Private hospitals in Malaysia are now extending their healthcare services to cater for patients travelling from the global market. These organisations are aggressively gearing themselves up to deliver quality services and to demonstrate quality assurance on their services. Hence, service quality strategies and initiatives have become critical for success in hospitals and the way forward. In pursuing quality initiatives, hospitals need to gain access to quality-related information and adopting the appropriate management accounting practices would be an important enabler and facilitator to generate useful management information leading to organisational successes. This study examines the usage of management accounting practices in these hospitals and attempts to develop a management accounting framework that would effectively facilitate the implementation of service quality initiatives pursued. Structured questionnaire was used to gather the perceptions of hospital management on service quality implementation level, usage level of management accounting practices usage and performance level of hospitals. Quantitative methods using MANOVA and structural equation modelling with AMOS were employed for data analysis. The results show that service quality implementation level was not found to be higher in hospitals that have obtained more types of quality achievements as compared to those that have obtained less or no achievements. Hospitals have benefitted from the implementation of quality initiatives related to management, process and analysis. However, such benefit was not found in quality initiatives related to patient care. In terms of the mediating role of management accounting practices, the results show no mediation effect on the impact of patient care on hospital performance. Meanwhile, there was partial mediating effect on the impact of management, process and analysis on hospital performance. Specifically, the mediating effect was found to be stronger from the advanced accounting practices compared to the basic accounting practices. The findings lead to a conclusion that adopting the appropriate management accounting practices would effectively facilitate hospitals in their quality pursuits. Limitations of this study and recommendation for future research are presented.

The aim of this research is to present and discuss the development and deployment of Lean thinking models and techniques applied to improve the decision-making within the planning and design processes of new infrastructures, within a healthcare organisation. In the UK, healthcare organisations are responsible for planning, designing, building and managing their own infrastructures, through which their services are delivered to the local population (Kagioglou & Tzortzopoulos, 2010). These processes are long and complex, involving a large range of stakeholders who are implicated within the strategic decision-making. It is understood that the NHS lacks models and frameworks to support the decision-making associated with their new infrastructure development and that ad-hoc methods, used at local level, lead to inefficiencies and weak performances, despite the contractual efforts made throughout the PPP and PFI schemes (Baker & Mahmood, 2012; Barlow & Koberle-Gaiser, 2008). This is illustrated by the long development cycle time – it can take up to 15 years from conception to completion of new infrastructure. Hence, in collaboration with an NHS organisation, an empirical action research embedded within a mixed-methodology approach, has been designed to analyse the root-cause problems and assess to what extent Lean thinking can be applied to the built environment, to improve the speed and fitness for purpose of new infrastructures. Firstly, this multiphase research establishes the main issues responsible for the weak process performances, via an inductive-deductive cycle, and then demonstrates how Lean thinking inspired techniques: Multiple Criteria Decision Analysis (MCDA) using ER and AHP, Benchmarking and Quality Function Deployment (QFD), have been implemented to optimise the decision-making in order to speed up the planning and design decision-making processes and to enhance the fitness for purpose of new infrastructures. Academic literatures on Lean thinking, decision theories and built environment have been reviewed, in order to establish a reliable knowledge base of the context and to develop relevant solutions. The bespoke models developed have been tested and implemented in collaboration with a local healthcare organisation in UK, as part of the construction of a £15 million health centre project. A substantial set of qualitative and quantitative data has been collected during the 450 days, which the researcher was granted full access, plus a total of 25 sets of interviews, a survey (N=85) and 25 experimental workshops. This mixed-methodology research is composed of an exploratory sequential design and an embedded-experiment variant, enabling the triangulation of different data, methods and findings to be used to develop an innovative solution, thus improving the new infrastructure development process. The emerging developed conceptual model represents a non-prescriptive approach to planning and designing new healthcare infrastructures, using Lean thinking principles to optimise the decision-making and reduce the complexity. This Partial & Bespoke Lean Construction Framework (PBLCF) has been implemented as good practice by the healthcare organisation, to speed up the planning phases and to enhance the quality of the design and reduce the development cost, in order to generate a competitive edge. It is estimated that a reduction of 22% of the cycle time and 7% of the cost is achievable. This research makes a contribution by empirically developing and deploying a partial Lean implementation into the healthcare‟s built environment, and by providing non-prescriptive models to optimise the decision-making underpinning the planning and design of complex healthcare infrastructure. This has the potential to be replicated in other healthcare organisations and can also be adapted to other construction projects.

