Introduction: The integration of health (and social) care services has been an objective of policy-makers internationally since the 1970s. Patients and practitioners alike want effective and timely care, without having to sacrifice safety or quality. Yet, how system-wide coordination is enabled for a seamless delivery of services remains unclear. Fragmentation continues in healthcare, widely contributing to miscommunication, and inadequate treatment. Background: ‘Boundary spanning’ interventions purport to bridge silos between professional disciplines and provide links across organisations and sectors. Individual boundary spanners often serve as liaisons and conduits for expert knowledge in large and complex systems. Management literature has examined boundary spanning since 1967, and over the last few decades research in the information technology sector has examined how innovative knowledge moves through boundary spanners between organisations. In the health professions, evidence-based practice has been taught widely, and ways to implement effective teamwork in the hospital has been well studied. Yet relatively little is known about how people and groups who function in boundary spanning positions, particularly in complex healthcare systems, effectively share knowledge and collaborate to improve the quality of care and clinical outcomes. PURPOSE The purpose of this study is to describe how boundary spanning activities function in healthcare settings to provide solutions for linking and improving patient care across professions, organisations and sectors. There are two research questions: (1) Does boundary spanning actively lead to knowledge exchange, and if so, what activities facilitate or impede the sharing of information across boundaries? (2) Does knowledge exchange lead to vertical and horizontal integration and if so, how do boundary spanning activities contribute to, or counteract, improvements in patient care, particularly in the effort to provide more seamless services. Design: A longitudinal nested case study design was used to investigate four multidisciplinary cases working to improve healthcare services. Boundary spanning activities were observed in context for 34 months using ethnographic methods. The setting consisted of an newly formed multi-disciplinary project called the ‘Westpark Initiative’ in inner-city London where local stakeholders sought to design their own interventions to improve the integration of local healthcare services. Four multi-disciplinary groups were formed by interested members of the professional community. Each group focused their efforts to integrate services across different boundaries: (1) the Anxiety & Depression in Black and Minority Ethnic Populations case attempted to link primary care and community-based mental health services, (2) the Diabetes case attempted to link primary care and hospital-based specialist care, (3) the Dementia case attempted to link primary and social care, and (4) the Child & Family Services case attempted to link primary care and care in the community and voluntary sector. Methods: Mixed qualitative methods were used with instruments designed specifically for this study. A longitudinal design was used to identify system-wide barriers and enablers to horizontal and vertical service integration from 2009-2012. Data were collected across a broad system of care including: 42 semi-structured staff interviews, 361 hours of participant observations, 36 online serial diaries, two patient and carer focus groups, and historical document analysis. NVivo 9 was used analyse the data to generate themes from the fieldnotes and recorded interview transcripts. Themes from a boundary spanning literature review, including noted barriers and enablers of vertical and horizontal integration were identified. A management theory that describes knowledge exchange in complex organisations was selected as an additional analytical framework to add further depth to the investigation. Nonaka’s SECI (Socialisation → Externalisation → Combination → Internalisation) model was used to explore how tacit and explicit knowledge were exchanged, how innovative solutions surfaced, and how patient outcomes were defined by each of the cases, and in combined dimensions. The SECI model has never previously been applied to the healthcare setting. Results: Facilitated learning events provided empowering professional socialisation for participants of all four cases, which helped tacit knowledge cross individual, organisational, and sectoral boundaries. Missed opportunities for sharing expertise was observed in all contexts, noting that mentored group meetings, flexible meeting agendas, and appropriate goal setting was crucial to move tacit knowledge across boundaries and surface integrating solutions through combination and dialogue. Socialisation and charismatic leadership was not enough to affect integration. Barriers to exchanging both tacit and explicit knowledge included practice managers functioning as gatekeepers, supervisors’ adaptive style, competing accountability concerns, and political (and financial) imbalances. Explicit knowledge exchange through construction of products and introduction of systemised solutions was noted in the Anxiety & Depression, Diabetes, and Child & Family Services cases, particularly where enabled by external resources (including funding). The Anxiety & Depression case had a well-defined goal (from national guidelines) of increasing referrals to talk therapy, which was measurable, and achieved. The Diabetes case achieved vertical integration with the opening of community-based clinics staffed by Diabetic Specialist Nurses. These two cases also demonstrated movement of explicit knowledge to internalised tacit knowledge, which routinised integrating solutions for more chance of lasting success. Only limited knowledge exchange was accomplished through informational sessions and leaflets by the two remaining cases, as the Dementia and Child & Family Services case struggled to make any lasting links between general practice and secondary care. Scalability was a concern, particularly where redundancies and reorganisations were experienced in the local context, which impeded horizontal integration efforts by these cases. All four cases struggled to define meaningful measures to link their integration goals with patient outcomes, and all experienced top-down pressures to use quantitative national measures, despite being deemed too insensitive to judge impact of integration on patient care. The Anxiety & Depression case had the most ability to embed reflection in their daily practice, more ability to surface innovative local solutions, and the benefit of funding for routinised team-building activities. Persistent mentoring and routine learning sets about embedding data collection in practice was a necessary though time-consuming factor in leading quality improvement efforts, especially by those groups attempting new local methods of integration. Conclusion: Boundary spanning activity can increase opportunities for knowledge exchange, which in turn can lead to integration – but there are important variations in context, which enable the kind of local innovations, which contribute to lasting connections between professions, organisations, and sectors. Knowledge exchange did enable integrating solutions, especially when moving from tacit to explicit, though socialisation was not enough. Horizontal integration was achieved with link workers and frequent outreach to the local population and practitioners. Vertical integration was achieved through political negotiations and repeated accountability-sharing discussions. Locally responsive cross-boundary teams and adaptable management styles appear to play a role in the development of innovative solutions. Systemising problem-solving processes and embedding data collection were also important aspects of integration efforts. / Reflective practices, which included learning about how to embed data collection, appear to play a role in longitudinal success. Future research will need to clarify methods for measuring the impact of boundary spanning activities through a range of tools that describe, examine, and measure the outcomes of multi-disciplinary, multi-level interventions that span complex interfaces in healthcare. There remains a distinct need to further the empiric study of how integration contributes directly to improving patient outcomes and the quality of care – and how to extend this learning to teach future healthcare practitioners to span boundaries, recognise, and implement innovative solutions, and provide truly continuous services in all settings.

