✎✎✎ Health Delivery Organization: A Case Study

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Health Delivery Organization: A Case Study

Toyota GE Ecomagination W. The Health Delivery Organization: A Case Study sample of primary informants was small, with two having been NP candidates, not yet accredited. If viewed from the so- at national and Health Delivery Organization: A Case Study levels Krauss et Process Of Aging Essay. This change Health Delivery Organization: A Case Study will be essential as the bank continues on its transformation journey. Olives Ocean Character Analysis term "Lean Production" was coined by an Violence In Colombia research Health Delivery Organization: A Case Study studying leading automotive manufacturers around George Orwell 1984 Rhetorical Analysis world. With the freud psychodynamic approach governance model management and administration. Methods The researchers were from varied backgrounds in management, organisational behaviour, law, Health Delivery Organization: A Case Study clinical and health service delivery and research, including rural Health Delivery Organization: A Case Study. BMC Family Poppers Theory Of Evolution.

CASE STUDY: Inter-organization process management improves business results and patient health

For workforce strengthening, actions such as recruit- tributing to health workforce strengthening services across the three ment, salary payment, in-service training, and provision of incen- study districts. The table also provides the mean number of organ- tives were used to list organization. A standard set of questions izations relating with the respondent unit Degree , the density of Likert-scale 1—10 lowest to highest was used to generate informa- the interconnections in the network and the total inter- tion about how vital each relationship was to the performance of the organizational ties that existed for each service in the study districts.

Finally, alongside the socio-metric inter- Gulu district had the highest number of organizations participat- views above, open-ended questions were asked to establish the main ing in maternal delivery and HIV treatment services. In contrast, objectives at the centre of the relationship between the respondent Amuru district had the least. The network size for HIV treatment agency ego and each listed partner alter. For respondent organ- and that of maternal delivery services involved a large set of organ- izations that had many partner organizations, the interviews were izations compared to the network supporting health workforce conducted in two separate appointments each lasting about hour.

The density of a network here refers to the total number of ties divided by the total number of possible ties in the network. To enable comparison for network density, a square Data transformations, analysis and visualization matrix for each service and workforce consisted of all the 87 organ- For this paper, the relational socio-metric data were organized in izations found in the three districts. The number of ties and density symmetrized and dichotomized square matrices and analyzed using of the collaborating organizations in Gulu was about four times UCINET analytical software for social network analysis Borgatti higher than the ones in Amuru. The ties and densities in Kitgum dis- et al.

Separate matrices for HIV treatment, maternal delivery trict lay in between the measures in Gulu and Amuru. Two data transformations were made to facilitate the com- parative analysis of the service networks matrices. First, the data Network structure and membership for each service network matrix was converted to a square matrix The visual graphs of the network Figure 1 illustrate the relational a matrix with the same number of rows and columns. This study districts, while Figure 2 illustrates the structure for organiza- was aimed at generating comparable matrices for analysis. Secondly, tions that were supporting each service in Gulu district.

Different a fourth matrix network was created by adding all the three HIV, colours are used for different organization categories and their pos- Maternal and Workforce matrices in each study district. This cre- ition in the network. For instance, the Gulu district graph shows ated an aggregated matrix in each district composed of all the three more organizations in the HIV service network compared with other services and enabled the comparison of organization structure districts. Gulu also has relatively more fund-holders both at the cen- across the three study districts. Structural differences in the district- tre and at the periphery of the service networks.

Figure 2 shows that level and service-level networks were explored using correlations the service network structure for strengthening workforce activities matrices in UCINET analytical software Borgatti et al. The is more sparse compared with the networks supporting HIV treat- extent the network ties were addressing each of the three selected ment and Maternal services in Gulu district. Similar patterns of net- services was explored by the proportion of ties in each service net- work structure were observed from the perspective of the three work compared with the overall aggregate network for each district districts and the three services.

Other network graphs are available see Figure 4. For visualization and applied interpretations, the from the authors on request. In theory, the organizations with high index core are those tions that were more highly connected core from those that were that are potentially most efficient in terms of mobilizing the district less connected periphery network for the delivery of the selected services. Figure 3 shows the Also analyzed was the qualitative data generated from the list of organizations and the extent to which they are contribute to open questions regarding the purpose served by the listed organiza- the core set of organizations in the network providing the three tion alter with regard to HIV treatment, maternal delivery and focal services in Gulu and Kitgum districts.