This research has investigated and analysed why and how Management Accounting (MA) has contributed, at the institutional level, to improving Health Care Quality (HCQ) within the Saudi Arabian Public Health Sector (SAPHS). Analysing these developments as a form of change consistent with the dynamics found in the emergence of New Public Management (NPM), this study draws on Neo-Institutional Sociology (NIS). The research studies how MA change operated across institutional contexts within an NPM-based approach to improving health care and public health in the Kingdom of Saudi Arabia (KSA). It focuses on how, in this context, the roles and practices of MA have been defined, designed and implemented to promote ‘quality outcomes’ in health care. Methodologically this has involved two extensive case studies of MA change in two carefully selected hospitals, including semi-structured interviews with accountants, management, consultants and clinicians along with the collection and analysis of key documentary information used in managing the human and financial resources within the hospitals. The findings show how and how far new management accounting practices (MAPs) have promoted the ability and ‘right’ of management to coordinate control and monitor the human and financial resources, but in a way that specifies HCQ outcomes for patients, thus meeting both economic and social/political objectives. It is argued that MAPs had significant success because the allocation of budgetary resources by the Ministry of Health (MOH) was based on hitting non-financial quality and productivity targets. In both hospitals MAPs came to operate within a ‘non-accounting budgetary style’ (Hopwood, 1973) de-emphasising cost control, and managers and staff focussed just on effectiveness and efficiency measures. However, this initiative can also be seen as a response to significant institutional pressures and concerns at both government and professional levels, responding to ‘public voice’ concerns over HCQ. The response drew on world-leading medical research and practitioners to introduce best-practice HCQ solutions allied to internationally accredited quality standards into the KSA hospital sector. The study found that coercive, mimetic and normative isomorphism all contributed to the successful implementation of the HCQ agenda, and the new MAPs here contributed to strengthening the internal and external legitimacy of certain key KSA institutions. There was some institutionally significant resistance from clinicians who saw these MAPs as compromising their professionally-defined focus on quality outcomes for patients. But over time, the mix of ‘soft’ quality and ‘hard’ MA derived targets was increasingly accepted and internalised as integral to delivering HCQ.

Decision-analytic models have an important role in healthcare funding decisions in the UK and internationally. However, errors have been reported in published models, which may indicate poor modelling practices, potentially leading to sub-optimal recommendations on cost-effectiveness. Little in-depth research has been undertaken to investigate the processes used by modellers in model development. The objective of this research was to explore the modelling methods used by modellers, with particular focus on problems encountered. This work involved two qualitative phases of research. In the first phase, twenty-four in-depth interviews with modellers were undertaken. Constant comparative analysis was used to compare informant practices, and identify common issues in model development. The second phase involved two separate model-building case studies with teams of modellers and clinicians. Methods of non-participant observation, qualitative interviews, and think-aloud were used to investigate model development. The findings of the case studies were compared using framework analysis. Important themes emerging from both phases of the research concerned the diversity of practices in structural development, problems with clinician involvement in modelling, and a lack of time and resources to carry out good practice methods. This work offers important recommendations for modelling practice, and suggestions for future research to improve modelling methods.