Study aims: This study aimed to explore: the interprofessional attitudes of first- and final-year healthcare students, recent graduates, and senior healthcare professionals; the influences upon those attitudes (including participation in interprofessional education (IPE)); how attitudes change over time and between groups; and the factors influencing interprofessional interaction in education and practice settings. Methods and methodology: This study used a mixed methods convergent parallel design. Quantitative data were collected from first- and final-year healthcare students using the Attitudes to Health Professionals Questionnaire. A control group of first-year students who had not participated in the IPL programme was used to determine the effect of participation in the Interprofessional Learning (IPL) programme. Data from first- and final-year students were compared to explore changes in interprofessional attitudes during students’ training. Qualitative data were collected from first- and final-year students using focus groups and from graduates and senior healthcare professionals using individual interviews. These data provided insight into the attitudes of participants to IPE and practice and into factors that influence their attitude towards interprofessional interaction and other professions. Key findings: The interprofessional attitudes of first-year students who participated in the IPL programme are more positive than those of the control group, but this effect does is not sustained with final-year students. Students’ attitudes towards the IPL programme are mixed, but graduates’ views are more positive. The qualitative data showed there are many factors aside from participating in the IPL programme that influence the interprofessional attitudes, and these factors affect the attitudes of all participants. Conclusions: IPE is a viable way of improving students’ interprofessional attitudes. Ensuring that students value IPE and that IPE addresses issues influencing student attitudes should produce graduates who will be better equipped to deal with the necessity of interprofessional working, benefitting patients, and meeting the evolving needs of the health service.

By 2033 the number of elderly people in England and Wales is expected to exceed 16.4 million. The consequent increase in prevalence of chronic illness and demand on the health and social care services are major causes of concern for healthcare practitioners and policy-makers alike. In response, calls for greater service user autonomy, involvement, and self-care all indicate a shift away from existing paternalistic models of care to a model where service users knowledgably and competently manage their own healthcare and wellbeing. To equip healthcare professionals implement these fundamental changes, this thesis aims to capture, analyse, and articulate the process of healthcare service engagement. To investigate how healthcare services can be better designed to support healthcare engagement for service users with complex needs, this thesis conducts an empirical ethnographic study of a UK-based falls prevention service. Mixed methods were used to collect data from a wide range of sources, including twenty semi-structured interviews with healthcare professionals and service users, ninety-two surveys, referral forms, assessments, and healthcare promotional materials. The data were coded, conceptualised, and categorised to produce a grounded theory of healthcare service engagement represented in a specifically designed model. Key findings show that healthcare service engagement in the context of the chronically ill elderly needs to be understood as an interconnected, emergent, nonlinear, and situated process. It recommends that engagement should be supported in a more user-centric and personalised manner, assessing and responding to service users’ engagement needs as they emerge concurrently with the service’s pathway, integrating assessment practices within a wider healthcare context, and simplifying the existing multidisciplinary and multi-phase falls prevention pathway. Resulting from this thesis, healthcare professionals can more accurately, completely, and confidently reflect on the complex process of healthcare service engagement; better equipping the community for challenges it will face in the future.

