The purpose of this dissertation is to examine the organizational and environmental correlates of hospital EMR use and to examine the relationship between hospital EMR use and performance. Using a theoretical framework that combines resource dependence theory with Donabedian's structure, process, outcome model, a conceptual model is created. To test the hypotheses of this model, logistic regression and Data Envelopment Analysis (DEA) are used. The data included in this analysis come from the AHA, HIMSS, CMS, ARF, and HQA. In the analysis of hospitals correlates of EMR use, three hypotheses were supported, and one was partially supported. Hospital system affiliation, bed size, and environmental uncertainty were found to be positively associated with hospital EMR use. Hospital rurality was found to be associated with EMR use for all categories except one; at every other level of rurality, as the hospital moves on a continuum from least rural to most urban, the likelihood of hospital EMR use also increases. Hospital EMR use was not found to be associated with teaching status, environmental munificence, competition, operating margin, ownership, or public payer mix. In the hospital performance analyses, one hypothesis was supported, and one was partially supported. Regarding quality, hospitals with EMRs were found to provide higher quality than those without EMRs. In efficiency performance, only small hospitals with EMRs were found to be more efficient than hospitals without EMRs. No support was found that hospitals with EMRs improve their efficiency over time more than hospitals without EMRs. Hospital EMR use does vary by certain organizational and environmental characteristics. For this reason, hospitals and policy makers must take action that enables and encourages all hospitals to implement and use EMRs because some hospitals do not have the motivation or resources to begin using EMRs on their own. Hospital EMR use is positively associated with high quality care, thus justifying the practice. Hospital efficiency was not found to be associated with EMR use in medium or large hospitals, but it was found to be associated with EMR use in small hospitals. Interestingly, larger hospitals are more likely to use EMRs than small hospitals. It is possible that the efficiency gains of EMR use in hospitals will not be realized until a standardized, fully interoperable system is developed, allowing health care provides to quickly and easily share the medical charts of their patients.

The U.S. health care delivery system faces serious challenges such as an increasing demand for services due to an aging population, unhealthy lifestyles, growth in the number of uninsured individuals, and an increase in chronic diseases. At the same time, the system has to cope with a limited supply of money, physicians, and nurses inferior quality of care delivered by U.S. hospitals. While the U.S. hospital industry is adapting to address these issues, not much progress in improving the quality of care delivered has been made over the last decade. However, theories exist that management systems, organizational traits, and leadership are key factors for hospitals to improve quality of care outcomes. This study takes a holistic look at these factors to identify and analyze critical drivers for better quality of care outcomes of U.S. hospitals. The study also aims to identify differences between chief executive officers' (CEOs) leadership traits among lean (mediocre performance), high (top 20th percentile), and low performing (bottom 20th percentile) U.S. hospitals in regards to their quality of care measures. Two separate online surveys were conducted. The first online survey was targeted at all 4,697 U.S. hospitals that are required to disclose quality of care measures to the Federal government. Results of this first survey revealed that two management system factors drive quality of care outcomes of U.S. hospitals. Furthermore, findings also show that critical access hospitals have a lower quality of care performance than acute care hospitals. Thus, based on the results from this survey, we concluded that management system factors are main drivers of hospital performance, whereas organizational trait and leadership factors did not significantly contribute to hospital performance. A second survey to CEOs and CEO followers in 9 selected hospitals found significant differences between CEO traits leading lean and low performing hospitals, and, to a lesser degree, significant differences among high and low performing hospitals. However, the study did not find any significant differences in CEO traits between lean and high performing hospitals. Findings also include that some management system factors differed significantly between lean and high performing hospitals, but no evidence for such differences could be found between lean and high and high and low performing hospitals, respectively. These results suggest that management systems and CEO leadership traits play an important role in determining U.S. hospital performance as measured by their quality of care. / Ph. D.

