This thesis originated from a research question created by a focus group of National Health Service (NHS) senior estates managers, who considered that the systems of internal control do not give adequate assurance that NHS healthcare building services engineering day-to-day maintenance activities conform to the national guidance. The initial aim of this research was to test their concerns against empirical evidence from NHS Trusts. This was achieved by identifying the gaps within the participating Trusts' maintenance managerial activities when assessed against national standards. Central to the methodology used to assess the level of dynamic risk being generated was the rejection of the NHS national standard 5x5 risk criticality grid in common use throughout the health service, in favour of a series of specific 'Utility Functions'. This has created greater transparency and robustness of the risk assessment process. To the researcher's knowledge, this is the first time that 'Utility Theory' has been used in such scenarios. The result of this analysis has shown their fear to be correct. And for each of the 31 NHS Trusts taking part, the multi-professional focus groups composed of their own senior managers confirmed that there are areas of non-conformance within their maintenance regime, which were previously unknown. In all cases the organisations considered that their failings were exposing their patients, staff, public and stakeholders to substantial/intolerable risk through a 'systematic' failure of the Trusts' governance systems. The aim of this research then expanded to design techniques that specifically assesses the resource needs to close these managerial gaps employing industry standard techniques. Then again employing 'Utility Theory' examined various revenue levels of directly employed maintenance artisan resource with respect to risk, via a specifically designed simulation model. This has proved that the historical NHS methodology for assessing workforce planning to be fundamentally flawed, as it seriously underestimates the resource need. This research then developed and designed a generic day-to-day monitoring assurance framework from reference to the research into High Reliability Organisations, Normal Accident Theory and managerial governance needs. The overriding recommendation from the research was that NHS Trusts must redesign their governance systems to ensure that they are aware of their estates department's non-conformances when assessed against national standards.

Process modelling can be used to provide a comprehensive understanding of business activities and functions and thence a base for detailed process analysis. Business process improvement refers to a family of approaches which aim to help an organisation adjust its processes to fit a dynamic or complex business environment, particularly so as to take advantage of rapid advances in information technologies. However, most business process improvement methodologies do not make significant use of process modelling to guide the evaluation and improvement of business processes. The current research uses process modelling techniques in a systematic and generalisable manner to gain deeper understanding of processes in a particular complex case. By analysis and further probing of the process models, it then seeks to develop a practical methodology for business improvement which will be applicable not only in the case in question but also more broadly. The case explored in detail in this work is the process of Cancer Care and Registration (CCR) in Jordan. This is introduced after a discussion of business processes in general, business processes in healthcare, and methods of business process modelling. There is some comparative treatment of CCR processes in the UK. The main method used for modelling existing processes in the Jordanian CCR case is Role Activity Diagramming (RAD). Models for six major sub-processes were prepared. The models thus produced were validated in discussion with participants. They were then subjected to an extensive analysis, with the objective of discovering whether the processes might be improved. One form of analysis examined the structural properties of the models, to discover for instance how closely coupled different roles were. A second, model-led, form of analysis methodically queried, through interview or questionnaire, each activity or interaction in the models, to see how well it was working, in its particular context, in terms of general criteria such as efficiency or reliability. Thirdly, the notion of non-functional requirements (NFRs), borrowed from software engineering, was used to derive detailed NFRs from high-level business objectives, as a basis for a systematic examination of broad quality levels achieved in existing processes. These complementary analyses, supported by further validation with - I - participants, then provided the base for a remodelling of the processes with the goal of business improvement. The redesign suggestions included indications of where information technology might be introduced or strengthened with beneficial effect. The methods of detailed modelling, systematic analysis, and redesign for business improvement are, while thoroughly applied to the case under investigation, sufficiently abstract to be proposed as a general methodology for the design of business process improvements. The key features of the methodology are that it is grounded in process modelling and brings together functional, non-functional and structural process analyses.

The development of new knowledge about patient care continues to progress at an ever-increasing rate but its transfer into clinical practice can be slow and unpredictable. This doctoral statement provides a critical overview of a substantial programme of work that has explored the utility of theoretical models of behaviour for promoting the uptake of research findings into routine care. Guided by the MRC Framework for the design and evaluation of complex interventions, the supporting publications describe the development and testing of an innovative and systematic approach to intervention design. As well as providing methods for identifying and applying behavioural theory, this work has also set standards for transparency in the intervention development processes. The work demonstrates that psychological theories of behaviour do have an important function for improving healthcare delivery by supporting clinical behaviour change, but important limitations remain. In my critical reflection of this body of work I discuss these challenges, considering in particular the omission of the patient perspective and the dynamic influence of the patient-professional interaction during the clinical encounter. I go on to propose an extended dual-perspective model supported by theory and evidence from other improvement literatures, epistemologies and disciplinary perspectives. The dual perspective model functions at the very core of healthcare delivery and illustrates the interdependency of professional and patient behaviour in determining healthcare decision making and patient outcomes. By formally including the patient perspective the revised model encompasses all three dimensions of the EBM paradigm. I argue for a focus on better understanding of the interactional and relational processes that are generated during the clinical encounter as an essential step forward for implementation and improvement science. The paradigm of patient-centred care is then revisited through the lens of capabilities thinking and is proposed as a vital mechanism for supporting the uptake of appropriate, evidence-based healthcare.