Instead of covering all the 87 organizations, the qualitative structure. For Gulu district, there are more fund-holder organiza- analysis focused on 38 organizations that were identified as core tions among the core organizations compared with Kitgum district. Transcripts Unlike Gulu district, where the District Health Office is the most about organization with a centrality measure of 3 and above were highly connected organization, AVSI, a community-based civil soci- used for the qualitative analysis. For the purpose of identifying the ety organization, is most core in Kitgum district. Number, density, degree and network ties in study districts No. Table 3. Support laboratories e. Among the core or- ganizations, 9 out of 19 in Gulu district and 7 out of 17 in Kitgum district were international organizations with perceived Functional roles and objectives in networks short-term 1—2 year commitments to the roles they were serving in From the qualitative findings Table 3 , most central Core organ- these districts.

The pattern of these roles and functions in- dicates that fund-holder organizations played more diverse roles than other organization categories. In particular, fund-holders were Differences in network structure perceived to play prominent roles especially in supporting logistic Figure 4 shows that inter-organization networks are mostly focused functions, medicines, laboratories, technical assistance and informa- on HIV treatment in Gulu and Kitgum and least for workforce tion systems. Service providers and administrative organizations strengthening functions. Community level CSOs were perceived to play a ties contributing to HIV treatment activities ranged from 69 to wide range of roles but with little consistency across the networks.

Despite sparse organizations and interconnections in Amuru Although this study did not assess the funding directly, in districts district, the three services were fairly covered. This indicates that the with more fund-holding agencies like Gulu, opportunities exist for few service organizations in this district were able to support a more more financing of service delivery platforms. Health Policy and Planning, , Vol. Network graphs for organizations supporting the three services in the Study districts 0. Most central organizations in Gulu and Kitgum districts for the three services in the study Discussion and pattern of organizational relationships for service delivery in post- Strategic stewardship of development in post-conflict health systems re- conflict northern Uganda Namakula et al.

In general terms, quires attention to the process of how organizations inter-relate in re- the findings show that the three study districts have different organiza- establishing the wider health system functionality for service provision tional infrastructure to support service delivery. If viewed from the so- at national and sub-national levels Krauss et al. Proportion of organization ties focused on each service per district post-conflict studies Namakula et al. They also show the dominance of HIV programs of inter- that may not be prioritized through voluntary choice. In Uganda, national aid agencies especially in the reconstruction phase after the like many developing countries, the allocation of health develop- conflict NUMAT, ; Westerhaus et al.

In many situations, the allocation ment, maternal delivery and strengthening the health workforce. In the post-conflict setting where ities in the organizational architecture and development of the this study was done, there is clear difference in composition of the health systems at the sub-national level. This is also partly a result of inter-organization networks that supported health workforce prioritizing HIV service provision by heavily funded development strengthening compared with those supporting HIV treatment and and humanitarian NGOs—while workforce investments are usually maternal delivery as well as significant disparity in inter- seen as the responsibility of the national government in both conflict organizational ties across all services in the two older districts, Gulu and non-conflict situations Stierman et al.

This is despite Amuru Studies by Pavignani , Palmer et al. Although this Nonetheless, the few organizations in Amuru demonstrated more study does not cover issues of sustainability, it indicates the vulner- comprehensive ties to all the three services compared to Gulu and ability of service delivery networks in the event that the core organ- Kitgum districts with a lot more organizations.

This may be interpreted as dupli- conflict period Rowley et al. We demonstrate that profiling of core organizations can aid in This finding may also suggests that fewer organizations such as in understanding why some organizations occupy central positions in Amuru district, with a broader and comprehensive program may be the network. By profiling these organizations, their contribution to more effective than having many agencies with a narrow focus at system capacity can be clarified for synergistic developments. Role district level. As reflected in Figure 3, some strengthening. Although this case study is limited to three districts, organizations are central to the network and may provide opportun- our proposition is that districts that serve as hubs for humanitarian ity for leveraging the rest of the network as well as providing oppor- programs at the peak of the conflict e.

Gulu rest of the members. Collaborative interventions to link users and town is also the most economically established trading centre in the providers of HIV services, to control of tobacco in the USA, to re- Acholi sub-region. The inequality reflected in network size and roles duce fragmentation of government bodies in United Kingdom, to calls for purposive approaches for the distribution of organizations implement primary health care programs in Australia and to provide to uphold fair health system developments.

By recognizing the more patterns in health systems strengthening. Among other methods, snowballing among members working collaboratively is widely used along with social network analysis techniques to under- Acknowledgements take this task Wasserman and Faust, This study is supported by the are provided. Most importantly, this approach provides an opportunity to as- sess membership and structure of the collaborating organizations.