本研究主要在探討離島兩家公立醫院，在政府醫療整合政策下合併是否真能妥善利用當地有限資源並提升當地之醫療品質與醫療滿意度。本研究以澎湖醫療大樓落成啟用引進三軍總醫院及署立澎湖醫院醫事人力作為時間點，蒐集整理醫院經營管理資料，比較醫療大樓使用前後，醫療資源利用情形，對於民眾關切之四項議題：（一）醫療整合政策與提升當地醫療品質的關係。（二）醫療整合政策與成本效益的關係。（三）醫療整合政策與組織管理的關係。（四）醫療整合政策與民眾滿意度的關係之探討，採以質性田野調查方式作深入剖析與辯證，另對醫療品質滿意度觀察部分，則以門診就醫病患為調查對象，與質性調查結果作交叉驗證，分析探討整體社會對醫療服務品質滿意度之觀感。試圖從不同層面與角度來詮釋、剖析醫療整合政策與民眾對醫療服務品質滿意度間有無存在背後深層的意義及潛在的社會意涵。 / 本研究發現（一）政府的整合醫療政策，目的是將離島有限的資源作有效的運用，在方向上是正確的。，醫療大樓要做到何種規模須視其未來的定位與所開的床位數而定，若要求持續提供一定品質的醫療服務，政府常態性的預算補助是必要的。（二）假日緊急醫療需求無法在地圓滿解決，是澎湖地區長期以來醫療服務主要的缺口，兩院整合後目前仍未能解決該問題，是造成澎湖整體社會對醫療品質觀感不若預其的原因。（三）病患與醫療專業人員對醫療品質的認知是有差距的，這代表醫、病雙方所能掌握的醫療品質資訊是不對稱的，病患不瞭解醫界對醫療品質的評核標準，只能用直接的感受來體驗，是造成雙方在衡量醫療服務品質時出現落差的原因。（四）在組織重整過程中，「同工同酬」問題因不同公務體制無法於第一時間解決，造成員工內心不滿與不安，亦是影響整體社會對醫療服務觀感不若預其的因素。（五）在基本人口特質中，軍人、家人同住多者及醫療服務使用率較高者，這三類群體對醫療服務品質的認知有較客觀的認定，應與其對醫療服務的體驗有較多之經驗有關。（六）以模擬醫事人力供需情境分析，澎湖地區並非是一個醫事人力不足或醫療資源缺乏的地區，而是在健保制度下形成醫療資源分配不均的問題。本研究建議健保醫療給付應配合政府公共政策才是解決離島醫療問題有效的方式。（七）離島醫療成本相當昂貴，以侷限的地域、不足的消費人口及健保總額支付制度限制下，要發展在地醫療或提升至區域級醫療服務品質宜審慎考慮，建議遠距醫療合作、空中轉診後送結合軍方穩定的醫療人力支援，可能仍是最佳解決問題的模式。 / The purpose of this study is to explore how two public hospitals on Penghu Island can really make good use of limited local resources to improve medical quality and patient’s satisfaction under nation wide integration of health care policy. This study adopts qualitative research and interview method on the following four items that are of great concerns to the local general public: (1) the relationship between the integrated medical policy and improvement of local medical quality (2) the relationship between the integrated medical policy and hospital performance (3) the relationship between the integrated medical policy and organizational management (4) the relationship between the integrated medical policy and patient’s satisfaction. As to the observation of client satisfaction of medical treatment, the targets are out-patients with analysis of their satisfaction with the medical services. This study also intends to interpret from different aspects and perspectives the real social meaning presented by the relationship between the integrated medical policy and client satisfaction. / This study has discovered the following: (1) The decision of the integrated medical policy with purpose of effectively deploying limited resources on off-shore islands is correct. However to what extent a medical building should provide its service is dependent on its hospital beds capacity and the definition of its role. Regular budgetary support from the government is necessary if stable quality of medical services is desired. (2) One of the main reason about people’s satisfaction with overall medical services provided on Penghu has not met the expectation is that there still did not provide a good resolution to the urgent medical support on Holiday after the integration of two hospitals medical resources. (3) There is a gap between professional medical services providers and patients in recognizing the quality of medical services. This means that the information obtained by both parties regarding the quality of medical services is asymmetric. Patients do not understand the criteria used to review the quality of medical services and as a result, they depend on very direct feeling or experience to make the judgment, thus causing the gap. (4) During the process of reorganization, the issue of “equal work with equal compensation” did not receive appropriate attention and was not resolved properly by different governmental bureaucratic systems which led to the fact that the quality of medical services is not as good as expected. (5) Three fundamental elements of population, military personnel, families