The purpose of this research study is to examine the Implementation of quality management systems in Iranian hospitals with particular emphasis on the role of top management commitment and leadership on quality management (QM) in service organizations. Taking both private and public Iranian hospitals as cases, a conceptual framework based on the theoretical dimensions and the findings is proposed. This study explores how contextual factors influence the implementation of Quality Management (QM) practices. It contributes to the contingency theory of quality management effectiveness. The analysis empirically examines the internal fit between QM and organizational structure, organizational culture and top management commitment as well as its external fit with environmental uncertainty. How these factors affect the implementation of quality management is also considered. Data were gathered from four hospitals from semi-structured interviews with hospital leaders, hospital managers and other staff who dealt with the implementation of quality management, fundamentally through semi-structured interviews. This was supplemented by document analysis. This research study demonstrates both internal fit and external fit affect implementation of quality management; however, top management commitment has a significant role in quality management implementation. Additionally, the findings offer insights for managers to customize quality management programs to achieve optimal performance benefits. This thesis makes an original contribution to the literature in integrating a contingency approach to quality management with an emphasis on distributed leadership as an approach to facilitating effective quality management in a hospital context.

One of the key challenges for a modern day health care provider is to dispense high quality of medical care while limiting or even reducing the health care expenditures. This research work endeavours to meet this challenge through effective management of hospitals logistics systems. The aim of this research work is to provide a structured mechanism for modelling and analysing health care logistics to be able to understand its dynamic behaviour and effectively manage its logistical activities on the basis of the model. In order to achieve the research objectives, this research uses system dynamics as the main medium of analysis, and in particular, employs an integrated system dynamics framework which has been used previously for manufacturing industry supply chain designs and tests the feasibility of the framework for analysing and modelling health care logistics. This is ascertained by developing and incorporating a decision making metrics in the system dynamics model based on item criticality, usage, and value to optimise overall logistics costs. System Dynamics methodology is employed at first to develop a model for existing inventory control decisions, and subsequently to produce two alternative approaches based on traditional (R, s, S) inventory control approach and Continuous Replenishment Inventory and Order Based Production Control CR(IOBPCS) approach. These approaches are tested for two case hospitals, namely: Children's National Medical Center (CNMC) USA, and Derbyshire Royal Infirmary (DRI) UK. The dynamic analysis for each case revealed problems in terms of multistage inventories and order batching, which could lead to demand amplification causing a detrimental effect on the inventory management throughout the supply chain. Accordingly, the simulations results produced for the two cases are benchmarked using alternative strategies in terms of lower inventory cost, and robustness to meet the unpredictable demand arising from a large number of items. Overall, this research work has enhanced the understanding of hospitals logistics systems by building qualitative and quantitative models. More specifically, this research work has illustrated the applicability of the integrated system dynamics framework in analysing and modelling hospitals logistics systems and inventory control decisions. One particular contribution of this study is introducing inventory classification based on the criticality of items for patient needs which is more suited for health care situations rather purely cost based policies prevalent in other manufacturing and service chains. Therefore, this work has rigorously tested a multi-criteria based inventory classification method that takes into account the criticality of use, cost, and usage value of items for optimising overall inventory cost while maintaining the required patient care/service level. Future studies may be conducted to further evaluate the trade-offs in between different logistics decision making (such as, inventory control, service level, purchasing, transportation and warehousing) in order to design a set of "best practice" simulation models to optimise the overall dynamic behaviour for health care supply chains.

Annual NHS clinical negligence expenditure is rising every year. The overarching NHS clinical governance strategy aims at a reduction in adverse incidents in the health service. However, adverse incidents in the health service continue to rise and in NHS hospitals these account for 10% of admissions (in excess of 850,000 per year) and cost an estimated £2 billion in additional hospital stays alone. This thesis investigates software methods that could reduce the frequency of adverse incidents in hospitals, using available best practices. The objective is to reduce the number of incidents in hospitals by helping the NHS staff gain a deep understanding of risk management with minimal distraction from their daily duties. The solution is an e-learning tool which combines web based e-learning and database management functionality. It provides the users with risk management educational material and appropriate database tools in order to be able to build up a risk action plans database based on their job experience and those educational materials. The software application has been developed based on a development methodology and a customized software development life cycle model. The research addressed the complexity and multidimensional nature of the risk management e-learning development approach in the health care environment. Throughout the research a deeper understanding of variety of concepts and aspects in different fields has been gained and the appropriate educational platform and pedagogy for the system has been identified.