Conflict of interest statement. None declared. The intention is to repeat this study in the near future and compare with the baseline findings reported here. This variation over time will be used to assess how organizational networks change in post- References conflict northern Uganda. Critical veys, if linked to decision making, can help to redirect the organiza- interactions between the Global Fund-supported HIV programs and the tions number size, roles and capacity in a manner that strengthen health system in Ghana.

Journal of Acquired Immune Deficiency district-level health systems. Many analyses of health systems pre- Syndromes 57 Suppl 2: S72—6. Audit C. When faced with the ob- Blanchet J, James P. The role of social networks in the governance of jectives of building health systems in highly dynamic settings such as health systems: the case of eye care systems in Ghana. Health Policy and post-conflict setting, decision makers need to find information that Planning — How to do or not to do.

Health Policy Plan — Social Like any study of relationships, the limitations related to recall Networks — Ucinet for Windows: Software from study respondents. This was mitigated to some extent by a val- for Social Network Analysis. Harvard, MA: Analytic Technologies. Commission A. A fruitful Partnership: Effective Partnership Working. Research Strategy — London, UK: Department for respondent indicated an existence of a relationship.

Models for service delivery in conflict-affected environments. Doreian P. Fixed list versus snowball election of social networks. Social Likewise, the assumption of efficiency with increasing size of the Science Research — Fisher J. Third World Quarterly — A comprehensive framework for human resources for health system development in fragile and post- Conclusion conflict states. Plos Medicine 8: e Study Exploring the Evidence level participation, an empirical method like the one used here can Relating Health and Conflict Interventions and Outcomes. Health in Post-Conflict and Fragile States. Special Report Measuring for health system developments. Effective health system stewardship and managing process in the establishment of basic health services: the in complex and dynamic settings will benefit from tools that are Afghanistan health sector balanced scorecard.

International Journal of able to monitor the density, relational structure and roles of health Health Planning and Management — Seeing the forest and the especially in highly dynamic setting similar to post-conflict settings. Social Science and Medicine — International humanitarian actors and governments in areas Pavignani E. Beyond the Aid Horizon: Charting Poorly-Understood of conflict: challenges, obligations, and opportunities. Transition and the Role of NGOs.

Implementing a Abt Associates Inc. Implementation structures: a new unit of adminis- stakeholders. Social Science and Medicine 42—9. When the senior medical officer for the district … is on-board with saying that the nurse practitioners should be doing it, it gets listened to by a lot of people. In contrast to earlier examples of organisational resistance, there were instances where NPs found senior management supportive. Informants recounted circumstances where their local health service manager sought to implement the NP model, particularly for chronic disease management and primary health care. In some cases, NPs were supported with access to professional development, even access to rural generalist medical training and updates NP8.

The micro-level relates to day-to-day practice, in which NPs recounted stories of resistance from some other health professionals. This arose from poor understanding of the NP role, resulting in lack of support from colleagues. It often stemmed from issues of role clarity and relationships as new roles evolved. It's been an interesting journey … , so how do we work with the services that were pre-existing and that's taken two years to sort of work that out really.

Lot of time and effort goes into sorting out the roles in relation to other pre-existing roles. Some NPs did not have a clear job description when they commenced and it was left to them to define their own scope of practice. I had no job description, I had no idea what on earth my role was supposed to be. I just had to hit the ground running and start off by asking questions, seeing what was there and looking for gaps in places that I value, so I probably didn't see a patient for the first six months of my role NP In addition, in many instances, the presence of NPs clearly challenged traditional professional status and hierarchy.

Working in isolation was a barrier for remote area NPs. For one NP working in a remote Aboriginal community it was difficult to organise annual leave coverage, there was little respite and, at times, exposure to personal risk. Not withstanding comments above under micro-barriers, resistance to the NP role from other health professionals was not universal. Some informants received support from other nurses, allied health professionals and doctors. One NP explained that she encountered significant resistance from nursing colleagues and would have resigned if not for the support from medical colleagues.

I had a very supportive regional medical director, a cardiologist and very pro-nursing. Both of those two in terms of mentoring and support were fantastic. I would probably have quit if I didn't have the two of them NP The capabilities of the NPs played an integral role in gaining acceptance from other health professionals and contributing to improvements in service delivery. This appeared to be an important micro-level enabler, with attributes of diplomacy, negotiation, resilience, advocacy and promotion of the role considered important. You have to get out there, you actually have to be the diplomat, be supportive of others and acknowledge their expertise as well and through that you will get buy-in into it.

Another described how, through diplomacy and resilience, resistance eroded over time:. All those places that were resistant have now asked me to consult, so I don't have any areas left now where people don't want me. Drawing on established socio-institutional theory, this study has examined how health care professionals enact extended scope of practice roles in light of the combination of both formal regulatory and institutional and informal normative interprofessional and interactional factors that guide behaviour and shape practice [ 27 , 28 , 29 ].