with most of their members living together, and frequent users of medical services, have possessed more objective recognition of the quality of medical services due to their more sufficient experience in using medical services. (6) a simulated analysis of demand and supply of medical services has indicated that Penghu Island shall not be regarded a region lack of medical personnel or barren of medical resources. This study suggests that the compensation provided under the National Health Insurance System must go hand in hand with government public policies to provide an effective way to resolve medical problems on off-shore islands. (7) The cost of medical services on off-shore islands is high. Under the conditions of limited population in limited areas and the per-quota-compensation provided by the National Health Insurance System, we need to carefully consider how to develop or upgrade its quality level. It is, therefore, suggested that distant medical cooperation, aerial medical transport together with stable supply of medical personnel from the military provides probably the best model for resolution of the problems.

The formation of multi-hospital systems represents one of the largest structural changes in the hospital industry. As of 2008, system affiliated hospitals outnumbered stand alone hospitals 2511 to 2167 and the percentage of system affiliated rural hospitals has increased dramatically from 24.8% in 1983 to 42.2% in 2008 (based on AHA data for non-federal acute care general hospitals). The effects of system membership on hospital performance have been of great interest to health care researchers, but the majority of research on multi-hospital systems has either focused exclusively on urban facilities or pooled urban and rural facilities in the same sample, and thus failed to allow for potential differences in membership effects between urban and rural hospitals. The result is that the effect of system membership on rural hospital performance has remained largely unexplored, creating a gap in the body of health services research. The objectives of this study are both theoretical and empirical. Theoretically, this study is intended to be a deliberate empirical application of contingency theory, which is the one major organizational theory that seeks to explain variations in organizational performance as its fundamental purpose. Empirically, this study seeks to explore the relationship between rural hospital system membership and rural hospital performance, taking into account the environment of the rural hospital and the structure of the multi-hospital system to which it belongs. The study sample consists of 1010 non-federal, short-term, acute care general rural hospitals with consistent system membership and critical access hospital (CAH) status from 2004 to 2008. Hospital economic performance is represented by the dependent variables of hospital total margin and a productive efficiency score calculated using Data Envelopment Analysis (DEA). Four contingent pairs containing measures for environmental munificence, system membership, the presence of local system partners, the presence of hierarchical system partners, and CAH status, were used to measure a hospital’s fit between environment and structure. Regression analysis was used to determine the relationship between hospital performance and the fit between a hospital’s environment and its organizational/system structure. Results of the analysis indicate that hospitals with a better fit have significantly higher total margins, but results for productive efficiency were largely insignificant.

