The health industry in Canada, as well as in other industrial countries, has been in the process of reform for many years. While such reform has been attributed to fiscal necessity due to increased health costs, the underlying causes are far more complex. Demographic changes, new technologies, expanded health care procedures and medications, increased demand and the globalization of health services have all contributed to the change and complexity of the industry. Health reform varies from country to country. In Canada, with a publicly funded health industry, the main reform method has been regionalization. This decentralized reform method arranges health services under a regional corporate management structure. The primary objective of this study was to assess the effects of health reform on the educational development of health-care managers in British Columbia, a western province of Canada. The study had a two-fold approach; to ascertain how health reform had changed the skill needs of health-care managers, and whether e-learning could benefit health management education. The key research questions that guided the study were: How might recent changes in the health industry have affected the learning needs and priorities of health-care managers? What factors might hinder attempts to meet any learning needs and priorities of health-care managers? and What benefits might e-learning provide in overcoming hindrances to effective health management education? / A combination of quantitative (survey closed questions) and qualitative (survey open-ended questions, interviews and stakeholder feedback) methods was employed in this study. Overall, this study is described as productive social theory research, in that it addressed a recognized change in learning needs for health-care managers following a period of health reform, a socially significant phenomenon in the health industry. Relying on such tools as a survey, interviews, and stakeholder discussions, data was collected from over five hundred health-care managers. The data collected in this study provided valuable insight into the paradigm shift occurring in the educational needs of these managers. The study found that health reform had expanded the management responsibilities of healthcare managers and increased the complexity of service delivery. Restructuring of the health industry decreased the number of managers, support systems, and career opportunities for managers and increased the manager’s workload, communication problems and the need for new knowledge and skills. In addressing the learning needs of health-care managers, the study found there were limitations in health management educational opportunities available to health-care managers. The findings also show that current health management education was focused on senior managers leaving the majority of industry leaders with limited learning opportunities to upgrade their knowledge and skills at a time of great organizational change. / In addition, a classroom format dominated the learning delivery options for many managers. A list of fourteen management skills was used in the survey instrument to ascertain what new skills were needed by health-care managers following thirteen years of health reform. The findings show that of the fourteen skills, twenty-nine percent of health-care managers had no training and fifty-seven percent received their training through in-service, workshops and seminars. Irrespective of gender, age, working location and education the data showed that healthcare managers were mainly receiving training in change and complexity and people skills with less training occurring in planning and finances. Using the same fourteen skills, health-care managers priorized their immediate learning needs, listing the top three, as: evidence-based management, change and complexity and financial analysis. While evidence-based management and financial analysis could be attributed to the introduction of a corporate management structure in the health industry, change and complexity was an anomaly as managers were already receiving training in this skill. Health industry stakeholders believed this anomaly was due to continued uncertainties with ongoing health reform and/or a need for increased social interaction during a time of organizational change. In addressing the many learning needs of health-care managers a new health management education strategy was proposed for the province which included the need for an e-learning strategy. / The e-learning approach being proposed in this study is an integration of skill training and knowledge sharing directly blended into the workflow of the managers, using a variety of learning technologies. To support this idea, the study found that the majority of health-care managers were not only familiar with e-learning, they also felt they had the computer and Internet skills for more learning delivered in this manner. While a strong need for face-to-face learning still remained, a blended e-learning strategy was proposed for skill training, one that would accommodate the learning needs of managers in rural and remote areas of the province. Knowledge sharing technologies were also proposed to improve the flow of information and learning in small units to both newcomers and experts in the industry. Since this would be a new strategy for the province, attention to quality and costs were identified as essential in the planning. The study found that after years of health reform a new health management educational strategy was needed for the health industry of British Columbia, one that would incorporate a number of learning technologies. Such a change in educational direction is needed if the health industry wishes to provide their leaders with a responsive learning environment to adapt to ongoing organizational change.

