The concept of Shifting the Balance of Care was first introduced to NHS Scotland in 2005 through the Kerr Report. The key messages from the report were to: ensure sustainable and safe local services, which are supported by the right skills, change the emphasis of care into the community, provide preventative reactive care, and fully integrate the system to tackle the changes, use technology more effectively, and involve the public in finding solutions to change. Following the report, a framework was developed which highlighted and prioritised eight areas of improvement. These areas for improvement are the focus by which this research examines if Operational Research (OR), specifically OR models, can have a positive impact in Shifting the Balance of Care. The research utilises underlying OR methodologies and methods and provides evidence from the literature of the ability of nine selected models to facilitate the Shift in the Balance of Care. A contributing factor to the research is the barriers to implementation of OR models into the NHS. With reference to the literature, the common barriers to implementation of OR models are categorised and used to provide direction to modellers where implementation barriers are more prevalent in some models than in others. The research also provides empirical evidence of three selected models’ (the Lean Methodology, Process Mapping and Simulation, developed over two Case Studies) ability to address and influence the prioritised Improvement Areas, with the addition of a newly developed model: SoApt. The development of SoApt follows the Principles of Model Development derived as a guide to modellers who wish to develop a new model. SoApt is also empirically explored in a Case Study and provides some evidence of the models ability to aid Decision-makers, faced with limited budgets, to choose between options which will Shift the Balance of Care. OR methods and methodologies are examined to ascertain the Roles of Models for each model explored in the Case Studies. Examination of the Roles of Models against the Improvement Areas provided evidence of a models’ ability to address more than one of the priority areas and that models can be used together or sequentially. In addition, with reference to OR methods and methodologies, a theoretical Evaluation Framework is proposed which suggests the User and User Satisfaction is key to the evaluation of a model’s success; positive experiences of the User and Use of the model may help to eliminate some of the barriers to implementation.

This thesis was born from a concern the researcher had with regard to negative reports in the media emanating from 4 babies that died at Cecilia Makiwane Hospital Peadiatric ICU unit due to power supply failure. The most significant of these negative reports was in 2007 when the Daily Dispatch ran a series of articles regarding what they termed avoidable deaths over the last 14 years. The ease with which staff communicated with the media together with the high absenteeism rate and high turnover was a cause for concern. When the researcher analysed the history of the problem, it immerged from the respondents’ responses that the rationalistion process undertaken by the Eastern Cape Department of Health (ECDoH) was a significant root cause to the problem. The literature review focused on three areas viz.: Organisational Culture, Organisational Change, Foundations of Satisfaction. This focus was used to confine the problem to a manageable project but secondly each of the aspects are interwoven. Routledge (2010) notes that culture is the reflection of the values advocated by a founder or leader by way of his/her day to day actions. This is done by the leader creating a perception or viewpoint that assists the employees to achieve the organisation’s mission, vision and goals. In any organisation change is a constant and it needs to be effectively managed. With government institutions like the East London Hospital Complex (ELHC) directives come from the top and are implemented by an unprepared and untrained leadership and management cadre and clear communication of vision and objective of the desired outcomes never happens. The aim of the research was to: describe the existing Organisational Culture present at ELHC (Perform an organisational diagnosis); describe the impact of change (rationalisation) and to analyze why there was such a high staff turnover. It is clear from the results of the survey conducted that significant dissatisfaction prevailed relating to how the institution was managed. Dissatisfaction amongst the health professionals was general but also specific to the following: leadership and management issues, fairness, remuneration and lack of resources. The recommendations therefore focused on developing management and leadership within the proposal of Dubrin’s model (2001).