Singapore hospitals are attempting to adopt a Total Quality Management (TQM) philosophy and a customer orientation strategy to meet customer's demand for higher quality. An earlier study by Yap on Quality Assurance in Singapore hospitals failed to adequately establish the contributions of Quality Assurance in improving customers' satisfaction. Against this background, the central thrust of this exploratory research project involves the identification of: (1) the need for a common definition of quality within a hospital, (2) the principles of TQM and a critique of orthodox TQM implementation models of the Gurus and TQM writers; (3) TQM tools and the applicability of Quality Function Deployment in the development of a total quality model. Information was obtained on the research areas through: (1) extensive review of Quality Management literature; (2) questionnaire surveys investigating the management quality practices in Singapore hospitals, patients and doctors/staff expectations and perceptions of hospital service quality, and the critical success factors for the implementation of the total quality model; (3) structured interviews and focus group sessions investigating the specific management quality activities and service elements adopted by 3 Singapore hospitals; (4) case studies to demonstrate the wide applicability of QFD as an organisational tool in healthcare. The adoption of this Action Research methodology identified that service quality in Singapore hospitals is generally below patients' expectations. These gaps arose from the failure in understanding the voice of the customer, which is itself symptomatic of the need for a holistic TQM model. In the final analysis, this research project, as a major contribution to knowledge in the quality management field, provides the first empirically developed total quality healthcare model using the QFD tool. This represents the first holistic QFD-led total quality model validated by the experiences of 30 focus group members and 2 top level executives of Singapore hospitals. In addition, a framework involving infrastructure and measurement management to implement the proposed model is offered.

The use of workarounds has been mentioned in various healthcare discipline by different approaches. However, there has been limited research thoroughly investigating the workaround phenomena and none provided a comprehensive approach that considered all stakeholders involved. The aim of this thesis is to develop a framework that can be used to enhance the understanding and knowledge of workarounds that occur in hospitals and consequently improve hospital management's ability to manage those workarounds. That is obtained by considering workarounds main elements; nature as a process, factors behind their existences, and their impact so that the level of patient safety and service quality can be improved. In order to understand the workarounds, the above can be investigated as three aspects: the process aspect of workarounds, the factors influencing professionals to use workarounds, and the impact of workarounds. First, workarounds are analysed in terms of the existing and alternative process, roles of users and the number of people involved, and time consumed to complete the process compared to the original formal work process. Data was obtained by an exploratory study conducted by semi-structured interviews at early stage of this research and six workaround cases were collected and mapped using Business Process Modelling Notation (BPMN). The exploratory study conducted, an extensive literature review, lead to the identifications of the factors influencing the use workarounds. Based on the findings a conceptual model, Workaround Motivational Model (WAMM), was formed based on the Theory of Interpersonal Behaviour (TIB) in order to investigate professional' behaviour intentions to use workarounds. A questionnaire has been developed to examine the following factors: attitude, social factors, perceived consequences (personal value), perceived consequences (patient value), perceived behavioural controls, ease of use, usefulness, facilitating conditions, and habits. Exploratory factor analysis was applied to detect the main factors followed by a linear regression analysis to identify the most significant ones. The main factors identified that have a significant influence on professionals' intention to use workaround were: social influence, habit, perceived ease of use, and perceived consequences (patient value). Finally, in order to evaluate the impact of workarounds, a Workaround Assessment Sheet (WA-AS) was developed based on the earlier findings and applied to the workaround cases. The theoretical contribution of this thesis was identifying four different types of workarounds based on their process structure. There are four types: simple workaround, process workaround, compound workaround, and consequential workaround. In addition, the workaround Motivational Model (WAMM) is a statistical model that theories professionals' intention to use workaround in healthcare context. The practical and methodological contribution was a Workaround Conceptual Knowledge Framework (WACKF) that can be applied by quality specialised and decision makers to understand workarounds used in their organisations and consequently be able to manage them. The framework has got three main components. First component is the use of process techniques to analyse workarounds and identify activities, role and number of people involved, and time consumed to complete the process and compare it to the formal work process. Second, the use of the WAMM questionnaire to identify the factors that influence professionals to use workarounds. Third, the use of the Workaround Assessment Sheet (WA-AS) to evaluate the upside and downside from workaround use in the organisation. The framework provides guidelines, underpinned by theory, that enables management level to have a holistic view of workaround in their organisation and then decide whether to adopt this workaround or strongly eliminate it. In Delphi study experts in quality and hospital management were used to assess and confirm that the components of the framework are appropriate and logically lead to better understanding of workarounds. Results of the framework validation by the decision makers also indicated that the WACKF contributes in understanding the workarounds and consequently improve the patient safety and service quality.