In collaboration with the Training and Education Unit of the Hong Kong Hospital Authority, an evaluation study on the effectiveness of the patient-centered communication skills (PCCS) program was carried out for 106 residents in the out-patient clinics of the New Territories East Cluster Region from May 2001 to March 2002. A training evaluation framework was formulated to measure residents' reaction, learning and behavior. An attempt was also made to relate the results of the program to organizational improvement, Le. improvement in patient satisfaction. A number of evaluation tools were used, such as an end-of-program evaluation questionnaire, pre-program and post-program behavioral assessment questionnaires and complaints digests. Focus group interviews with residents were also arranged to solicit in-depth information on the effectiveness of the PCCS program. Encouraging results were recorded from different levels of evaluation. The residents were satisfied with the PCCS program with respect to program objectives, contents, materials, methodology and learning environment. Particularly, they were satisfied with the trainers who were perceived to have played an important role in sharing their hands-on experience in interacting with patients. As for the learning of residents, the pre-/post-learning quiz results demonstrated that the program had increased residents' knowledge and skills relating to patient-centered communication. Despite a number of identified barriers for the transfer of learning, the behavior of the residents was felt to have improved after training, as confirmed by the results of the pre-/post-behavior assessments by the residents and their supervisors. The program also had some significant impact on patient satisfaction as reflected from the complaints and appreciation digests. Patients had shown positive response to the doctors' communication skills during the consultation process. A number of valuable recommendations on program contents, implementation strategies and reinforcement activities were put forward to the Hospital Authority's management for consideration. Key words Patient-centered communication, Evaluation, Reaction, Learning, Behavior, Organizational Results.

A combination of methods was used in the development of the discharge intervention for patients on medical wards, these included: (1) Patient interviews and professional focus groups which explored barriers to a successful discharge; (2) A systematic review of comprehensive discharge protocols examined the effects of standardising discharge practices; (3) Reviews of patient education methods informed the intervention's components; (4) Patient and professional surveys explored perspectives, perceptions of information needs and current practices which influenced the intervention's content and design. A pilot study tested the usability and acceptability of an educational intervention in hospital and the community. The facilitated intervention (computer presentation and booklet) was designed to give patients confidence to participate and ask questions about their discharge. Patient outcome measures included knowledge, SF36, a validated patient diary and self-efficacy questionnaire. Barriers to a successful discharge included lack of knowledge, poor communication and co-ordination of discharge and no clear definition of professionals' roles. The systematic review of discharge planning protocols showed no significant improvements in patient outcomes. Patient and professional questionnaires highlighted a lack of written information and patients identified the need for specific information, with greater importance placed on information post-discharge. The patient education intervention was piloted with 50 patients, 48 understood their diagnosis and 46 could explain their medication. Significant differences were found in the SF36 (pain, social functioning and activities) and the self-efficacy questionnaire (between discharge and one month post discharge). Patients found the intervention usable and reported increased confidence to ask questions. A definitive randomised controlled trial is required to establish the effect of the education package on patient outcomes.