Organisational change within the NHS is a familiar event. This study explored the impact it has on staff in a clinical setting , and focuses on how staff experience such change. The study took place in two Child and Adolescent Mental Health Services, in two separate NHS Trusts in England. The exploration is qualitative, using grounded theory, and data collection is through semi-structured individual interviews completed at two points in time: the initial principal interview, and a follow up interview. Sampling is purposive and focused on staff within multi-disciplinary teams providing front-line clinical services. The study took place across two NHS Trusts to enhance reflexivity of the researcher, and methodological rigour. The interviews were audiorecorded and transcribed verbatim. The transcripts were analysed using grounded theory, underpinned by a social constructionist epistemology. A sample of 11 professional clinical staff members across two NHS Trusts volunteered to participate in the study, each completing two interviews. The findings are derived from 22 extended interview transcripts. Analysis of the data generated led to the conceptualisation of a process of being organisationally changed impacting on individuals' work identity and sense of self. There was a perceived mismatch between clinical and organisational values leading to incongruence, and re-valuing . Through the processes of deprofessionalisation and deskilling , participants experienced loss and diminishment of identity, and a process of becoming indistinct, culminating in a grieving of identity. Emergence from this was conceptualised as a process of reconciliation, which took the form of either accepting a sub-identity, or finding a way of preserving aspects of professional identity within organisational constraints. The process of being organisationally changed is developed and discussed, with use of illustrative data extracts. The findings illustrate the ways organisational change can impact on the "human dimension", as experienced by participants. This study contributes to an in depth exploration and understanding of organisational change impact on NHS clinical staff.

The use of temporary staff in healthcare presents a management challenge. There is a case for minimising their use to reduce the risks associated with their limited familiarity with the context and knowledge of protocols. However, staff shortages can negatively affect patient outcomes. Consequently, temporary staff are required but need to be carefully managed. This thesis uses the analytic framework of the psychological contract to explore the previously neglected management of the employment relationship with temporary staff. The empirical research consisted of two studies. The first explored the management of temporary staff in Emergency Departments (ED), analysing management perspectives at macro, meso and micro levels. The second studied the management of the launch of a Major Trauma Centre introducing a Consultant Resident On-Call for trauma, which required temporary contracts. The research was conducted through case studies utilising semi-structured interviews. The ED was specifically chosen because of its high use of temporary staff, and its particular challenges associated with patient care. Results indicated a conflict between the priorities of senior management to minimise staff costs, and department level management, concerned with staffing levels to maintain patient care and service delivery. Risks to patient safety, particularly when ad-hoc agency staff were recruited, were identified. Study 2 revealed a shift from relational to transactional psychological contracts when consultants were placed on temporary contracts due to the protracted management of the change process and perceived psychological contract breach. The results highlighted the distinctive characteristics of temporary staffing in healthcare, and the hierarchy of preferences between the types of temporary staff identified. The research also revealed the consequences of the competing priorities between different management levels in the hospital. Finally, the studies revealed that the psychological contracts of temporary staff were predominantly transactional, whereas a more relational contract could improve temporary staff use and patient outcomes.

This thesis investigates the relationship between objects and organisational forms, with particular reference to the transformation and enactment of clinical and administrative objects, practices and relations within NHS inpatient and community care settings. Through the use of an ethnographic style of enquiry this thesis investigates inpatient admission and discharge processes in the light of various health and social care practices, service commissioning issues, the Department of Health's initiative of the Care Planning Approach and other local electronic-based initiatives, and how this relates to the notions of "good" and "bad" practices, changing regimes of trust from practitioners to administrators, and from experts to documentary evidence. In particular, a range of narratives associated with mental health care which seek to provide a coordinating frame for different relations are reviewed. This involves exploring the attempts to link different information practices and ontologically distinct objects, and how this process relies on both multiplicity and singularity (e.g. both a sense of stability and heterogenous relations). Finally, this research examines how these mediating objects and processes in acute inpatient care settings seek to contribute to the creation of composite conditions and multiple bodies that fractionally relate to one another, but also the many problems experienced by those involved in the process of mental health care. In conclusion, this thesis explores several issues relating to specific organisational practices of care planning and record keeping, as well as broader questions of how objects are both enacted and enact practices in relation to complex modes of orderings and standardisation.

This thesis explores the leadership role of chief executives of National Health Service (NHS) health authorities in England. Implicit in the exploration is whether the chief executives have a leadership role at all since the NHS is a public service managed by government. As such it is government that specifies the main operational and strategic targets for the NHS for chief executives and their organisations. The research is conducted against the backdrop of the general leadership, public sector management, and network and networking literature. The latter is included because it potentially provides a bridge between the emerging network-based working of NHS management today and the leadership and public sector management literature A qualitative, case study approach to the research is adopted using as its basis the implementation of the main component of the 1997 Labour government's policies for the NHS. This is the introduction of primary care groups that for the first time in its history will formally involve general practitioners (GPs) in the corporate management of the NHS. This is a significant development because GPs are not employees of the NHS but independent contractors. Research is undertaken in four of the 99 English health authorities. Analysis of the research results revolve around three propositions, formulated to explore tlie environmental aspects of the chief executive's role, whether leadership is found and if so, what are its key characteristics. The thesis ends with a discussion of the research outcomes in the context of some contemporary literature on research approaches to organisational change, aspects of leadership and networks such as power and trust, and leadership development.

No description available.

No description available.

No description available.