This research investigates the relevance of professional subcultures in a climate of change at a large hospital in South-Western Sydney and addresses the question : 'How do changes associated with health reform impact upon cultural interdependence between professional identities?'. As a corollary, cultural interdependence between professional identities may have profound consequences for health reform and for hospital management. By exploring the two main ideas, Professional Sub-group culture and change, this research draws from existing theory in areas such as organisational culture and cultural change, professional identities and health reform. The thesis addresses three anthropological perspectives of cultural change. It addresses the integration perspective as a homogenous unity by analysing the organisation-wide key ideas (or myths) that make action possible, often espoused by senior management. It addresses the fragmentation perspective as a gathering of transient concerns, by acknowledging the ambiguity and anxiety associated with a state of constant flux. It analyses the differentiation perspective as a collection of subcultures and its commonalities and differences. The change discussed in the thesis was not of an archetypal nature. There was no transformation of the organisational business model at government level. However, at lower levels, actors in the organisation experienced jolts through decreed change from a small district level hospital to a large tertiary level trauma centre. This research re-evaluates the theory on professional identity by establishing to what extent environmental changes and organisational changes impact upon professional identity from three cultural perspectives. This research does this by first assessing the health care organisation for existence of occupational subcultures through survey. The research continues by investigating the relationships between occupational groups through focus group discussion and in-depth interviews. Participant observation is used to illustrate and reflect commonality and diversity. This combination of methods facilitates the analysis of change and professional identity / Doctor of Philosophy (PhD)

Health care reform in Latin America has been a continuous process over recent decades, and several countries have implemented programs of universal care. This dissertation looks at the implementation of universal care programs in Brazil and Mexico, and highlights the politics of implementing these reforms. In the first paper, I evaluate the implementation of infrastructural reforms as part of Seguro Popular in Mexico. I conclude that the reforms were partially successful, but that success varied considerably by region. In the second paper, I show that spending on health care in Brazil is strongly related to political partisanship, and that the reform process has not significantly changed this relationship. In the third paper, I suggest that individual characteristics, and not political variables, best explain variations in the quality of care patients receive in Brazil. As a whole, these papers serve to highlight the understudied role of politics in the implementation of health care reform. / Government

The Austrian mental health care system has been characterized by reform initiatives since the 1970s. The reform strategies can be summarized under the term 'community mental health care'. The thesis focuses on an analysis of the reform (context) and the related challenges for mental health care financing with respect to its interdependencies with service provision in the process of change. In a qualitative research process, firstly, reform documents and transcripts of qualitative interviews have been analyzed via a discourse-analytical approach. Secondly, secondary data on mental health care financing in Austria and in western European countries have been collected. An analytical framework was, finally, applied to analyze the interrelations between mental health care financing and reform discourse with respect to its impact on the micro-level and on the macro-level of the mental health care system. The results show that the reform discourse reflects broader welfare state transformation processes. Yet, financing issues have hardly been addressed in reform discussions. Nevertheless, discursive elements are either explicitly or implicitly associated with financing issues or are even linked to specific financing models. A central impact from the restructuring processes on the micro-level is an increasing (financial) responsibility for people who are affected by a mental disorder and/or their relatives. On the macro-level, the processes of change are related to decreasing (financial) responsibility for the sector 'state' while responsibility for the sectors 'family' and 'voluntary/community' is rising. The international development shows similar characteristics. The thesis finishes with some recommendations for developing an alternative financing model and provides a guideline for a comprehensive discussion of alternative mental health care financing approaches. (author´s abstract)

