, pour faire face aux tensions de rôle qui pourraient se développer. Les changements vécus suite à la mise en place du Nouveau Management Public dans les hôpitaux ont modifié le rôle et les fonctions des cadres de santé qui sont désormais à l'interface entre une culture du soin et une culture gestionnaire. Cette recherche est basée sur une étude exploratoire menée auprès de 15 cadres de santé dans un CHRU et sur une enquête confirmatoire réalisée auprès de 445 cadres de santé répartis dans 39 établissements hospitaliers publics français. Les résultats révèlent que les cadres de santé se trouvent dans une position délicate qui suscite différents types de tensions de rôle quotidiennes. Des stratégies d'ajustement utilisées par les cadres de santé pour faire face à ces tensions de rôle ont également été identifiées
Over the past three decades, the modernization of the hospital sector has given rise to a new way of organizing the activity and a new distribution of power in hospitals. New management methods have been transposed from the private sector with the aim to improve and modernize the public sector action. However, the objectives of these two sectors are not the same: satisfaction of the public interest for one of them and profitability for the other one. This difference can be beneficial (emulation in link with competition, substantial savings), but also a source of resistance and stress. This new public management destabilizes the different hospital actors who must respond, in the same time, to the principles of public service and to the economic logics of performance. In this context, role stresses can they develop for caregivers? This research is particularly concerned with the different strategies used by the healthcare managers to cope with this kind of potential role stresses. Different changes implemented with the new public management in hospitals, have modified the role and functions of healthcare managers who are henceforth at the interface between a culture of care and a management culture. This research comprises an exploratory study conducted among 15 French healthcare managers in a public hospital and a confirmatory survey conducted among 445 French healthcare managers in 39 public hospitals. The results show that the healthcare managers are in a delicate position that raises different type of daily role stresses. Strategies used by healthcare managers to cope with these role stresses have been also identified

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Fundação de Amparo à Pesquisa do Estado de Goiás - FAPEG
The Sanitary Districts are the extension of the central level of the Municipal Health Department in the Health Units which are part of the process of decentralization of the municipal management. To develop assistance continuously in a solvable way it is necessary that the manager and the teams in the units and Sanitary Districts know about the flows, that partnerships are established and agreed upon. In this study we aimed to diagnose elements of the work developed in the management of the Sanitary District in the Municipal Health Department in Goiânia, Goiás. We used a descriptive exploratory research methodology with professionals working in the health field who carried out duties of directors and supervisors in the seven Sanitary Districts of the Municipal Health Department in 2011. A well-structured interview was used to collect data. Thus it was organized in a way that allowed its analysis in the SPSS 15.0 program. Data were coded to proceed with the descriptive analysis based on the theoretical frame of reference. This study was assessed and approved by the Ethics Committee for Human and Animal Research of the Clinical Hospital of the Federal University of Goiás, under Protocol number 031/2009. Twenty managers of various professional categories who represent 95% of the district directors, took part in the research at the time of the study. The results show that most managers are female between 31-50 years old, and are graduated from private universities for more than 10 years. 80% of them have active employment whereas 90% exert their management under exclusive dedication. The political appointment is the aspect which influenced 55% of the management positions. 80% of the managers participated in specific training in management. Amongst the management activities considered important, the team management was cited by many, whereas the planning was devalued. From this study we intend to consolidate proposals of ongoing training, reinforcing the aspects appointed as weak and those which are essential to good management.
Os Distritos Sanitários são a extensão do nível central da Secretaria Municipal de Saúde no território das Unidades de Saúde e fazem parte do processo de descentralização da gestão municipal de saúde. Para o desenvolvimento da assistência, de forma continua e com resolubilidade, é necessário que o gestor e a equipe das unidades e Distritos Sanitários conheçam os fluxos e as parcerias sejam estabelecidas e pactuadas. Neste estudo, tivemos como objetivo diagnosticar elementos do trabalho de gestão desenvolvido nos Distritos Sanitários na Secretaria Municipal de Saúde de Goiânia – Goiás. Utilizamos a metodologia de pesquisa descritiva exploratória, realizada com profissionais da área de saúde que desenvolvem funções de diretores e supervisores dos sete Distritos Sanitários da Secretaria Municipal de Saúde no ano de 2011. Para a coleta de dados utilizou-se uma entrevista estruturada, organizada de forma que permitisse a sua análise no programa SPSS 15.0. Os dados foram codificados para proceder com a análise descritiva com base no referencial teórico. Este estudo foi avaliado e aprovado pelo Comitê de Ética em Pesquisa Médica Humana e Animal do Hospital das Clínicas da Universidade Federal de Goiás, sob Protocolo Nº: 031/2009. Participaram da pesquisa 20 gestores de diversas categorias profissionais que representam 95% dos diretores distritais na ocasião do estudo. Os resultados demonstram que a maioria dos gestores é do sexo feminino, possuem idade de 31 a 50 anos e se graduaram há mais de dez anos em universidades privadas. 80% possuem vínculo empregatício efetivo além, de 90% exercerem a gestão com dedicação exclusiva. A indicação política é o aspecto que influenciou em 55% dos cargos de gestão. Participaram em capacitações específicas para a gestão 80% dos gestores. Dentre as atividades de gestão consideradas importantes a gestão da equipe foi citada por muitos, enquanto o planejamento foi pouco valorizado. Pretendemos, a partir deste estudo, consolidar propostas de capacitações continuadas, reforçando aspectos apontados como fragilidades e aqueles imprescindíveis para uma boa gestão.