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.

Thesis (M.A.(Applied))--Victoria University of Wellington, 2006. / Includes bibliographical references.

Thesis (Ph. D.)--York University, 1998. Graduate Programme in Philosophy. / Typescript. Includes bibliographical references (leaves 351-366). Also available on the Internet. MODE OF ACCESS via web browser by entering the following URL: http://wwwlib.umi.com/cr/yorku/fullcit?pNQ27298.

Thesis (Ph.D.)--Memorial University of Newfoundland, 2002. / Bibliography: leaves 261-289.

No description available.

The thesis looks in detail at three inter-related aspects of Alison's life. It examines, firstly, his role in the development of Edinburgh's rudimentary 'health' network, achieved through the expansion of the existing medical charity structure and the introduction of a more interventionist and coordinated approach to the city's health problems. It traces, secondly, the development of Alison's social thought - in 1820 he believed that medical and practical relief for the poor could and should be supplied through the voluntary charities and only when that proved unsatisfactory through the poor law, whereas by 1840 he argued that public health should be the responsibility of government and that the excessive increase in poverty and disease in Scotland, which he believed had occurred, was proof that the charitable and legal relief provided was inadequate. Finally, Alison's influence on the passage of Scottish poor law and public health legislation in the 1840s and 1850s is examined - the latter involving an assessment of how far he was responsible for the legislative delay. The poor law debate, 1840-1845, which reveals the forces shaping the reform and the prevailing attitudes to poverty, highlights the challenge which Alison's opinions represented and the resulting turmoil in Scottish social thinking, while his reasons for opposing health legislation, which established London control are of great importance. They reveal differences in the rationale behind, and way in which, the concept of public health was developed in Scotland and England. Unlike Chadwick and his supporters, Alison emphasised poverty amelioration and sanitary reform. Part of the explanation for the differing opinions lay in their respective miasmatic and contagionist theories for fever generation, but it also reflects, perhaps more significantly, the impact of European medical police ideas on Scottish medical opinion - Alison's view of public health closely resembled that of the French hygienists.

This study explores how formal and informal social networks and decision making about resources in the hospital setting are related. Over the last few years, tensions between new public management of hospitals and increased demands has led to an increase in bottlenecks, stagnation of patient flow, and overcrowded emergency departments. These problems have led to an increase in access block for patients attempting to access the public hospital system. The introduction of Patient Flow Units has instigated the formalisation of a nurse manager function to coordinate patient flow. Nurses in such a pivotal position and who greatly influence hospital operations, tend to have special characteristics and use these to “get things done”. This thesis investigates interpersonal associations between professional (e.g. doctors and nurses) and functional groups (e.g. clinicians and managers), when making clinical and operational decisions when transferring a patient from the emergency department to a ward bed. By employing a mixed methodology, this thesis first sought to establish a snapshot of organisational culture in three hospitals. Drawing on Degeling et al. (1998) and Fitzgerald (2002), an organisational cultural survey was distributed to a total of 1750 participants. The response rate was 11.65% This survey particularly addressed five cultural constructs including a sense of organisational commitment, perceptions of managerial role characteristics, perceptions of currently pursued organisational goals, perceptions of orientation to work values when choosing a job, and interactions with various professional constituencies. In addition, 18 interviews were conducted and a total of 150 hours of observation of work processes, interactions between staff and environmental conditions were studied. This investigation largely confirmed earlier studies by Degeling (2002) and Fitzgerald (2002) that professional groups believed that their organisation primarily exhibited an Elite style of management, that financial viability is the most important goal their organisation is pursuing, and staff welfare was a low priority. In addition, it found significant differences in cultural footprints between the small hospital, which had a more integrated culture, and the large hospital, which was more fragmented in nature. However, the major contribution of this investigation is demonstrated in the qualitative chapter. This thesis found that the role of “who matters the most” in relation to decision making about patient flow, changes depending on the stage of the decision making process. It also found that non-managerial nursing staff with no formal power or legitimacy could affect urgency. The thesis comprises eight chapters. Following the introductory chapter, Chapter 2 considers the literature associated with the public health system in Australia with a focus on public hospitals in NSW. Chapter 3 critically examines the literature describing organisational culture, with an emphasis on subcultures. Chapter 4 contains a review of professional identity and roles, networks and alliances, social capital, deep smarts, and stakeholder theory. Description and justification of the research method selected to explore the thesis proposition follows in Chapter 5. Chapter 6 contains an outline of the findings concerning the analysis of the survey questionnaire to determine a cultural footprint of the three hospitals studied. Chapter 7 considers the different roles of professional groups (doctors, nurses, and others) and functional groups (clinicians and managers) in the operational phase of patient flow and in doing so contributes to knowledge. Finally, in Chapter 8, a discussion summarises the thesis findings, describes the implications, acknowledges limitations of the study and identifies avenues for future research. / Doctor of Philosophy (PhD)

Thesis (Ph.D.) -- Flinders University of South Australia, School of Medicine, 2005. / Typescript (photocopy). Includes bibliographical references (leaves 252-270). Also available online.

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

Thesis (Ph.D.)--Victoria University (Melbourne, Vic.), 2008.