Made available in DSpace on 2016-06-02T19:50:22Z (GMT). No. of bitstreams: 1 5781.pdf: 1740434 bytes, checksum: 87cd892ed73f7bca1a84e2813ef47f5c (MD5) Previous issue date: 2013-12-17 / Universidade Federal de Sao Carlos / The demand for improving the health care services from social actors (Government, Insurance Companies, Patients and Payers) has carried out the hospitals to implement actions of performance improvement. In Brazil, it occurs in a context of deficiency in the management and efficiency of the processes. This thesis analyzes the implamentation impact of NAO‟s Accreditation practices (the brazilian certification most required in the healt care services) on the hospital performance as well as the moderators factors (hospital ownership, hospital size, Accreditation level and Accreditation time) influence in this relationship. A survey research involving the 32 Accredited hospitals from Sao Paulo State was carried out during six months. The survey evaluated the managers‟ perception about the hospital performance improvement comparing the current hospital performance with the hospital performance before the adoption of Accreditation practices. A statistic analysis determined the statistical significance between the Accreditation practices and the hospital performance improvement. Moreover, the most critical Accreditation practices for improving the hospital performance were identified. Finally, managerial actions were proposed to improve the performance of hospitals clusters composed by hospitals with similar management characteristics. The statistical analysis results identified a significant influence of the Accreditation practices in operational efficiency under the action of size and Accreditation time of the hospitals. The critical practices to the hospital performance improvement are the risks management practices and the managerial inovation practices. The first improve the hospital infection rate and the latter improve the medication errors rate. / A exigência dos atores sociais (Governo, Planos de Saúde, usuários e financiadores) para melhoria dos serviços tem conduzidos os hospitais à busca de ações de melhoria de desempenho. No Brasil, isso vem ocorrendo em um contexto caracterizado pela precariedade em termos de gestão e eficiência dos processos. Esta tese analisa o impacto da adoção das práticas de Acreditação da ONA, uma das ações e certificações mais requisitadas atualmente, sobre o desempenho hospitalar e a influência de fatores intervenientes (porte e propriedade dos hospitais, tempo e nível de Acreditação) nesta relação. Um survey coletou informações de 32 hospitais Acreditados do Estado de São Paulo durante 6 meses a fim de avaliar a percepção dos gestores quanto à melhoria do desempenho hospitalar, comparando o desempenho atual da instituição com o desempenho anterior à adoção das práticas de Acreditação. A partir de técnicas estatísticas, determinou-se a significância de influência das práticas de Acreditação sobre o desempenho hospitalar e suas dimensões, identificando as práticas mais críticas à melhoria deste desempenho. Complementarmente, foram propostas ações gerenciais focadas em características comuns de gestão dos hospitais pesquisados, que podem ser implementadas pelos mesmos para que melhorarem seu desempenho. Houve influência estatisticamente significativa das práticas de Acreditação na Eficiência operacional dos hospitais, sob ação do porte e do tempo de Acreditação. As práticas mais críticas à melhoria do desempenho foram as de gestão de riscos e aquelas com foco em inovação. Ambas geram melhorias diretas na taxa de infecção hospitalar e de incidência de erros de medicação, respectivamente.

MPH / Department of Public Health / This study was aimed at gaining an in-depth understanding into the managerial factors that are associated with hospital performance. Out of all the contributing factors, managerial factors have the greatest impact on hospital performance. In South Africa, despite the availability of policies and guidelines and adequate funding, hospital performance is still poor. This study investigates the different aspects of managerial performance, looking specifically at organisational factors such as organisational culture, available resources, and performance monitoring methods; as well as personal factors of the managers; namely, their focus on quality, and personal leadership styles and skills. The study is a quantitative cross-sectional descriptive survey, utilising questionnaires distributed at the two largest district hospitals in Vhembe District. The study was aimed at a total population sample of managers, doctors and professional nurses in the two hospitals. The study highlighted areas of management in the two hospitals studied that were commendable, as well as those needing urgent attention. There was a statistically significant association between managerial factors associated with hospital performance, and better perceptions of hospital performance. In particular, leadership skills such as motivation and dedication, methodical and logical management styles, and a hands-on approach had a significant contribution to perceptions of hospital performance. The study also highlighted the importance of good communication between senior management and subordinates. / NRF

