Interorganizational team research is a growing body of literature and research has started toexamine team related factors such as interorganizational trust (i.e. Stock, 2006) in theinterorganizational setting. This research applies insights from the intraorganizational teamfield into the interorganizational team setting in order to determine the team related factorspertaining to effective collaboration in medical device innovation projects. Interorganizational collaboration has been a persistent feature within the interorganizationalrelations literature, due to the added benefits that can come with working collaborativelytowards a common goal (Berg-Weger & Schnieder, 1998). While much research has exploredthe structures and performance outcomes of engaging in this cross-boundary working, theliterature is sparse with respect to interpersonal relationships, practices and processes leadingto effective collaboration (Bergenholtz & Waldstrom, 2011; Majchrzak, Jarvenpaa & Bargherz,2015). An interpretivist perspective has informed an exploratory mixed methods approach to datacollection, with contextual insights informing each phase of data collection. Three exploratoryphases of data collection have provided (1) qualitative ethnography data, (1i) qualitativeinterview data and (2) quantitative survey data. The NHS has recently set out agendas to increase innovative procurement (Department ofHealth, 2008), work more closely with industry and SMEs (Innovation and Procurement Plan:Department of Health, 2009) and to increase innovative practice (IHW: NHS, 2011). SMEsdeveloping novel medical devices require input from the NHS to ensure that their devices areclinically applicable and therefore will be adopted by the NHS. These contextual insightsprovide the backdrop for Studies 1i and 2. The findings suggest that the intraorganizational team literature can be extended into theinterorganizational collaboration literature, whilst also explaining the factors relating toeffectiveness and success of interorganizational team innovation.

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Health sector decentralisation has been a recurring theme in health systems reform discourse for several decades, particularly in developing countries. Decentralisation is promoted for its ability to strengthen community participation and accountability, and to enhance technical efficiency in the management of limited health sector resources. However, most of the literature on health sector decentralisation has been descriptive, reporting outcomes of different decentralisation models, with minimal analysis of how contextual factors contribute to the observed outcomes. In 2010, Kenya passed a new constitution through a nationwide public referendum. A key feature of this constitution was the introduction of 47 semi-autonomous devolved county governments. This study aimed to describe and analyse the effects of this major political decentralization on planning and budgeting in the health sector at the sub-national level, including the goals and intended strategies for health sector operational planning and budgeting, and stakeholder expectations and experiences of decentralisation. I used a case study design, focusing on Kilifi County, guided by a conceptual framework which drew on decentralisation and policy analysis theories. I used three tracers: planning and budgeting for recurrent expenditures; Human Resources for Health (HRH); and Essential Medicines and Medical Supplies (EMMS) management. I collected qualitative data through document reviews, key informant interviews, and participant and non-participant observations. I found that the Kenyan devolution was largely driven by the need to address political rather that technical challenges in public sector management. To this effect, county level functions were rapidly transferred without proper structures and capacity to undertake these functions leading to major disruption of public services at county level. Within the health sector, the early days witnessed perverse re-centralisation of operational financial management roles from health facility level to the county level. On HRH, there were major disruptions in staff salary payments, political interference with HRH management functions and confusion over certain HRH management roles; leading to industrial strikes and mass resignations by health workers. On EMMS, there were significant delays in the procurement process leading to long periods of stock outs of essential drugs in health facilities. With time though, and with the county governments establishing their structures and progressively building their capacity, a general improvement in counties’ ability to manage devolved functions, including health sector functions has been witnessed and there are deliberate efforts to find local level solutions to some of the emerging challenges. In conclusion I argue that the political push for decentralisation is often stronger than the technical intentions and implementation processes. There is thus need for health sector policy actors to have a broader understanding of the countries’ political context whenever designing technical strategies for implementing health sector decentralisation. In addition, I propose that the allocation of functions between central level and decentralised units should always be guided by considerations around decision space, organisational structure and capacity, and accountability arrangements and practices within the health system.