The recent Francis Report (2013) emphasised how organisational culture within the NHS represents an important determinant of safe and effective health care systems. Therefore, it is crucial to inquire into the contexts and causes of dysfunctional organizational dynamics within the NHS. A review of the literature was undertaken, focusing on the relationships between professional role ambiguity, role conflict and team culture in community mental health. The review identified that role ambiguity and role conflict have detrimental consequences to services, creating tensions between staff members, adversely impacting on the continuity and appropriateness of workload. The need for further research into the impact on client care is also highlighted by this review. Finally, the review suggests that there is a need for role ambiguity and conflict to be managed more effectively, enabling staff to work within a stable and supportive context. The second part of this thesis comprises a research study using grounded theory methodology to explore the impact of organisational change on staff working within a community mental health team. The study revealed that staff experienced a sense of denigration of professional values and low morale in the face of austerity measures, incessant regulation and industrialising therapy. The analysis identified a number of social defences within the team. The findings of this study suggest increased consideration should be given to the way in which rapid change and restructuring of mental health services dismantle the containing aspects of the organisation. The practical implications include a need for better balance between work structures and systems, and the needs of individuals. The final part of this thesis is a reflective account of the author’s experience of undertaking the research, including reflections on the literature review, methodology and findings, implications of the study and possible areas for future research.

The healthcare sector is promoting the use of process improvement approaches resulting in several successful improvement projects. However, evidence, based on literature, points out that in a significant number of cases, healthcare organisations have failed to sustain the deployment of process improvement tools for long-term continuous improvements. Lean Six Sigma, which incorporates the speed and impact of Lean, with the quality and variation control of Six Sigma, is considered to have a high impact. Nevertheless, to reap the full benefits of LSS, it is necessary to develop a systematic approach to sustain LSS in healthcare organisations. Organisations have been shown to approach change from only three ways: functional, operational and ad hoc, neglecting a holistic or systemic analysis. Hence, the literature has not provided a systemic approach to change and improvement, which also includes the assessment of readiness for change. Therefore the objectives are to carry out an extensive literature review and survey to identify the reasons for organisations failing to sustain Lean Six Sigma. A list of factors critical for successfully sustaining Lean Six Sigma are identified and analysed using the ISM methodology. With the view to support healthcare professionals in integrating Lean Six Sigma in their organisation, this research develops a new framework (SLSS) to shift focus away from short term and towards long-term improvement. Furthermore, using a semi structured interview approach experts validate the framework. The framework will allow professionals to pay more attention on strategically important factors when integrating Lean Six Sigma in their organisation. The major outcome of this research is that the relationship between CSFs is analysed providing a distinctive view on how to handle them. Common approaches have focused on other aspects of research and were content with having identified CSFs, which led to the misconception that all CSFs are equally important. Hence, this research provides a more sophisticated view on this topic. In addition, the SLSS framework was build to fill the gap between implementation-focused and organisational culture focused frameworks. It can be used in conjunction with the organisation's preferred implementation framework in order to guarantee that the strategic component is covered.