Introduction: There is an increasing need for economic evaluation of public health interventions to ensure efficient allocation of resources. Outcomes of such interventions often consists of health and non-health and do not fit in the conventional economic evaluation of quality-adjusted life year (QALY) framework. A cost-benefit analysis (CBA) could be appropriate but has concerns of assigning monetary values to health outcomes. Questions remain on how to consider the broad outcomes of a public health intervention in an economic evaluation. Objective: This thesis aimed to develop an integrated approach for an economic evaluation of a public health intervention that combines the standard cost-utility analysis (CUA) for health outcomes with the stated preference discrete choice experiment (SPDCE) approach for non-health outcomes on a single monetary metric. Methods: A natural experiment of the Woods In and Around Towns (WIAT) study in Scotland was used for empirical analysis. Costs were assessed using a top-down approach based on resources used. A difference-in-differences (DiD) approach was used to establish the impact. A CUA valued the health outcomes in terms of QALYs while a previously developed conceptual model of the WIAT was used to identify the SPDCE attributes and levels for the non-health outcomes. The WIAT study questionnaire was mapped to the SPDCE which generated relative willingness to pay (WTP) values from a general Scottish population. The WTP estimates were applied to the changes or improvements in the attributes and levels resulting from the intervention. A net monetary benefit (NMB) framework was then used to combine the CUA with the SPDCE on the same monetary scale, effectively deriving a CBA. Results: The WIAT interventions were of low cost despite the base case DiD analysis showing a statistically insignificant effect for interventions. The incremental cost-effective ratios (ICERs) for the interventions revealed that they were cost-effective. The probabilistic sensitivity analysis (PSA) showed that the physical intervention was 73% likely to be cost-effective at WTP of £20,000 and £30,000. The combined physical and social interventions had 74% and 75% likelihood of being cost-effective at WTP of £20,00 and £30,000, respectively. There was a great deal of uncertainty around QALY results. Overall, the integrated approach revealed that the WIAT interventions were cost-beneficial in terms of both health and non-health outcomes. Conclusion: This thesis has proposed and demonstrated the integrated approach that combines the conventional QALY framework with the SPDCE on a single monetary scale, hence a broader economic evaluative space particularly suitable for an economic evaluation of a public health intervention.

Although information on variations in healthcare utilisation is increasingly available, its constructive use to improve health systems is often hindered by the lack of a clear standard to evaluate what is “good“ and “poor“ performance. This thesis investigates how regulators and managers of the system might address this lack of a standard. The thesis distinguishes between the purpose (to manage ambiguity in the absence of a standard or to determine a meaningful standard) and the approach used to achieve either purpose (socio-political or technical-evidential). The resulting four types of strategies are examined by drawing on concepts and methods from public health and epidemiology, health economics, operations research and public administration and empirical evidence from England and Scotland. To manage ambiguity in the absence of a standard using a socio-political approach, the thesis finds that one must overcome a series of barriers including awareness, acceptance, perceived applicability and capacity of potential users. Clinical and managerial leadership appear to be enabling factors for the use of information on variations for strategic problem framing and stakeholder engagement. To manage ambiguity in the absence of a standard using a technical-evidential approach, the use of ranking intervals and dominance relations obtained from ratio-based efficiency analysis can help to avoid the forced assignment of a single, potentially controversial ranking to each organisation under scrutiny. To determine a standard using a technical-evidential approach, estimating capacity to benefit in populations provides a theoretically sound and feasible benchmark to assess the appropriateness of service utilisation against population needs. However, uncertainty about criteria of capacity to benefit and lack of epidemiological data remain practical challenges. To determine a standard using a socio-political approach, an experimentalist governance logic focused on learning and dialogue between central government and local organisations can complement a hierarchist logic focused on accountability when both the ideal ends and the means for attainment are ambiguous. As a whole, the thesis reinforces the insight that both improved technical tools and social and political processes are required to make information on variations useful to decision-makers.