In hospitals of Addis Ababa, there is a high turnover of leaders while patient and health workers’ satisfaction is low, and safety and quality are in dire situations. The purpose of this study was to explore and propose strategies to improve effectiveness of hospital leadership in order to enhance the quality of health care provided in hospitals through improving health workers’ empowerment, job satisfaction and patient safety culture. Thus, a sequential explanatory mixed method research design was used. The research had three phases, in which the first phase used five structured questionnaires explored leadership styles, the health workers’ satisfaction and empowerment, patient safety culture, and the patient experience of quality of health care; while the second involved a qualitative study (content analysis); and third phase focused on the preparation of a strategy document. Data in the form of interview responses was gathered from 75 leaders, 542 health workers, 532 patients and 11 key informants. The analysis shows that, overall, hospital leaders considered themselves more transformational (M=2.98, SD=0.41) than transactional (M=2.85, SD=0.46). Job satisfaction of private and public hospital health workers were 70.8 % and 57.1 % respectively (P-value<0.001). In addition, private hospital workers had a higher score in structural and psychological empowerment than their pubic hospital counterparts; the difference was statistically significant in all dimensions (P-value <=0.03). The analysis reveals that public and private hospitals’ mean total patient safety scores were 3.58 and 3.77 respectively (P-value=0.02). Finally, the “overall rating of hospital” was better for private hospitals: 84.8% and 88.4 % respectively (P-value=0.03). The study makes a number of observations. It notes that, firstly, transformational leadership has direct and strong correlation with structural and psychological empowerment (r=0.70, P-value=0.04 and r=0.83, P-value=0.01 respectively). Secondly, structural empowerment has a direct and significant effect on psychological empowerment (β=0.28, P-value=<0.01); and minimal indirect effect on patient safety culture through psychological empowerment (β=0.05, P-value=<0.05). Thirdly, health worker job satisfaction also has had a direct effect on patient safety culture (β=0.44, Pvalue=< 0.01. The fourth and final observation is that psychological empowerment has had a direct and statistically significant effect on patient safety culture (β=0.19, Pvalue=< 0.01). These observations indicate that, although private hospitals are better in every dimension of this study, the current hospitals situation in Addis Ababa needs urgent attention. Hence, the identification and recommendation for the preparation of eight strategic priority areas along with key interventions seeking to improve the hospital leaders’ effectiveness. / Health Studies / D. Litt. et Phil. (Health Studies)

Background: The demand for and retention of talent worldwide is aggravated by revolutionary trends that include global competition, demographic changes and technological advances. In South Africa this phenomenon according to Frost (2002) is further challenged by the emigration of skilled people; the relative scarcity of specialist and managerial employees; employment equity and affirmative action procedures. But the development of strategies first requires an understanding of the factors which influence decisions to leave or stay particularly in rural and remote areas. St. Andrews Hospital is a rural district hospital in Ugu District, KZN. Its remoteness from urban areas and the lack of resources contributes towards challenges of attracting and retaining health care professionals to the area. It is the aim of this study to identify the ten most prevalent turnover and retention factors in a rural district hospital with the intention of making recommendations towards strategies to mitigate turnover and improve retention of health care professionals. This study will not only serve the local Human Resource Department but may also be used to inform district and provincial policies as well as departments’ decisions in the design or the review of current retention strategies aimed at reducing turnover. Method: The survey method was used to collect the primary data by distribution of self-administered questionnaires to Health Care Professionals at St. Andrews Hospital. Of the one hundred and fifty questionnaires distributed, one hundred and seven were returned (71% response rate) and formed the basis of the study. Results: Based on the impact scores, the top three turnover factors identified were, the way the organisation is led by top management (0.934); the size of the workload (0.862); and the way problems are dealt with by managers in the organisation (0.817). No statistically significant relationships were found between turnover factors and biographical variable. Availability of quality health services was ranked as the external factor that had the highest influence (78%) on turnover, while geographical location was ranked the lowest. The main reason given by respondents for leaving their previous employment was promotion, followed by distance and personal/family reasons. The top three retention factors identified from the impact scores were the quality of relationships with colleagues (1.698); the amount of support received from managers and colleagues (1.484); and the level of engagement and involvement with the job (1.390). This demonstrates that the salary package often thought to be a first priority factor Mobley, Horner and Hollingsworth (1978); Mobley (1982) and Herzberg (2003) is far less of a determining factor at St. Andrews Hospital than management support, job involvement and person-organisation fit as well as the social relationships formed in the workplace. A positive relationship was found between leadership and job dimension factors at the 1% level of significance. This supports the strong social bond (person-organisation fit) formed in the work environment between management and colleagues that supports retention and increases level of commitment. An important result of the study was that 46% of the respondents were thinking of leaving the town within the year while 29% were considering resigning from St. Andrews Hospital within the year. Conclusion: The results reveal a complex interaction of factors impacting on turnover and retention. The Human Resource Management function has a pivotal role to play in improving its ability to attract and retain professionals through developing comprehensive strategies based on external and internal and environmental factors. The study conveys to the St. Andrews Hospital management that turnover and retention factors are unique to the location and the working environment and differs amongst Health Care Professionals – this should be deliberated on when formulating Hospital Human Resource retention policies.