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.
| Identifer | oai:union.ndltd.org:ADTP/187646 |
| Date | January 2002 |
| Creators | Sorensen, Ros, Public Health & Community Medicine, Faculty of Medicine, UNSW |
| Publisher | Awarded by:University of New South Wales. School of Public Health and Community Medicine |
| Source Sets | Australiasian Digital Theses Program |
| Language | English |
| Detected Language | English |
| Rights | Copyright Ros Sorensen, http://unsworks.unsw.edu.au/copyright |
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