Thèse de doctorat effectuée en cotutelle au Département d’administration de la santé Faculté de médecine, Université de Montréal et à l’École doctorale Biologie-Santé Faculté de médecine, Université de Nantes, France / L’objectif de la thèse est d’approfondir la compréhension des enjeux liés au processus d’introduction du changement dans les organisations. Ce sujet semble important vu les enjeux majeurs auxquels sont actuellement confrontées les organisations pour implanter des changements jugés nécessaires. Notre recherche aborde l’analyse du changement dans les organisations selon une approche systémique. Cette approche a été développée dans le cadre de la thèse et propose de voir l’implantation du changement jugé nécessaire dans les organisations, non comme des initiatives isolées et déconnectées de l’environnement, mais plutôt comme des processus émergents ou programmés permettant autant le changement de l’organisation que le changement et l’évolution de l’environnement dans une perspective de co-évolution des organisations et de leur environnement. Au niveau des organisations, cette approche systémique amène à se pencher sur la question des possibilités réelles des organisations de produire les changements jugés nécessaires. Elle cherche à comprendre pourquoi, malgré les possibilités réelles des organisations de créer des conditions favorables à l’acceptation et à l’implantation du changement et de l’innovation, les organisations ne s’engagent pas à créer de telles conditions et par conséquent ont des difficultés à produire le changement. Dans le cadre de la recherche, nous avons étudié le changement des pratiques professionnelles et managériales dans le contexte hospitalier français suite à l’introduction d’une innovation d’amélioration de la performance hospitalière, et notamment le projet PATH de l’OMS Europe. Il s’agissait pour nous d’analyser la dynamique de l’implantation de PATH dans la production des effets et le degré d’implantation de PATH, tout en faisant ressortir les facteurs contextuels qui permettent d’expliquer les variations dans le degré d’implantation et les effets. Les résultats de notre recherche soutiennent la proposition qu’il est probablement possible de prédire le niveau d’atteinte des objectifs poursuivis par un changement à partir de la connaissance des capacités collectives de l’organisation pour produire le changement et la façon dont elles ont été mobilisées pour atteindre les objectifs poursuivis. Ils envoient un signal fort aux établissements de santé qui voudraient réussir l’implantation des pratiques novatrices d’amélioration de la performance hospitalière qu’ils doivent s’occuper du contexte dans lequel les efforts de l’implantation sont pratiqués et que ces efforts ne sauraient être entrepris tant que des conditions favorables à l’acceptation et à la réalisation du changement ne sont pas mises en place. Les conditions favorables se matérialiseraient dans les établissements par la mise en place de structures favorisant le travail en groupe multi professionnels, de formations relatives à l’implantation de l’innovation, de coordination de l’action collective, d’implication des utilisateurs finals de l’innovation dans tous le processus d’implantation et de soutien du leadership médical et administratif. / The objective of the thesis is to look further into the comprehension of the issues related to the process of introduction of the change into the organizations. This subject seems important in view of the major challenges currently facing the organizations to implement changes considered to be necessary. Our research approaches the analysis of the change in the organizations according to a systemic approach. This approach was developed within the framework of the thesis and proposes to see the introduction of the change considered to be necessary in the organizations, not like isolated and disconnected initiatives from the environment, but rather like emergent or programmed processes allowing the change of the organization as much that the change and the evolution of the environment in a context of co-evolution of the both entities. To the level of the organizations, this systemic approach for analysing the change in the organizations brings to consider the question of the real possibilities of the organizations to produce changes deemed necessary. She seeks to understand why, despite the real possibilities of the organizations to create favourable conditions for the acceptance and to the implementation of the change and of the innovation, the organizations are not committed to create such conditions and consequently have difficulties in produce the change. Within the framework of research, we studied the change of the professional and managerial practices in the French hospital context following the introduction of a hospital performance improvement innovation: the WHO Europe’s project PATH. Our objectives were to analyse the dynamics of the implementation of PATH in the production of effects and the degree of implementation of PATH, and to identify the contextual factors that allow explaining the variations in the degree of implementation and the effects. The results of our research support the proposal which it is probably possible to predict the level of achievement of objectives pursued by the change from the knowledge of the collective capacities of the organization to produce the change and the way in which they were mobilized to achieve the objectives pursued. They send a signal to the hospitals which would like to introduce innovative hospital performance improvement practices that they must deal with the context in which the implementation efforts are practiced and that these efforts could not be undertaken as long as favourable conditions for the acceptance and for the implementation of the change are not put in place. These favourable conditions are materialized in hospitals by structures supporting multidisciplinary group work, by training related to the implementation of the innovation, by a coordination of the collective action, by the end-users of the innovation implication in all the implementation processes and by the medical and management leadership support.