Proponents of Canadian health reform in the 1990s argued for regional structures, which enables budget silos to be broken down and integrated budgets to be formed. Although regionalization has been justified on the basis of its potential to increase home care resources, political science draws upon the scope of conflict theory, which instead suggests marginalized actors, such as home care, may be at risk of being cannibalized in order to safeguard the interests of more powerful actors, such as hospitals. Prince Edward Island, Nova Scotia, and New Brunswick, constitute a natural policy experiment. Each has made different decisions about the regionalization model implemented to restructure health care delivery. The policy question underpinning this research is: What are the implications of the different regional models chosen on the allocation of resources to home care? Provincial governments are at liberty to fund home care within the limits of their fiscal capacity and there are no federal terms and conditions which must be complied with. This policy analysis used a case comparison research design with mixed methods to collect quantitative and qualitative data. Two financial outcomes were measured: 1) per capita provincial government home care expenditures and 2) the home care share of provincial government health expenditures. Hospital data was used as a comparator. Qualitative data collected from face-to-face, semi-structured interviews with regional elite key informants supplemented the expenditure data. The findings align with the scope of conflict theory. The trade-off between central control and local autonomy has implications for these findings: 1) home care in Prince Edward Island increased it share from 1.6% to 2.2% of provincial government health spending; 2) maintaining central control over home care in Nova Scotia resulted in an increase in its share from 1.4% to 5.4%, and 3) in New Brunswick, home care share grew from 4.1% to 7.6%. Inertia and entrenchment of spending patterns was strong. Health regions did not appear to undertake resource reallocation to any great extent in either Prince Edward Island or New Brunswick. Resource reallocation did occur in Nova Scotia where the hospital share of government spending went down and was reallocated to home care and nursing homes. But, Nova Scotia is the only province of the three in which home care was not regionalized. Regional interests in maintaining existing levels of in-patient hospital beds was clearly a source of tension between the overarching policy goals formulated for health reform by the provincial governments and the local health regions.

Purpose - The thesis determined how policy implementation and change management can be improved in Nigeria, with the health insurance scheme as the basis for narrative exploration. It sets out the similarities and differences in assumptions between supra-national organisations such as the World Bank and World Health Organisation on policy implementation and change management and those contained in the Nigerian national health policy; and those of people responsible for implementation in Nigerian organisations at a) the federal or national level and b) at sub-federal service delivery levels of the health insurance scheme. The study provides a framework of the dimensions that should be considered in policy implementation and change management in Nigeria, the nature of structural and infrastructural problems and wider societal context, and the ways in which conceptions of organisations and the variables that impact on organisations¿ capability to engage in policy implementation and change management differ from those in the West. Design/methodology/approach - A qualitative approach in the form of a case study was used to track the transformation of a policy into practice through examining the assumptions and expectations about policy implementation of the organisations financing the policy's implementation through an examination of relevant documents concerning policy, strategy and guidelines on change management and policy implementation from these global organisations, and the Nigerian national health policy document. The next stages of field visits explored the assumptions, expectations and experiences of a) policy makers, government officials, senior managers and civil servants responsible for implementing policy in federal-level agencies through an interview programme and observations; and b) those of sub-federal or local-level managers responsible for service-level policy implementation of the health insurance scheme through an interview programme. Findings - There are conflicts between the rational linear approaches to change management and policy implementation advocated by supra-nationals, which argue that these processes can be controlled and managed by the rational autonomous individual, and the narratives of those who have personal experience of the quest for 'health for all'. The national health policy document mirrors the ideology of the global organisations that emphasise reform, efficiencies and private enterprise. However, the assumptions of these global organisations have little relevance to a Nigerian societal and organisational context, as experienced by the senior officials and managers interviewed. The very nature of organisations is called into question in a Nigerian context, and the problems of structure and infrastructure and ethnic and religious divisions in society seep into organisations, influencing how organisation is enacted. Understandings of the purpose and function of leadership and the workforce are also brought into question. Additionally, there are religion-based barriers to policy implementation, change management and organisational life which are rarely experienced in the West. Furthermore, in the absence of future re-orientation, the concept of strategy and vision seems redundant, as is the rationale for a health insurance scheme for the majority of the population. The absence of vision and credible information further hinder attempts to make decisions or to define the basis for determining results. Practical implications - The study calls for a revised approach to engaging with Nigerian organisations and an understanding of what specific terms mean in that context. For instance, the definitions and understanding of organisations and capacity are different from those used in the West and, as such, bring into question the relevance and applicability of Western-derived models or approaches to policy implementation and change management. A framework with four dimensions - societal context, external influences, seven organisational variables and infrastructural/structural problems - was devised to capture the particular ambiguities and complexities of Nigerian organisations involved in policy implementation and change management. Originality/value - This study combines concepts in management studies with those in policy studies, with the use of narrative approaches to the understanding of policy implementation and change management in a Nigerian setting. Elements of culture, religion and ethical values are introduced to further the understanding of policy making and implementation in non-Western contexts.

No description available.