This study explores the changing nature of employment and employment management within multi-organisational public services ‘partnerships’. In line with international trends, a major feature of the 1997-2010 New Labour government’s public policy was encouraging partnerships between organisations of all sectors to run public services. Within healthcare, central government has increasingly been seen as taking on a role of market regulator, with organisations from all sectors allowed to plan as well as provide public services (Illife and Munro, 2000). As part of this picture, bringing private companies into partnership arrangements with the National Health Service has been seen as a catalyst for workforce re-configuration and employment change through furthering the reach of private sector type Human Resource Management. However, research has illustrated how inter-organisational contracts can also restrict an organisations choice of employment practice, disrupt the direct relationship between managers and employees, and undermine any aspirations for fair or consistent employment (Marchington et al, 2005). In more recent healthcare partnerships, employment is further complicated as partnerships involve powerful professional groups with their own protected employment systems and established norms of practice. This study seeks to investigate the prospects for HRM within such a professionalised partnership context through comparative case study of two Independent Sector Treatment Centres (ISTCs) operating under differing employment regulations and contractual agreements. In both cases, private sector management sought to impose a more ‘rationalised’ and standardised approach to work with a greater focus on outputs and productivity, placing ISTCs at the forefront of the Fordist ‘scientific-bureaucratic’ (Harrison, 2002) approach to medicine. However, the study identifies a number of limits to the degree to which the management of the private health care companies could shape HRM practices in line with these aims. The thesis also examines how being separate from, or integrated with, existing National Health Service organisations can lead to different types of contingencies affecting work and employment, and multiple varieties of inconsistency across the workforce. The findings of the study are explored in terms of the implications for public policy, health service management and HRM theory.

Background: In South Africa, 81 per cent of the population are dependent on the public health system. The country faces a complex burden of a combination of chronic infectious illness and non-communicable diseases and high maternal mortality, 310 deaths per 100,000 live births. These and many other systemic health challenges have meant the government is starting to invest in digital solutions to strengthen health services delivery and public health; due to their ease of use, broad reach and wide acceptance. Digital communication systems are an intriguing possibility for delivering healthcare in low-resource settings. This thesis considers how mobile (mHealth) and non-mobile communication technologies are currently and potentially being used by patients and health-workers within the rural South African health system. Health system dimensions are also analysed at the macrolevel to define the enablers and barriers to mHealth. Methods: This qualitative exploratory study was a case study design guided by theory-driven realist methodology. Mixed-methods research triangulated in-depth individual interviews, focus group discussions, prolonged engagement in nonparticipant observations and documentary analysis from a diverse range of participants (community members, patients, health-workers, policy-makers and experts) operating at different tiers within the country (community, facility, district, provincial and national). A realist review of patient mobile monitoring of chronic disease was conducted to determine hypotheses to inform the interpretation of empirical data and refine theory from the Context-Mechanism-Outcome configurations. These were supported by high-level theories of access, normalisation and the capability approach. Results: Supportive government policy combined with patient and health-workers’ informal mHealth use can act as enablers to the uptake of digital communication systems, particularly with improved maintenance and management strategies. Access to health information is a barrier to care, which may be overcome with an evidence-based health website though inequities may still remain. Likewise, digital reminders may support chronic disease management particularly for patients with hypertension. Poor patient referrals and remote diagnosis can be overcome by digital communication as smartphone ownership increases and mobile data prices reduce. Local digital innovation relies on government backing for greater scale. Conclusion: Informal digital communication solutions for health used by patients and health-workers are evident as mobile phone use becomes normalised within society. This is occurring in parallel with the government’s interest in digital health technologies to strengthen the delivery of care. A novel healthcare delivery framework proposes that a foundational electronic health and mHealth ecosystem (Context) can support a health system with multiple challenges. The four health system dimensions of government stewardship, organisational, technological and financial systems are necessary to support mobile health solutions. These dimensions give reinforcement (Mechanisms) to improve communication between patients and health-workers which may increase access to healthcare and continuity of care. Work practices are made more efficient, health service delivery is enhanced and patient outcomes can improve to maximise health gain (Outcomes).

