Management development for primary health care: a framework for analysis

Strengthening management has been widely promoted as a critical component of any strategy concerned with improving the implementation of primary health care (PHC). Management development programmes are, however, subject to conflicting demands and differing expectations. The situation is confounded by the wide diversity of strategies subsumed under the heading of management development, and the confusing nature of much of the terminology currently in use. This article presents a simple conceptual framework that can guide analysis and help programme planners review the options, opportunities and limitations of management development programmes. The framework presented examines management development from three different perspectives: the approach adopted; the outcomes expected; and the process of expansion, extension and adaptation. Our analysis of management development strategies allows us to reach some conclusions in areas where there is a degree of consensus. In countries where there is a mismatch between the strategies of PHC and the organizational structures through which they are to be implemented, management development has a role to play in effecting change. Its potential to do so is limited by powerful social, political, economic and organizational forces. Therefore, the capacity to critically analyse the context in which change is planned, emerges as a key element in programme design. We argue that there is no one best approach to management development, and the design of strategies will be contingent on a variety of factors. We do, however, reaffirm the view that where organizational structures and conditions do not support the implementation of PHC strategies, intervention through training alone is almost certain to be inadequate. To be effective, a more comprehensive programme will be required. Finally, the article points to a number of unresolved issues in areas where there is either controversy, lack of clarity or limited experience.     

Linkage strategies of rural hospitals--independent hospital, local health system, and/or externally linked facility

Strategies associated with ownership or management of a range of health service facilities, service sharing, and other coordination activities are important to the viability of many rural hospitals. This article articulates a set of linkage strategies employed by rural hospitals. Such strategies and their environmental and organizational correlates are assessed in a sample of 46 rural Pennsylvania hospitals.     

Rejection of an innovation: health information management training materials in east Africa

A shift towards decentralization in many low-income countries has meant more skills are demanded of primary health care managers, including data and information handling at all levels of the health care system. Ministries of Health are changing their central reporting health information systems to health management information systems with emphasis on managers utilizing information at the point of collection. This paper reports on a research study to investigate the introduction of new information management strategies intended to promote an informational approach to management at the operational health service level in low-income countries. It aims to understand the process taking place when externally developed training materials (PHC MAP), which are intended to strengthen health management information systems, are introduced to potential users in an east African country. A case study has been undertaken and this research has demonstrated that the dynamic equilibrium approach to organizational change is applicable to the introduction of new information management strategies and management approaches in low-income countries. Although PHC MAP developers envisaged a technical innovation needing implementation, potential users saw the situation as one of organizational change. Contributions to theory have been made and many implications for introducing new information systems or the informational approach to management are identified. This theoretical framework could also facilitate the introduction of future information management innovations and would allow practitioners to perceive the introduction of information management innovations as one of organizational change that needs to be managed. Consequently, issues that may facilitate or inhibit adoption could be identified in advance.     

Concepts of health and well-being in managers: An organizational study

Global changes and new managerial challenges require new concepts of health and well-being in organizational contexts. In the South African context, health and well-being of managers have gained relevance in organizations and in management sciences. International organizations, in particular, attempt to address the increasing demand for health care and the delivery of health services to their managers. Careful and appropriate health management requires research to evaluate context-specific health concepts and strategies. The purpose and aim of this article is to assess managerial concepts on health and well-being that could be used by the organization to contribute to managerial well-being by implementing health promotion according to managerial needs. At the same time, this article contributes to salutogenetic health research that is very rare with regard to the South African organizational management research.This study is a multi-method research study conducted in a selected international organization in South Africa. However, in this article, selected qualitative findings will only be presented.This organizational study presents selected research findings on health concepts and strategies employed by managers. Findings demonstrate that the managerial concepts of health and strategies mainly refer to not only physical but also to mental and spiritual aspects, with a priority on physical health and well-being.The findings presented are based on qualitative research methods and their research criteria.This assessment serves as a foundation for new approaches to health management within the international work context in South Africa. It also contributes to a paradigm shift from pathogenetic to salutogenetic concepts of health and well-being within the South African organizational work context.The article produces new insights into the qualitative health concepts of South African managers and expatriates and contributes to promoting salutogenesis in organization within South Africa.     

Organizational and Health Manifestations of Teacher Stress: A Preliminary Report on the Buffalo Teacher Stress Intervention Project

In an attempt to develop long-term stress management contingencies, four Buffalo City Elementary Schools were assessed on perceptions of organizational stress, personal manifestations, and health status. Relationships that were observed supported theoretical concepts of organizational stress, and supported the need for intervention within teacher populations. Organizational and promotional strategies to enhance participant involvement are discussed.     

Hospital adaptation to risk-bearing: managerial implications of changes in purchaser-provider contracting

A number of countries have adopted contracting reforms in which hospitals are placed at financial risk. This risk has stimulated a number of adaptive strategies to achieve organizational success. This paper presents a model of six forms of contracting relationships and reviews the adaptation strategies observed in three health systems: the USA, England and the Netherlands. These strategies include service diversification, improved management information systems, the employment of marketing and contract managers, the use of clinical pathways, case management and concurrent/retrospective review of hospital stays, quality management and quality assurance programs, pre-admission authorization, discharge planning, and physician profiling and participation in management. These adaptive strategies have three implications for managers: increased 'partnering', with purchasers, collaboration with medical staff, and assumption of managed care roles. Two groups of institutions are at risk from the changes in hospital contracting: university teaching hospitals and inner-city hospitals serving socially deprived populations. The paper ends with implications for the education of hospital managers and research on hospital management and adaptation to contracting.     