Accountable care organizations (ACOs) are a new health care reform initiative that has been highlighted as one of the most important organizational structures that could lead to quality improvements and cost savings in the United States through shared savings. The inability of health care managers to successfully implement ACOs could result in financial losses, reduced patient access to health care, and poor patient outcomes. Grounded by von Bertanlaffy's general systems theory, the purpose of this multiple case study was to explore the system change strategies health care managers used to implement an ACO to meet ACO quality and cost standards. Health care managers from Arizona, New York, and Wisconsin who successfully implemented ACO system change strategies in their organizations comprised the population for this study. Data were collected through face-to-face semistructured interviews with 9 health care managers. Data were analyzed using methodological triangulation, thematic analysis, and Yin's 5 analytic techniques to identify patterns and themes. Three main themes resulted from the data analysis and included leaders with system change strategies improved successful ACO implementation, leaders who implemented health information technology improved successful ACO implementation, and leaders with care management system change strategies improved successful ACO implementation. The application of the findings from this study may contribute to positive social change because health care managers may use these system change strategies to successfully implement ACOs to improve patient care and access and reduce the financial burden of health care costs throughout the United States.

acase@tulane.edu

Purpose: The thesis determined how policy implementation and change management can be improved in Nigeria, with the health insurance scheme as the basis for narrative exploration. It sets out the similarities and differences in assumptions between supra-national organisations such as the World Bank and World Health Organisation on policy implementation and change management and those contained in the Nigerian national health policy; and those of people responsible for implementation in Nigerian organisations at a) the federal or national level and b) at sub-federal service delivery levels of the health insurance scheme. The study provides a framework of the dimensions that should be considered in policy implementation and change management in Nigeria, the nature of structural and infrastructural problems and wider societal context, and the ways in which conceptions of organisations and the variables that impact on organisations' capability to engage in policy implementation and change management differ from those in the West. Design/methodology/approach - A qualitative approach in the form of a case study was used to track the transformation of a policy into practice through examining the assumptions and expectations about policy implementation of the organisations financing the policy's implementation through an examination of relevant documents concerning policy, strategy and guidelines on change management and policy implementation from these global organisations, and the Nigerian national health policy document. The next stages of field visits explored the assumptions, expectations and experiences of a) policy makers, government officials, senior managers and civil servants responsible for implementing policy in federal-level agencies through an interview programme and observations; and b) those of sub-federal or local-level managers responsible for service-level policy implementation of the health insurance scheme through an interview programme. Findings - There are conflicts between the rational linear approaches to change management and policy implementation advocated by supra-nationals, which argue that these processes can be controlled and managed by the rational autonomous individual, and the narratives of those who have personal experience of the quest for 'health for all'. The national health policy document mirrors the ideology of the global organisations that emphasise reform, efficiencies and private enterprise. However, the assumptions of these global organisations have little relevance to a Nigerian societal and organisational context, as experienced by the senior officials and managers interviewed. The very nature of organisations is called into question in a Nigerian context, and the problems of structure and infrastructure and ethnic and religious divisions in society seep into organisations, influencing how organisation is enacted. Understandings of the purpose and function of leadership and the workforce are also brought into question. Additionally, there are religion-based barriers to policy implementation, change management and organisational life which are rarely experienced in the West. Furthermore, in the absence of future re-orientation, the concept of strategy and vision seems redundant, as is the rationale for a health insurance scheme for the majority of the population. The absence of vision and credible information further hinder attempts to make decisions or to define the basis for determining results. Practical implications: The study calls for a revised approach to engaging with Nigerian organisations and an understanding of what specific terms mean in that context. For instance, the definitions and understanding of organisations and capacity are different from those used in the West and, as such, bring into question the relevance and applicability of Western-derived models or approaches to policy implementation and change management. A framework with four dimensions - societal context, external influences, seven organisational variables and infrastructural/structural problems - was devised to capture the particular ambiguities and complexities of Nigerian organisations involved in policy implementation and change management. Originality/value: This study combines concepts in management studies with those in policy studies, with the use of narrative approaches to the understanding of policy implementation and change management in a Nigerian setting. Elements of culture, religion and ethical values are introduced to further the understanding of policy making and implementation in non-Western contexts.