Background: The managers of Zenith Medical Centre, a Nigerian hospital, desired to experiment a change to a process of evaluation that could improve training effectiveness for all stakeholders. Concern about evaluating training for effectiveness is not new. The past 50 years have witnessed a growing number of evaluation methods developed by scholars and practitioners to provide human resource development (HRD) professionals with alternatives for measuring training outcomes. However, investigation on the uses of evaluation data to improve training outcomes from the perspectives of divergent stakeholders is limited. Participatory evaluation (PE) through action research (AR) intervention was particularly considered as a viable means of improving training effectiveness by increased use of evaluation data. Aims of the Investigation: The aims of the intervention were to deepen insight and understanding of PE from the perspectives of stakeholders, practically implement a change of the evaluation system and produce new knowledge for the action research community. Design/Methodology/Approach: The action research approach was used from a social constructionist perspective to engage training stakeholders in the organization as participants. This perspective required working in the participatory action research (PAR) mode. Therefore, the project followed a cyclical process model (CPM) of the AR iterative process of constructing, planning, acting and evaluating. The CPM model was to accommodate the quality principles for using theory to both guide issue diagnosis and reflection on the intervention. Data on participatory evaluation were generated through focus groups and one-on-one interviews and analyzed using template analysis. Findings: By identifying and discussing their stakes, contributions and inducements in training, participants were able to reflect on their own learning, gain insight into their own work situation by sharing experiences and these facilitated peer and management support. The results were deeper insight into training evaluation; change in behavior and perceptions; and the use of quality data to improve training design, delivery and participation. The participatory process also enabled participants to learn self-direction and self-management by becoming aware of discussing problems or issues of concern to them in the workplace, group coherence and social support. Profoundly, all levels of stakeholders tried actively to change their working conditions by participating in action research activities. Implications: The study has implications for research and practice in three perspectives: First-person implications of deepening the researcher’s understanding and knowledge and providing professional development for his practice; second-person implications of deepening understanding and knowledge and providing improved day-to-day practice for the participants, practical solutions to the issue and organizational learning for the client; and third-person implication of providing specific knowledge for the wider action research community. Limitations: The research does not cover the political implications of the findings and opportunities they create for further research. It is limited to evaluation process while leaving out organizational decision making which is another factor affecting the utilization of evaluation data. Future studies should consider the question of what happens if the process of evaluation is right but the organizational politics or decision making structures hinders evaluation use.

Currently, UK healthcare is encountering an unprecedented quality crisis, especially considering the overwhelming challenge of improving patient care in the face of growing demands and limited resources. Although past efforts to adopt Total Quality Management (TQM) initiatives have failed to produce desired results, this thesis investigates the limitations of TQM applicability and explores the development of an innovative Quality Improvement model germane to a healthcare context. By integrating TQM with concepts from Corporate Social Responsibility (CSR), Complexity Theory (CT) and Knowledge Management (KM) a novel TQM conceptual framework, called EALIM—Ethical, Adaptive, Learning and Improvement Model—was devised. Using an Action Research (AR) study, EALIM was implemented within a private healthcare firm by working collaboratively with organisational members over a period of eighteen months. The study included gathering qualitative data in three AR cycles: 1) pre-implementation, 2) implementation and 3) post-implementation. The first cycle involved gathering data to form a baseline assessment of the organisation, which was used to provide feedback to top management on areas for improvement. In the second cycle, an action plan was developed with top managers and EALIM’s implementation was examined. In the third cycle, further data were gathered and findings were evaluated against the baseline assessment from the first cycle to identify the overall impact of EALIM on the organisation. Findings indicated that EALIM’s adoption generated a moral perception of the organisation, a learning culture, increased organisational commitment and an improvement in patient self-advocacy and independence. Factors that contributed to these outcomes were top management commitment, employee empowerment, the use of trans-disciplinary groups and practice-based training. However, other findings indicated that poor leadership and staff nurses’ use of managerial control created variability in service quality. These findings suggest that while EALIM can lead to organisational improvement, the commitment of all internal stakeholders is required to achieve sustainable quality patient care.