This thesis considers how policy ‘works’ as an instrument of governance. I report an ethnographic study of health care policy in the contested field of hospital planning. In this study I explored how a controversial policy to centralise hospital services was presented in national policy documents and implemented in one locality in England. I identified a shift in the framing of the policy, from one that presented centralisation as a means of improving access and making services more responsive to patients, to one of clinical necessity. In the new framing plans to close hospital services were presented as clinical decisions that were based on the evidence and necessary to ensure safety. I have interpreted this framing as a rhetorical strategy deployed at both national and local levels with the aim of realising change in the face of community resistance to closing local hospitals and a concomitant policy rhetoric emphasising the need to involve the public in decisions about how services are provided. Although the persuasive power of the framing was limited, a more insidious form of power was identified in the way the framing disguised the political nature of the issue by defining it as a clinical problem. The framing had the effect of restricting the extent to which alternative courses of action could be considered, and undermined public participation in decisions about the delivery and organisation of services. My thesis is that, beyond the often quite obvious use of rhetoric, power operates in policy practices in ways that are often difficult to see. Central to these processes are medical knowledge and expertise which serve to frame the debate, shaping how the problem is understood, which solutions are considered (and which are not) and who is included in decision making. To the extent that health services research is orientated to problems as defined by policy makers and service managers, and in our adoption of the scientific paradigm, we are implicated in these processes. The knowledge and analytic techniques of health services research constitute an indirect control technology, shaping how an issue is understood, creating subjectivities and assigning authority, constructing versions of health care, and influencing the practice of health care professionals. I conclude by proposing a reorientation from ‘science’ to ‘scholarship’. Unlike the scientific paradigm which abstracts policy issues from their social and cultural context, scholarship assumes that policy issues can only be understood in their relational settings. Scholarship supports public deliberation of policy issues and is of practical benefit to decision-makers, opening up policy options and illuminating the different perspectives on policy issues and thereby contributing to more creative, more acceptable, and more effective policies.

The current study aims to explore the explanations and favoured management approaches of High Secure Hospital staff, concerning aggressive behaviour by patients. It sets out to establish whether staff's attributions and preferred approaches vary according to whether the patient is male or female, and the target a member of staff or another patient. More specifically, it attempts to explore a bias often mentioned in criminological studies; that men who offend are seen as bad, whilst women are viewed as being mad. A secondary aim was to establish whether relationships between the attributions, preferred management approaches and attitudes to High Secure Hospital patients exist for staff who work in this setting. The 118 participants in this research completed a questionnaire (consisting of a number of statements with Likert scales) in response to a hypothetical vignette. Participants were allocated to one of eight conditions on the basis of the gender of the vignette figure, the target of aggression, and the participants' gender. The sample consisted of 63 men and 55 women. Analyses of variance indicated that staff viewed internal enduring attributions as important in explaining the behaviour, but that a wide range of explanations were considered to be important. However, there were few differences perceived according to gender of the vignette figure. Whilst the male vignette figure was not seen as bad, nor the female counterpart as more mad, there were some differences in attributions of blame, responsibility and controllability according to the staff gender, patient gender and target of aggression. Some relationships were found between attributions, management strategies and attitudes to patients. The study provides evidence that some differences in attributions occur according to the target, patient's and staff's gender, and also as a result of the hospital context. The findings are discussed in relation to past research, the double deviance and mitigation hypotheses, and theoretical models of attributions and helping behaviour.

Facilities Management (FM) is commonly defined as managing physical workplace and property, which have a direct link with design and construction activities in one aspect, and managing services and performance of resources in the organisation as another. Aspects of FM are inter-related and share information from project brief until the design life of the building. Information plays a major role in integrating FM stakeholders. This thesis highlights the importance of strategic IT in facilitating the implementation of strategic FM in the health sector. In the health sector FM department must be innovative in utilising IT technology to deliver value-for-money services. The current uptake of IT in the Facilities Directorate (NHS Trusts) is at an operational level, while the strategic FM demands the implementation of strategic IT in FM. The gap between the current operational IT and the need for it to be considered strategically has made this research important. Facilities Directorate should be ready to implement changes in managing its information systems to meet client's demand. The effective use of information for the maintenance and operation of hospitals, hospital development, benchmarking, performance measurement, managing finance and human resources, requires strategic information systems (IS). This thesis introduces a Strategic System Planning framework for FM (SSPfFM) in the health sector to capture the strategic information on FM that facilitates the implementation of strategic FM. Case study research methodology was adopted in support of this research. SSPfFM is derived from a pilot study conducted at Central Manchester and Manchester Children's University Hospitals (CMMC), NHS Trust. It is further validated with other three case studies and by survey questionnaire. This research has identified; gain top management commitment, align Information System development with FM business needs, establish technology path and policies on IT in FM, and forecast Information System requirements in FM as the main components of SSPfFM that focuses on short, medium and long-term strategies of FM in the health sector.

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