Les problèmes de santé mentale représentent un pourcentage important du fardeau de morbidité mondiale. Cela, ajouté aux ressources limitées disponibles pour le fonctionnement des établissements, encourage l’intérêt pour l’évaluation de leur performance. Ce projet propose d’utiliser le modèle ÉGIPSS pour évaluer la performance de deux hôpitaux psychiatriques dans deux systèmes de santé différents, le « Hospital Psiquiátrico Universitario del Valle » (HPUV) situé en Colombie et l’Institut universitaire en santé mentale Douglas au Québec. Le modèle a été choisi en raison de la richesse des dimensions qu’il comprend et son caractère global. Les données ont été recueillies à travers des entrevues et de la documentation disponible dans les établissements. L’analyse des résultats montre que le Douglas a une meilleure performance générale, même tenant compte qu’il se trouve dans un pays à haut revenu avec des standards d’évaluation supérieures. De vingt-et-une sous-dimensions évaluées, l’HPUV a présente six avec un état préoccupante et le Douglas aucune. L’analyse des résultats a aussi servi pour identifier des facteurs de causalité critiques des problèmes de performance, soit l’organisation à l’intérieur des établissements, la communication interne, les plans de santé mentale et la disponibilité des professionnels. La comparaison a permis apprécier l’influence de ces éléments dans les deux contextes. / Mental health problems account for a significant percentage of the global disease burden. This, coupled with the limited resources available for the functioning of health institutions, impulse the interest in evaluating the performance of such organizations. This project proposes the use of the EGIPSS model to evaluate the performance of two psychiatric hospitals in two different healthcare systems, the « Hospital Psiquiátrico Universitario del Valle » (HPUV) in Colombia and the Douglas Mental Health University Institute in Quebec. The model was chosen because of the richness of dimensions it offers and its comprehensiveness. Data were collected through interviews and documentation available at the institutions. Analysis of the results shows that the Douglas Institute has a better general performance, even when considering that it is located in a high revenue region with highest standards of evaluation. Out of twenty-one evaluated sub-dimensions, six were classified as concerning for the HPUV and none for the Douglas. The analysis of results was also used to identify critical causal factors of problems in the performance, which are organization and communication within the institutions, mental health plans and availability of professionals. Benchmarks were established to assess the influence of these factors in both contexts.

Submitted by JOSIANE SANTOS DE OLIVEIRA (josianeso) on 2017-09-22T13:25:26Z No. of bitstreams: 1 Fabricio Colvero Avini_.pdf: 3377321 bytes, checksum: b18160c29f04c7b1de74a9b4ccdf5f40 (MD5) / Made available in DSpace on 2017-09-22T13:25:26Z (GMT). No. of bitstreams: 1 Fabricio Colvero Avini_.pdf: 3377321 bytes, checksum: b18160c29f04c7b1de74a9b4ccdf5f40 (MD5) Previous issue date: 2017-06-01 / Nenhuma / A saúde apresenta enorme desafio de conciliar qualidade com viabilidade financeira. Como premissa, é uma área que demanda fazer mais, com menos recursos e com resultados que podem impactar na vida das pessoas. No Brasil, hospitais de excelência têm iniciativas muito próximas as internacionais de destaque, visando atender requisitos de qualidade elevada, medindo sua performance, como os hospitais da ANAHP (Associação Nacional de Hospitais Privados), mas a principal questão desta pesquisa é em relação a quais indicadores representam melhor a área de atenção hospitalar e poderia ser aplicada para todos perfis de hospitais do país. Os indicadores avaliados neste estudo foram agrupados nas dimensões do BSC (Balanced Scorecard), onde foram considerados processos de gestão e