Management and sociology literature [ 28 ], particularly relating to health professions [ 19 ], suggests that analysis of macro, organisational factors integrated with persistent informal constraints to lowering traditional barriers between professions at the meso- and micro-level can provide insights into barriers and enablers of innovative work practices. The study aimed to examine the ostensibly successful NP practice model to better understand the influences on the development of extended scope of practice more generally, making use of the macro, meso and micro socio-institutional structure.

In relation to the NP model, Haines and Critchley found a relatively narrow range of factors, categorised broadly into barriers and enablers [ 16 ]. Some, such as limited access to education, balanced against having some fee support and designated study time, were also apparent in this study at the macro-level Fig. Common barriers evident across several studies include: other health professionals negative perceptions or lack of awareness of the NP role [ 16 , 18 , 45 ] micro-level ; the inflexibility of the MBS and PBS funding model [ 16 , 45 , 46 ] macro-level ; workload issues, unclear career pathways and lack of peer or management support [ 41 , 45 , 46 ] meso- and micro-level.

Meanwhile, these were potentially balanced against enablers like: building support networks and local teamwork [ 16 , 18 , 45 ] meso-level ; and clarity of leadership and organisational structure [ 41 , 45 ] meso- and micro-level. Some studies broke down barriers and enablers into different levels similar to the structure used in this study, such as the healthcare system, organisational, team and individual practitioner levels [ 41 ] or the policy, workplace and personal levels [ 45 ]. For the most part, there is a considerable degree of cross-over between categories in this and previous studies, although the importance of community understanding and support was more apparent at the meso-level, as was the value placed on negotiation and advocacy of roles micro-level by informants in this study.

Such initiatives have been considered and, in some cases implemented in other countries. Calls have also been made in Australia to boost the capacity of the rural health workforce by, for example, expanding the scope of pharmacists and facilitating the introduction of physician assistants [ 22 , 23 ]. While some progress has been made in the renegotiation of role boundaries, it has been limited. Examining the evolution of NPs through an institutional lens may shed further light on the factors that inhibit the development of other extended scope of practice roles both in Australia and in other developed countries by providing a framework for other health professions to reflect on and potentially formalise extended and advanced practice roles.

Health service innovations are primarily governed by legislative and regulatory provisions and by policy at the macro- and meso-level. It is apparent from extant literature, as well as from the strong views of some informants in this study, that at the macro-level the MBS and PBS are barriers to innovative extended scope of practice models in Australia [ 16 , 22 , 43 ]. It has been argued elsewhere that consideration should be given to revising Medicare legislation and regulations that restrict access to the payment system for most health professionals and potentially increase the cost of health care. While cost is not an isolated issue and service quality and patient safety are priorities, account must also be taken of risks to patients and practitioners of having to work-around perceived restrictive regulatory barriers in order to deliver optimal care in rural and remote locations where service access and availability are limited.

It was also perceived by respondents that barriers persisted around a lack of awareness and understanding of the NP role by managers, at the meso-level. Opportunities to implement NPs roles were either not realised, in which case positions went unfilled, or else funding was limited and short-term. There was a perception that health services were unwilling to commit funds to sustain NP roles, with funding directed elsewhere. Such findings reinforce perceptions that senior management lacks understanding of extended scope of practice roles and the potential to address health service gaps using innovative models of care [ 50 , 51 ].

Established health service models and structures are often inflexible and not adaptable, with managers retaining allegiance to their clinical professional identity and having limited understanding of roles beyond their own occupational domain [ 52 ]. Consequently, NPs apparently spend considerable time explaining, negotiating and advocating for their role micro-level ; time that could perhaps be better spent providing patient care. Indeed, the need to explain and advocate for their role and negotiate role boundaries, implies a need for high-level behavioural competencies and interactional skills in order to be effective in extended scope of practice roles generally, because of threats to professional jurisdiction, whether genuine or perceived.

Such micro-level enablers seemed to counter-balance barriers associated with lack of role clarity at the boundary with medicine [ 54 ], as well as with other nurses and allied health professionals. Where such barriers exist, there is a risk of sabotage of extended roles due to professional jealousy or perceived threats to role distinctiveness [ 55 ]. Preservation of professional identity and hierarchical practice models are common features of the health care system, with the apparent dominance of the medical profession being institutionally embedded [ 56 ]. Medical resistance to the NP model has been identified previously [ 57 , 58 ], arguably stemming from concerns about encroachment on medical scope of practice and threats to power and income [ 59 , 60 ], which apparently manifest at the micro-level.

