Hospitals worldwide are under pressure to perform and models abound to remedy poor performance. Reform, however, is contested, uneven and slow. One reason is that few models address a core issue in reform: the management of clinical work. A further reason is that stakeholder groups, specifically policymakers, managers and clinicians, limit opportunities for collaborative problem solving as they seek to impose their own frame of reference in the struggle for control. I hypothesise that performance will be relatively better in hospitals that have in place strategies of agreement to set the objectives of reform, such as participative problem identification, problem solving and decision making, together with a method to manage clinical work. This hypothesis was tested in twelve public hospitals in three Australian states between 1999 and 2001 using both quantitative and qualitative research methods. Government and hospital policy documents were assessed and semi-structured interviews were conducted to gauge the attitudes and practices of managers and clinicians regarding health care reform. The results of the research show that hospitals with inclusive strategies for change, principally strategies of agreement, joint education and skills development, team-based incentives to direct and reward effort and a method of clinical work management, performed better than those without. Findings indicate that policy was developed and communicated as a rational top-down process that tended to exclude diverse views. Although the effect of different jurisdictional policy processes on hospital performance was not clear, they had considerable impact on the environment of reform. Cost containment and patient safety dominated as policy objectives. These alone did not engage clinician interest or address service quality. The connection between the quality of care and its cost did not appear to be understood. Organisational structures and processes necessary to support reform, that is communication forums for objective setting and performance review, integrated clinical and corporate accountability systems and organisational capacity building were not in place in the majority of hospitals studied. An organisational model of clinical work management was developed to improve cost-effectiveness by balancing clinical autonomy and clinical accountability based on the research results.

Internationally, health systems have been undergoing an extended period of endemic change, where one effort at health system reform inevitably seems to lead to further attempts to make adjustments, re-direct the focus of the reform effort, or bring about further, sometimes very different changes. This phenomenon is described as churning in this thesis. Churning is a result of continual efforts to adjust and �improve� health systems to address intractable �wicked� problems, often through applying solutions based on neo-liberal reform agendas that have influenced public sector reform in developed countries since the early 1980s. Consistent with this, the South Australian health system has been caught up in a cycle of change and restructuring for almost thirty years. This qualitative study explores a case study of unsuccessful organisational change initiated by a group of health care agencies in the southern metropolitan area of Adelaide, South Australia, which took place between 1996 and 2001. The agencies sought to develop and establish a regional health service through a process they called �Designing Better Health Care in the South� which aimed to improve the way that services were provided in the area, and to enable the agencies to manage the increasing budgetary and workload pressures that they were all experiencing. A significant policy shift at the state government level meant that this initiative was no longer supported by the central bureaucracy and could not proceed. The agencies reverted from a focus on regional planning and service delivery to an institutional focus. The changes that are described within the scope of the case study are universally recognisable, including centralisation, decentralisation, managerialism and integration. The experience of Designing Better Health Care in the South as an unsuccessful attempt to implement change that was overtaken by other changes is also a universal phenomenon within health systems. This study locates the case study within its historical and policy contexts. It then analyses the key themes that emerge from consideration of the case study in order to understand the reasons for constant change, and the structural and systemic impediments to successful reform within the South Australian health system as an example of health systems in developed countries. As a case study of organisational change, Designing Better Health Care in the South was a story of frustration and disappointment, rather than of successful change. The case study of Designing Better Health Care in the South demonstrates the tensions between the differing priorities of central bureaucracy and health care agencies, and the pendulum swing between the aims of centralisation and regionalisation. The study uses the theory of negotiated order to understand the roles of the key themes of trust, partnership and collaboration, and power and control within the health system, and to consider how these themes affect the potential for the successful implementation of health care reform. Through analysis of the case study, this thesis contributes to an understanding of the difficulties of achieving effective reform within health systems in advanced economies, such as the South Australian health system, because of the complex power and trust relations that contribute to the functioning of the health system as a negotiated order. The study is multidisciplinary and qualitative, incorporating a number of social science disciplines including sociology, political science, historical analysis and organisational theory. Data collection methods for the study included interviews, focus groups, document analysis and a survey.

Purpose. To explore the experiences of healthcare managers at a reformed CSSS (Centres de sante et de services sociaux) in Montreal, Quebec and to document the provincial reforms. The objective is to understand the managers' experiences during a period of transition. / Method. This study consists of two methods: a document review of relevant policies and reforms of Quebec's health and social services. Secondly, qualitative interview methods were used to explore the experiences of seven managers within a CSSS and their attitudes towards the reform. / Results. Managers described the following: a new window of opportunity, importance of leadership in the reform process, distorted communication, environment of trust, and culture of the organisation. / Conclusion. Quebec's health and social services is an ongoing discourse. Distorted communication creates an atmosphere of uncertainty which hinders the reform process. Implications include the need for further research in understanding healthcare professionals and other actors in the reform process.

Thesis (Ph. D.)--University of New South Wales, 2002. / Also available online.

Senior Honors thesis--Regis University, Denver, Colo., 2009. / Title from PDF title page (viewed on May 11, 2009). Includes bibliographical references.

Thesis (Ph. D.)--State University of New York at Binghamton, Department of Sociology, 2008. / Includes bibliographical references.

Thesis (Ph. D.)--Florida State University, 2005. / Advisor: Dr. William D. Berry, Florida State University, College of Social Sciences, Dept. of Political Science. Title and description from dissertation home page (viewed June 9, 2005). Document formatted into pages; contains x, 198 pages. Includes bibliographical references.

Thesis (M.N.)--Memorial University of Newfoundland, 2002. / Bibliography: leaves 180-188.

Thesis (Ph. D.)--University of Missouri-Columbia, 1998. / Typescript. Vita. Includes bibliographical references (leaves 438-446). Also available on the Internet.

Thesis (Ph. D.)--University of Missouri-Columbia, 1998. / Typescript. Vita. Includes bibliographical references (leaves 438-446). Also available on the Internet.