assistenciais, além de aspectos financeiros, recursos humanos e percepção de qualidade pelo cliente. O trabalho propõe, a partir de 7 referências nacionais e internacionais, um conjunto de 30 indicadores, com preocupação de cobrir não apenas processos estratégicos de gestão, mas também assistenciais, menos avaliado em hospitais fora do grupo de excelência. Este conjunto de indicadores foi validado por especialistas em gestão e assistência, não apenas ligados a hospitais de excelência, mas também ao perfil de hospitais identificados como futuros “adopters”, mais prevalente no brasil, como os filantrópicos, na tentativa de explorar a percepção de viabilidade futura de adoção de uma plataforma nacional de bencharming hospitalar. Após validado o conjunto de indicadores, foi apresentado um protótipo não-funcional em uma plataforma tecnológica em ambiente web, disponível no domínio benchealth.com.br e realizada a avaliação sobre a viabilidade de importar estas informações a partir dos Sistemas de Informação Hospitalar (SIH) presentes no mercado e de acordo com o nível de sistematização, com intuito de avaliar a viabilidade de extração destes indicadores. O resultado deste estudo demonstrou aderência aos indicadores propostos, porém ficou evidente as dificuldades de obtenção de alguns indicadores, principalmente relacionados a processos assistenciais, menos sistematizados nos hospitais. Também entende-se como necessidade futura, avaliar viabilidade de outros indicadores que possuem representatividade em ambientes de excelência e ainda não fizeram parte deste estudo inicial. / The health area presents huge challenge of reconciling quality with financial viability. As a premise is an area that demands to do more, with fewer resources and with results that can impact lives of people. In Brazil, hospitals of excellence have initiatives that are very close to the most important international ones, aiming to meet high quality requirements, measuring their performance, such as hospitals members of ANAHP (National Association of Private Hospitals), which has a collection of indicators and comparison between participants, but the main question of this research is in relation to which Indicators better represent the area of hospital care and could be applied to all profiles of hospitals in the country. The indicators evaluated in this study were grouped into the BSC (Balanced Scorecard) dimensions, mainly related within management and assistance process, besides financial aspects, human resources and customer perception of quality. The work proposes, from 7 national and international references, a set of 30 indicators, with concern to cover not only strategic processes of management, but also assistance, less evaluated in hospitals outside the group of excellence. This set of indicators was validated by a group of management and healthcare specialists, not only linked to hospitals of excellence, but also to the widespread profile of hospitals, identified as future adopters, more prevalent in Brazil, such as non-profit, in an attempt to exploring the perception of future feasibility of adopting a national hospital benchmarking platform. After validating the set of indicators, a non-functional prototype was presented in a web-based technology platform, available in the benchealth.com domain, and an assessment was made to visualize the feasibility of importing this information from the Hospital Information Systems (HIS) most used in market, considering systematization level within HIT, in order to evaluate the viability of extracting these indicators. The result of this study showed adherence to the proposed indicators, but also signaled difficulties in obtaining some indicators, mainly related to care processes, less systematized in hospitals. It is also clear the need to assess the viability of other indicators that have representativeness in environments of excellence and have not yet been part of this initial study.