The Department of Health (DH) is responsible for one of the largest estates in Europe. In this capacity, the DH produce and disseminate estates-related Standards & Guidance (S&G) to provide support to the briefing and design processes for new, and refurbishment projects in old healthcare buildings. The estate is made up of a variety of buildings, many ageing and in need of extensive refurbishment or replacement. It is therefore important to the stakeholders in the procurement and provision of healthcare environments that the DH S&G provide them with the information and data they need at the relevant time in the process to enable them to design and construct healthcare facilities that are safe and fit-for-purpose. Policy changes over the past 20 30 years have had a profound effect upon the estate. The estate was seen to be in need of modernisation, but Government lacked the extensive funding necessary to achieve anything like the extent of redevelopment required. The introduction of private sector funding to achieve this resulted in a major shift in the ownership of the estate, and latterly the regulation of the estate, both private sector and National Health Service (NHS). The NHS Constitution, introduced in 2009, was the first Government document explicitly to recognise the estate and the importance of it being fit-for-purpose. This research seeks to establish the importance of the DH S&G, and their benefits and dis-benefits to stakeholders using them, including organisations and individuals from the private and public sectors. The groups have differing roles and priorities and the research seeks to establish how these affect their requirements for S&G, how effectively the S&G meet those requirements and how they contribute to the overall provision of healthcare environments. Moreover, hospital accommodation has been proven to have an effect on the patients and staff, therefore, the provision of useful and helpful S&G could be seen to have an indirect influence on patient outcomes, and also on providing a pleasant and efficient environment for staff. The research has identified three major strands: Policy; the DH S&G themselves; and what is important to users about them and any benefits or dis-benefits incurred. Policy is viewed as the driver for the need for DH S&G. The changing political environment, amongst many other factors, affects how the S&G have been operationalized. This study of the application of DH S&G aims to establish how users view the benefits and dis-benefits and their effects on the healthcare environment. Research in the construction industry sector spans the scientific and social worlds, and the methodology is deductive research orientated, exploiting a range of data. Qualitative and quantitative data have been collected through open interviews with known experts and an on-line survey of the stakeholders using the S&G from private and public sector organisations involved with the provision of healthcare accommodation. Reference to the DH S&G and related unpublished DH documents traces their development and examines their content. The results have been mapped to the stakeholder categories (Designers, Service Users, Estates and Facilities Managers, Contractors and the DH/NHS), thus enabling comparisons to be made between each group, and between the public and private sectors. Analysis of the data identified the characteristics users found to be of importance and of benefit or dis-benefit. On balance, it was clear that the DH S&G are beneficial, but not universally. Of prime importance to its users is the DH endorsement of the S&G and its independence from commercial influences. However, the classification of the DH S&G, defined as best practice is often regarded and applied as mandatory. The content of the S&G varies in its scope, content and characteristics, being perceived as incomplete, inconsistent and out-of-date. Taking all these factors, therefore there is a danger that the DH S&G may contribute to healthcare buildings being unfit-for-purpose or out-of-date.

The aims and objectives of the research presented in this thesis were to explore service user experience as a key element of the concept of service excellence in NHS Salford Primary Care Trust. . The link between health and social deprivation is well established. Thus, service users in worst economic and social problems in Europe. A phenomenological approach was adopted in order to get to the roots of the service user's own understanding of excellent healthcare. The study undertook a critical review of previous research into service concepts and instruments and their application in healthcare settings and identified current methods and techniques used in primary care. It has been shown that existing tools rely on previous work conducted in secondary care settings and do not have a basis in understanding of user experience.

Hospital-acquired infections (HAIs) are a major problem in the National Health Service (NHS) in the United Kingdom (UK). One reason for this is the failure of healthcare officials to tackle the root causes of HAIs. There is sufficient epidemiological evidence showing that HAIs can occur because of, inter alia, poor performance of Healthcare Maintenance (HM) services. Despite this link, HM has not received the level of attention it deserves from healthcare authorities. As a result, some HM managers do not measure the performance of HM services in infection control (IC). The aim of this research study therefore, is to improve the overall level of performance of HM services in the control of HAIs in the NHS. Hence, the adoption of six research objectives to identify the critical success factors (CSFs) and key performance measures in the control of maintenance-associated HAIs. In addition to an in-depth literature review, a content analysis approach was adopted to establish the link between HM services and HAIs. Conversely, CSFs and performance measures in HM in IC were identified through the application of ground theory analysis. An exploratory case study was then conducted with two NHS trusts. The results of the exploratory case study revealed that some HM managers did not have the required knowledge to fulfil the research need of the study, i.e. development of the performance measurement system (PMS). Therefore, the Delphi approach was considered suitable to achieve the aforementioned need. In total, eight CSFs and fifty-three key performance measures are identified for reducing the burden of maintenance-associated HAIs in hospitals. For example, establishing clear lines of communication between the IC team and HM unit is crucial in the prevention of maintenance-associated HAIs in hospitals. Dust prevention is also identified by the healthcare experts as an important measure to prevent the transmission of maintenance-associated HAIs in high-risk patient areas. Through the application of the Balanced Scorecard (BSC) approach, the CSFs and key performance measures were categorised into a performance matrix. The result was then used to develop a performance measurement system (PMS) to control maintenance-associated HAIs. Both performance tools i.e. the BSC matrix and PMS could be applied by HM managers to reduce rates of maintenance-associated HAIs in hospitals.