Some NPs in this study were reminded of their status during professional disagreements with doctors, although details of such interactions were not explored from both sides. In other reported instances, NPs were more likely to find support from medical rather than nursing colleagues, validating perceptions that NPs are increasingly accepted by local doctors [ 54 ], particularly once the scope of practice and benefits are appreciated [ 61 ]. Additionally, once patients understood the scope of the role and the improved access to care, community support was also a strong meso-level enabler. Indeed, patient support for NP roles has been reported internationally [ 62 , 63 ], largely linked to the longer consultations and the focus on patient education components of NP practice [ 64 ].

Challenging the status quo of the health professional hierarchy and traditional models of practice is likely to manifest in predictable patterns, no matter which interprofessional boundary is crossed or shifted. Therefore, examination of barriers and enablers of the rural NP role has potential to inform the evolution other extended scope of practice roles in rural health, with the opportunity to proactively minimise future challenges.

From this perspective there are some strong messages in this study. For example: clearly define and standardise the scope of practice, preferably within a regulatory framework macro-level ; ensure continuing educational and the development of support networks meso- and macro-levels ; appreciate the importance of negotiation with neighbouring occupational groups micro-level ; and promote the extended role to increase awareness of other health professionals and the community meso- and micro-level. However, in Australia, the future development of extended scope of practice roles in other professions is undoubtedly restricted by the current funding model, a major barrier at the macro-level, as it has been for the NP role.

The findings of this study also have implications for human resource management in health care and the development of requisite competencies to maximise the effectiveness of extended scope and advanced practice roles. For those in leadership positions, staff shortages in rural and remote areas are serious challenges that can only be addressed by adequate planning at the meso-level. From a retention perspective, the findings echo those of previous studies [ 65 ], that leadership and supervisor—practitioner relationships are central to positive experiences, influencing intentions to stay, be it in the rural community generally [ 66 ] or specifically in an extended scope of practice role. Health service managers and leaders, both within and beyond the immediate practice environment, must develop the necessary knowledge and abilities to advocate effectively for extended scope of practice roles.

There is a palpable need for relations-oriented leadership behaviours aimed at building commitment and cooperation among different occupations [ 67 , 68 ], both in specific workplaces and across the health care system. Managers and leaders can influence attitudes about and behaviours towards extended roles, as well as advocating across interprofessional, as well as intra- and inter-organisational boundaries. Because in many parts of the world there is an enduring geographic maldistribution of health workforce, there is a persistent need to explore workforce planning and alternative models of care in rural communities [ 69 ].

This study makes a timely contribution in this context, extending the understanding of the barriers and enablers of extended scope of practice in health care. While some previous studies have provided insights into the practical challenges, this study used a multi-level, socio-institutional lens to examine the issues, a method that has its origins in business management.

Few previous studies have examined the barriers and enablers to extended scope of practice roles from a multi-level perspective but none have so coherently integrated the practical insights with a socio-institutional lens. The study sample of primary informants was small, with two having been NP candidates, not yet accredited. This reflects the need as well as the shortage of NPs in non-metropolitan locations, so they were included. Another limitation of the study is that the analysis was confined to NPs, suggesting the findings may be extrapolated to other disciplines.

This approach may be questioned, given differences between the comparatively new, endorsed role of the NP and existing roles of other professions that may aspire to extend the scope of their practice. However, such an approach was necessitated by the lack of extended scope of practice roles in other disciplines in the Australian health care system, recognition of which motivated this study. A further opportunity exists to re-examine the application of the multi-level, socio-institutional lens with health professions in countries other than Australia where extended scope of practice roles are more common and diverse. NPs provide valuable services in rural and remote communities.

The nurse practitioner model illustrates many of the enablers and barriers to the development of extended scope of practice in other health professions and is a valuable source of several lessons. Two key service and policy recommendations arise from this study. Firstly, if underserved communities are to benefit from innovative models of health service delivery, including extended scope of practice, energy needs to be directed towards addressing legislative and regulatory barriers, such as the MBS and PBS in this case study.

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The list features a number of cases related to the interplay of state and commerce and social enterprise, traditional strengths Golden Ratio Research Paper the Yale Health Delivery Organization: A Case Study curriculum. Similarly, the company addressed Health Delivery Organization: A Case Study marketing-agency spending. Qualitative interviews with patients however Health Delivery Organization: A Case Study provide an insight into potentially critically appraise definition Health Delivery Organization: A Case Study aspects of the programme, such Health Delivery Organization: A Case Study greater, perceived patient involvement Health Delivery Organization: A Case Study care.

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