Seminal research at the Camegie school sparked studies in the early 1980s by Pfeffer and by Hambrick and Mason. Their development of demography and upper echelon theory promised to explain organizational performance in terms of the demography of top management teams (TMTs), primarily the average length-of-service or tenure of team members. Later research brought in mediating and management processes, and intervening variables as explanations of performance. Building on this research, the present study surveyed TMTs in NHS Trusts, the data collection being conducted in the mid-1990s. At the time, the Trusts were new types of organizations, retreaded from earlier bodies (such as District Health Authorities) but with a remit to replace welfare subventions with enforceable contracts - so that funds came from buyers, and not allocations. A variety of pressures created a turbulent milieu for the Trusts, which were essentially organizations in transition. The research developed a methodology with an interplay of qualitative and quantitative techniques. The latter made use of a proven survey instrument, and developed a replicable framework for analysing and presenting the results - a benchmark for follow-up or longitudinal studies in the same field or across wider applications. The results brought out the importance of management processes, including those promoting coalitions and affective agreement, and those likely to lead to cognitive conflict and enhanced performance. Findings from the research provide a hierarchical profile of the factors influencing Trust and Management performance. The results create a new and substantive method of measuring heterogeneity and homogeneity in TMTs, and they form a basis for distinguishing high from low performers. Hypotheses on homogeneity and heterogeneity of groups, on management and mediating processes, on intervening variables, and on how sensitivities affect performance should enrich understanding of TMTs in organizations that are radically changing, within a rapidly changing environment.

This research examined to what extent and how leadership is related to organisational outcomes in healthcare. Based on the Job Demands-Resource model, a set of hypotheses was developed, which predicted that the effect of leadership on healthcare outcomes would be mediated by job design, employee engagement, work pressure, opportunity for involvement, and work-life balance. The research focused on the National Health Service (NHS) in England, and examined the relationships between senior leadership, first line supervisory leadership and outcomes. Three years of data (2008 – 2010) were gathered from four data sources: the NHS National Staff Survey, the NHS Inpatient Survey, the NHS Electronic Record, and the NHS Information Centre. The data were drawn from 390 healthcare organisations and over 285,000 staff annually for each of the three years. Parallel mediation regressions modelled both cross sectional and longitudinal designs. The findings revealed strong relationships between senior leadership and supervisor support respectively and job design, engagement, opportunity for involvement, and work-life balance, while senior leadership was also associated with work pressure. Except for job design, there were significant relationships between the mediating variables and the outcomes of patient satisfaction, employee job satisfaction, absenteeism, and turnover. Relative importance analysis showed that senior leadership accounted for significantly more variance in relationships with outcomes than supervisor support in the majority of models tested. Results are discussed in relation to theoretical and practical contributions. They suggest that leadership plays a significant role in organisational outcomes in healthcare and that previous research may have underestimated how influential senior leaders may be in relation to these outcomes. Moreover, the research suggests that leaders in healthcare may influence outcomes by the way they manage the work pressure, engagement, opportunity for involvement and work-life balance of those they lead.

This thesis evaluates the extent to which relationship marketing (RM) strategies were prevalent within the former NHS Internal Market and the determinants of such strategies. The research achieves its aims through the analysis of a postal survey of NHS Trust hospitals and District Health Authorities in England and case studies of the Warwickshire and Dudley health markets. The impetus for the research is the paucity of literature evaluating RM in the NHS context, resulting from the predominance of the traditional economics perspective on the purchaser - provider relationship. The latter is unable to systematically evaluate relational behaviour within quasi - markets given its adversarial contracting focus. Subsequently, the Relationship Marketing Paradigm is used to design a framework appropriate to evaluating relational oriented behaviour within the NHS Internal Market. To further investigate the determinants of NHS Trust hospital's RM strategies a series of hypotheses were developed and tested using Logit modelling techniques. These hypotheses sought to explain contract augmentation, contract customisation, loyalty discounting, default contracting and the use of cost - sharing contracts. In addition the case studies further examined the role of 'trust' within the purchaser - provider relationship through evaluation of contractual, competence and goodwill trust typologies. Equally, the case studies investigated the negative impact of RM strategies from the perspective of purchasers, providers and service users. The key conclusion is that RM was significantly more widespread than the literature suggests, indicating the centrality of relational oriented contracting. Furthermore, the nature of and determinants of the identified relationship marketing strategies were found to be mature and complex. Moreover, this weight of evidence questions Government policy's success in generating a competitive environment within the NHS Internal Market based upon adversarial contracting. To explore the likelihood of RM remaining an important phenomenon within the "new" NHS arrangements, evidence is drawn from the case studies and predictions from the Logit analysis.