L’objectif de la thèse est d’approfondir la compréhension des enjeux liés au processus d’introduction du changement dans les organisations. Ce sujet semble important vu les enjeux majeurs auxquels sont actuellement confrontées les organisations pour implanter des changements jugés nécessaires. Notre recherche aborde l’analyse du changement dans les organisations selon une approche systémique. Cette approche a été développée dans le cadre de la thèse et propose de voir l’implantation du changement jugé nécessaire dans les organisations, non comme des initiatives isolées et déconnectées de l’environnement, mais plutôt comme des processus émergents ou programmés permettant autant le changement de l’organisation que le changement et l’évolution de l’environnement dans une perspective de co-évolution des organisations et de leur environnement. Au niveau des organisations, cette approche systémique amène à se pencher sur la question des possibilités réelles des organisations de produire les changements jugés nécessaires. Elle cherche à comprendre pourquoi, malgré les possibilités réelles des organisations de créer des conditions favorables à l’acceptation et à l’implantation du changement et de l’innovation, les organisations ne s’engagent pas à créer de telles conditions et par conséquent ont des difficultés à produire le changement. Dans le cadre de la recherche, nous avons étudié le changement des pratiques professionnelles et managériales dans le contexte hospitalier français suite à l’introduction d’une innovation d’amélioration de la performance hospitalière, et notamment le projet PATH de l’OMS Europe. Il s’agissait pour nous d’analyser la dynamique de l’implantation de PATH dans la production des effets et le degré d’implantation de PATH, tout en faisant ressortir les facteurs contextuels qui permettent d’expliquer les variations dans le degré d’implantation et les effets. Les résultats de notre recherche soutiennent la proposition qu’il est probablement possible de prédire le niveau d’atteinte des objectifs poursuivis par un changement à partir de la connaissance des capacités collectives de l’organisation pour produire le changement et la façon dont elles ont été mobilisées pour atteindre les objectifs poursuivis. Ils envoient un signal fort aux établissements de santé qui voudraient réussir l’implantation des pratiques novatrices d’amélioration de la performance hospitalière qu’ils doivent s’occuper du contexte dans lequel les efforts de l’implantation sont pratiqués et que ces efforts ne sauraient être entrepris tant que des conditions favorables à l’acceptation et à la réalisation du changement ne sont pas mises en place. Les conditions favorables se matérialiseraient dans les établissements par la mise en place de structures favorisant le travail en groupe multi professionnels, de formations relatives à l’implantation de l’innovation, de coordination de l’action collective, d’implication des utilisateurs finals de l’innovation dans tous le processus d’implantation et de soutien du leadership médical et administratif. / The objective of the thesis is to look further into the comprehension of the issues related to the process of introduction of the change into the organizations. This subject seems important in view of the major challenges currently facing the organizations to implement changes considered to be necessary. Our research approaches the analysis of the change in the organizations according to a systemic approach. This approach was developed within the framework of the thesis and proposes to see the introduction of the change considered to be necessary in the organizations, not like isolated and disconnected initiatives from the environment, but rather like emergent or programmed processes allowing the change of the organization as much that the change and the evolution of the environment in a context of co-evolution of the both entities. To the level of the organizations, this systemic approach for analysing the change in the organizations brings to consider the question of the real possibilities of the organizations to produce changes deemed necessary. She seeks to understand why, despite the real possibilities of the organizations to create favourable conditions for the acceptance and to the implementation of the change and of the innovation, the organizations are not committed to create such conditions and consequently have difficulties in produce the change. Within the framework of research, we studied the change of the professional and managerial practices in the French hospital context following the introduction of a hospital performance improvement innovation: the WHO Europe’s project PATH. Our objectives were to analyse the dynamics of the implementation of PATH in the production of effects and the degree of implementation of PATH, and to identify the contextual factors that allow explaining the variations in the degree of implementation and the effects. The results of our research support the proposal which it is probably possible to predict the level of achievement of objectives pursued by the change from the knowledge of the collective capacities of the organization to produce the change and the way in which they were mobilized to achieve the objectives pursued. They send a signal to the hospitals which would like to introduce innovative hospital performance improvement practices that they must deal with the context in which the implementation efforts are practiced and that these efforts could not be undertaken as long as favourable conditions for the acceptance and for the implementation of the change are not put in place. These favourable conditions are materialized in hospitals by structures supporting multidisciplinary group work, by training related to the implementation of the innovation, by a coordination of the collective action, by the end-users of the innovation implication in all the implementation processes and by the medical and management leadership support. / Thèse de doctorat effectuée en cotutelle au Département d’administration de la santé Faculté de médecine, Université de Montréal et à l’École doctorale Biologie-Santé Faculté de médecine, Université de Nantes, France