Collaborative partnering: a new paradigm in materiel management

Materiel managers have virtually unlimited opportunities to gain support through a measurable quality and service focus. This support can be achieved through organizational strategies, organizational development, customer service, advanced inventory management and purchasing systems, the power and use of information and, ultimately, mutually beneficial partnerships with distributors and manufacturers.     

Success under duress: policies and practices managers view as keys to profitability in five California hospitals with challenging payer mix

Hospitals with a challenging payer mix (CPM)-high proportions of uninsured and Medicaid patients and a low proportion of commercially insured patients-are an important source of care for low-income, uninsured people. Achieving profitability is difficult for CPM hospitals. From 2005 through 2008, only one-third of 67 CPM hospitals in California reported positive total margins. In-depth group interviews were completed with the management leadership teams of a diverse group of five profitable CPM hospitals to identify the management strategies and practices that the hospitals' leadership teams credited for their financial success. Twelve management policy and practice topics were identified. Four of the policies and practices that managers identified involve organizational actions to increase hospital revenue or operational efficiency. These factors are consistent with those identified in previous research. However, managers also identified eight factors not previously revealed in research on hospital profitability, including management policies and practices that establish the organizational culture, workforce, relationships, monitoring systems, and governance necessary to ensure that hospital employees and affiliated physicians support and successfully implement organizational actions necessary to achieve profitability.     

Developing a strategic human resources plan for the Urban Angel

In healthcare a significant portion of the budget is related to human resources. However, many healthcare organizations have yet to develop and implement a focused organizational strategy that ensures all human resources are managed in a way that best supports the successful achievement of corporate strategies. St. Michael's Hospital, in Toronto, Ontario, recognized the benefits of a strategic human resources management plan. During an eight-month planning process, St. Michael's Hospital undertook the planning for and development of a strategic human resources management plan. Key learnings are outlined in this paper.     

探索医院人本管理的策略和实施方法

在组织管理中,人本思想要求尊重人、关爱人,强调理解人的想法,解决人的诉求,强化人的合作,以此充分调动人的积极性、主动性和创造性。我院实施人本管理主要以三大策略为指导,确定相应的实施方法。三大策略分别为：因人而异,实行职工分类管理;关爱无限,善用情感对话管理;学以致用,打造学习创新团队。     

A stakeholder approach to community health management

Although community health management has become an important issue for health care organizations, there is little information on the roles that they and other community institutions ought to play in this area. This article develops a stakeholder approach to community health management, identifies the set of community health stakeholders, determines their salience to health care organizations, discusses the strategies they use to influence organizational involvement in community health management, and examines the responses of health care organizations. Implications for community institutions, health care managers, and researchers are discussed.     

Beyond physician burnout: keys to effective emotional management

Mismanagement of the complex emotions and work/life balancing challenges that come with a medical career is a risk factor that tends to go unaddressed in today's medical workplace. Visionary medical leaders recognize this dilemma and become ambassadors of effective emotional management (EEM) for physicians. EEM is a model for promoting stress resilience through management of personality-based stress reactions and the interpersonal consequences that come with coping habits. This article summarizes research that has shown how EEM affects physician, patient, and organizational functioning. It is proposed that training in EEM can serve as both the palliative and prophylactic intervention for physician distress, burnout, and the organizational problems it can cause. Taxonomy for assessing burnout is specified, and the special coping risks that come in the wake of malpractice litigation are discussed. Specific strategies from promoting EEM are detailed.     

The challenge of managing community mental health teams

Although community mental health teams (CMHTs) have become the main vehicle for coordinating health and social care for people with severe and long-term mental health problems, little research exists on their management. This paper reviews the available literature with reference to the wider literature on innovation and organizational behaviour and examines strategies for improving CMHT management at macro and team level. The challenges of researching the topic are described with recommendations for further research based on social constuctivist theorizing and triangulated methodology.     

Outsourcing in long-term care: a risk management approach

This article seeks to investigate outsourcing decisions in supply chain management of healthcare organizations, namely the motives and constraints behind the decision, the selection criteria for activities to be outsourced to third parties, the type of possible agreements, and the impact of this decision on the organization per se. A case study of the start-up phase of a Long-term Care unit with an innovative approach and high levels of customization was conducted to understand the outsourcing process in a start-up context (not in the standard context of organizational change) and a risk evaluation matrix was created for outsourcing activities in order to define and implement a performance monitoring process. This study seeks to understand how to evaluate and assess the risks of an outsourcing strategy and proposes a monitoring model using risk management tools. It was shown that the risk management approach can be a solution for monitoring outsourcing in the organizational start-up phase. Conclusions concerning dissatisfaction with the results of outsourcing strategies adopted are also presented.     