Patient safety measurement methods are dominated by outcome measurement, reducing them to counts of harm or adverse events. Performance measurement recognises the limitations of the sole use of outcome indicators and proposes the use of measures throughout the system, in particular the determinants of the desired outcomes. Furthermore, it promotes stakeholder engagement in the design of measures in order to understand their expectations and how they contribute. This is particularly important in healthcare services, such as the NHS case management programme, where patient contribution is growing. This programme is a response to the ageing population and the subsequent increase in complex long term conditions, aiming to deliver care in the home to empower patients so they are able to care for themselves to a greater extent. In comparison to the institutionalised setting, the home setting is relatively unexplored. Therefore, this research has provided an opportunity to examine the concept of safety in a care service with an increasing demand from a vulnerable population. The research aimed to develop a conceptual framework for safety measurement that was: 1) reflective of key stakeholders; 2) able to incorporate the system; and 3) representative of the home-delivered healthcare of the case management programme. An exploratory, sequential mixed method design within the critical realist philosophy, which was guided by the principles of performance measurement, was adopted. A case study utilising 13 interviews with nine patients and six carers (two interviews were held jointly) and three focus groups with 17 case management nurses was deployed. This enabled in-depth exploration of their perspectives regarding safety, including: their definitions of safety, who was involved, the contributing factors, and which outcomes were most important. Intriguing, important or contradictory findings were further examined using a survey (patient n=35, carer n=19 and case management nurse n=26), which aimed to determine the level of agreement with these qualitative findings and identify any statistically significant differences between the stakeholder groups. Through engagement with stakeholders, this research has established a definition of safety that represents the type of care provided by the case management programme. In particular, it recognises the importance of meeting the care needs of this patient population, acknowledging that the alternative would facilitate disease progression, exposing patients to unnecessary harm. Understanding the patient perspective has proven to be particularly important because of the level of control asserted by patients on the structure, processes and outcomes of care. This level of control is an integral component of the proposed conceptual framework. Of greatest significance is the incorporation of the patients' living environments and their resources into the structure of care, as well as the involvement of their daily self-care activities in the processes of care. Consequently, the framework is inclusive of non-traditional safety outcomes, such as functional health status, because they help sustain patient controlled structures and processes, which in turn influence traditional measures of harm. The conceptual framework is a guide to the assessment of safety in case management that specifies a range of factors that facilitate the condition of safety, providing a holistic overview of the complex, nested system of care required to manage long term conditions.

This thesis comprises three essays examining the roles of markets and intrinsic motivation in public organisations. Chapter 1 examines the impact of establishing Independent Sector Treatment Centres in the English National Health Service (NHS) during the 2000s on the performance of neighbouring NHS (public) hospitals. It finds that NHS hospitals that had an ISTC placed nearby became more efficient (measured using pre-surgical length of stay for orthopaedic surgery), but also received sicker patients on average, as ISTCs avoided treating the sickest patients. Average cost per patient at ISTC-exposed NHS hospitals increased, suggesting that any efficiency gains were swamped by the negative effect on costs of worsened patient casemix. Chapter 2 examines the 2006 introduction of patient choice of hospital for elective surgery within the English NHS, using Patient Reported Outcome Measures (PROMs) of health gain from surgery as a measure of hospital quality. The hospital competition brought about by this reform appears to have led to lower varicose vein surgery quality, but no change in groin hernia surgery quality. For orthopaedic surgery quality, the evidence in support of a negative effect of competition outweighs the evidence to the contrary. We explain these findings by explicitly modelling the hospital as a multi-product firm. Chapter 3 examines the rationale for the 2011 Busan Declaration, which states that foreign aid should be given in line with the priorities of recipients, by constructing a model of the interaction between donors and charitable entrepreneurs, where occupational choice is endogenous, donors can choose whether to give, and donors and entrepreneurs are paired in a stable matching. We show that mission conflict in the charitable sector can arise when mission preferences and income earnings ability in the private sector are correlated, and examine policy options to encourage the charitable sector to give greater weight to recipients’ objectives.

In Great Britain and Brazil healthcare is free at the point of delivery and based study only on citizenship. However, the British NHS is fifty-five years old and has undergone extensive reforms. The Brazilian SUS is barely fifteen years old. This research investigated the middle management mediation role within hospitals comparing managerial planning and control using cost information in Great Britain and Brazil. This investigation was conducted in two stages entailing quantitative and qualitative techniques. The first stage was a survey involving managers of 26 NHS Trusts in Great Britain and 22 public hospitals in Brazil. The second stage consisted of interviews, 10 in Great Britain and 22 in Brazil, conducted in four selected hospitals, two in each country. This research builds on the literature by investigating the interaction of contingency theory and modes of governance in a cross-national study in terms of public hospitals. It further builds on the existing literature by measuring managerial dimensions related to cost information usefulness. The project unveils the practice involved in planning and control processes. It highlights important elements such as the use of predictive models and uncertainty reduction when planning. It uncovers the different mechanisms employed on control processes. It also depicts that planning and control within British hospitals are structured procedures and guided by overall goals. In contrast, planning and control processes in Brazilian hospitals are accidental, involving more ad hoc actions and a profusion of goals. The clinicians in British hospitals have been integrated into the management hierarchy. Their use of cost information in planning and control processes reflects this integration. However, in Brazil, clinicians have been shown to operate more independently and make little use of cost information but the potential signalled for cost information use is seen to be even greater than that of their British counterparts.