How evidence based are recruitment strategies to randomized controlled trials in primary care? Experience from seven studies

BACKGROUND: Failure to recruit adequate numbers of participants represents a major barrier to the completion of randomized controlled trials in primary care and is associated with substantial opportunity costs. However, uncertainty exists regarding the relative effectiveness of different methods to promote recruitment. OBJECTIVES: The purpose of this study was to estimate the proportion of strategies used to promote patient recruitment to randomized controlled trials in primary care that are evidence based. METHODS: Investigators from seven primary care-based clinical trials of dyspepsia management aiming to recruit a total of 6070 patients participated. Following a survey of trial organization, a Delphi technique was used to reach consensus on levels of evidence on the effectiveness of interventions or organizational characteristics in influencing recruitment. The main outcome measures were the proportions of interventions or organizational characteristics for influencing patient recruitment that are based upon randomized controlled trials, on convincing non-experimental evidence or meeting neither of these criteria. RESULTS: Out of a total of 56 interventions used across the trials, 35 (63%) were judged as evidence based. Out of a total of 29 organizational characteristics possessed by the trials, five (17%) were judged as evidence based. Across the seven dyspepsia trials, the presence of 'favourable' organizational characteristics appeared to be important contributors towards successful recruitment. CONCLUSIONS: A wide range of interventions and organizational characteristics with the potential to promote recruitment were used or possessed by seven primary care trials. Many were not evidence based. Our experience suggests that organizational characteristics could be more influential in trial recruitment than the use of specific interventions. Given the costs of primary care-based trials, researchers need more rigorous evidence to inform recruitment strategies.     

Competition, capitation, and case management: barriers to strategic reform

Political support for competition, capitation, and case management in health services has come from successive Congresses and presidents. Benefits attributed to these organizational/financing strategies are consistent with society's preference for a private market approach. Yet, the promise has not been pursued in effective public policy or program. The systemic barriers to implementation of alternative delivery systems are examined in the context of Medicaid; they are neither trivial nor intractable.     

Roles of managers in academic health centers: strategies for the managed care environment

This article addresses survival strategies of academic health centers (AHCs) in responding to market pressures and government reforms. Using six case studies of AHCs, the study links strategic changes in structure and management to managerial role performance. Utilizing Mintzberg's classification of work roles, the roles of liaison, monitor, entrepreneur, and resource allocator were found to be used by top-level managers as they implement strategies to enhance the viability of their AHCs. Based on these new roles, the study recommends improving management practices through education and training as well as changing organizational culture to support management decision making and foster the continued growth of managers and their AHCs.     

提升酒店员工工作生活质量的策略探讨

提出现代酒店员工工作生活质量（QWL）的改善策略，为组织工作效能的提高建立基础。采取文献研究法，对酒店员工的QWL概念内涵、结构维度和特殊群体的QWL等方面的研究作相关的文献分析。提出现代酒店员工QWL的内容结构和维度包括劳动报酬与劳动强度、组织制度、工作与休闲生活环境、工作氛围与人际关系、参与与决策、自我发展与成长、社会责任感等7个方面。酒店需要通过工作模式的改善和员工关爱计划的实施等策略，整体提升酒店员工的QWL，进而提升组织运作和管理效能。     

Building departmental influence in health care organizations

This article has outlined several steps to follow in assessing and building department influence at the top management levels of health care organizations. Identifying and contributing to resolving the organization's key areas of uncertainty are strategies that have improved the influence of many departments in recent years. Individual strategies, such as developing one's expertise and sharing that expertise with other departments and top management (an example of the "involvement" technique), also are being used daily by effective department managers. Decentralized management, which entails the assignment of greater responsibilities to middle managers, is increasingly popular in health care organizations. This trend will no doubt facilitate the building of departmental influence in organizational decision making. However, the steps outlined in this article can be implemented whether or not top management endorses a decentralized management style. In a critical sense, departmental influence is too important to be left to top management. It is up to department managers to exert their influence for the good of their employees, the organization as a whole, and their own careers.     

The utilization of systematic outcome mapping to improve performance management in health care.

Performance management is an important mechanism for ensuring accountability and improving the quality of health-care services. The last decade has witnessed a proliferation in the development of performance measurement systems for assessing health-care processes and outcomes at the program, hospital, district, system and national level. This has allowed for comparison and benchmarking between similar aspects of care at each of these levels. Unfortunately, most performance systems are devoid of clear mechanisms for translating feedback from measures into strategies for action, thus leaving largely unfulfilled the quality and management aspect necessary to improve health-care services. Therefore, the thinking that goes into designing these systems must change. This article outlines a management framework called systematic outcome mapping that provides for performance management rather than just performance measurement by allowing for quality improvement to be built into performance indicator development. It utilizes evidence-based medicine and expert consensus opinion to establish linkages between processes of care and their outcomes with the clear intent that feedback from information provided by performance indicators can be used to modify health-care activities so as to improve health outcomes. This fulfils the quality improvement aspect of performance measurement and makes it an integral part of a performance management framework that reinforces organizational learning through feedback from outcomes and the assessment of organizational routines.