e
p
o
s
a
ú
d
e
p
ú
b
l
i
c
a
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2
0
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3;3
1(2):129–144
www.else ie .p / psp
O iginal
a icle
A
glance
a
he
compe ing
alues
amewo k
o
Quinn
and
he
Miles
&
Snow
s a egic
models:
Case
s udies
in
heal h
o ganiza ions
Luis
F.
Mo ais∗,
Luis
M.
G ac¸a
Escola
Nacional
de
Saúde
Pública,
Lisboa,
Po ugal
a
i
c
l
e
i
n
o
A icle
his o y:
Recei ed
31
May
2012
Accep ed
19
Decembe
2012
A ailable
online
13
Ma ch
2013
Keywo ds:
S a egy
Leade ship
Inno a ion
Change
Heal h
o ganiza ions
Case
s udy
a
b
s
a
c
The
p esen
esea ch
seeks
o
desc ibe
and
unde s and
how
s a egy
influences
leade -
ship
and
how
his
in
u n
in e ac s
in
he
p ocess
o
inno a ion
and
change
in
heal h
o ganiza ions.
This
is
an
explo a o y
and
desc ip i e
s udy
ha
in ol ed
fi e
heal h
o ganiza ions:
ou
Po uguese
and
one
Spanish.
We
used
a
mixed
app oach
o
esea ch
(quali a i e
and
quan-
i a i e),
which
enabled
us
o
unde s and,
h ough
case
s udy,
how
s a egy
and
leade ship
we e
a icula ed
wi h
inno a ion
in
hese
fi e
heal h
o ganiza ions.
Despi e
hei
complexi y
and
specifici y,
bo h
he
model
o
Miles
&
Snow
(o ganiza ional
s a egy)
and
he
model
o
he
Compe ing
Values
F amewo k
o
Quinn
(o ganiza ional
cul-
u e
and
leade ship),
sui ably
adap ed,
ha e
p o en
heu is ic
powe
and
a e
able
o
be
applied
o
heal hca e
o ganiza ions.
Public
and
p i a e
heal hca e
o ganiza ions,
as
well
as
public–p i a e
pa ne ships,
can
be
acked
and
moni o ed
in
hei
p ocesses
o
inno a ion
and
change
in
o de
o
unde s and
i s
kind
o
cul u e,
leade ship
o
o ganiza ional
s a egy
adop ed.
Heal h
o ganiza ions
coexis
in
a
con inuum,
whe e
he
en i onmen
(in e nal
and
ex e nal)
and
ime
a e
key
ac o s
which
de e mine
he
s a egy
o
be
adop ed.
He e
oo
depending
on
he
dynamic
and
complex
eali y
whe e
he
o ganiza ion
mo es,
he e
a e
no
pu e
ypes.
The e
is
indeed
a
g ea
o ganiza ional
plas ici y
and
flexibili y.
Leade s
usually
ca y
he
o mal
au ho i y
by
ci cula
no ma i e.
They
a e
no
pai s
(o
p imi
in e
pa es).
Ins ead
hey
a e,
some imes,
in
a
posi ion
o
supe io i y,
when
he
bes
hing
is
pa ne ship,
collabo a ion,
coope a ion,
building
consensus
and
coope a ion
wi h
all
s akeholde s,
in
o de
ha
hey
a e
he
eal
p o agonis s
and
acili a o s
o
change
and
inno a ion.
©
2012
Escola
Nacional
de
Saúde
Pública.
Published
by
Else ie
España,
S.L.
All
igh s
ese ed.
∗Co esponding
au ho .
E-mail
add ess:
luismo ais@chm .min-saude.p
(L.F.
Mo ais).
0870-9025/$
–
see
on
ma e
©
2012
Escola
Nacional
de
Saúde
Pública.
Published
by
Else ie
España,
S.L.
All
igh s
ese ed.
h p://dx.doi.o g/10.1016/j. psp.2012.12.006
130
e
p
o
s
a
ú
d
e
p
ú
b
l
i
c
a
.
2
0
1
3;3
1(2):129–144
Es a égia,
lide anc¸a
e
ino ac¸ão
à
luz
dos
modelos
de
es a égia
de
Quinn
e
de
Miles
&
Snow:
es udos
de
casos
nas
o ganizac¸ões
de
saúde
Pala as-cha e:
Es a égia
Lide anc¸a
Ino ac¸ão
Mudanc¸a
O ganizac¸ões
de
Saúde
Es udo
de
caso
e
s
u
m
o
A
p esen e
in es igac¸ão
p ocu a
desc e e
e
comp eende
como
a
es a égia
influencia
a
lide anc¸a
e
como
es a,
po
sua
ez,
in e age
nos
p ocessos
de
ino ac¸ão
e
mudanc¸a
em
o ganizac¸ões
de
saúde.
T a a-se
de
um
es udo
explo a ó io
e
desc i i o
que
en ol eu
cinco
o ganizac¸ões
de
saúde,
qua o
po uguesas
e
uma
espanhola.
U ilizou-se
uma
abo dagem
mis a
de
in es igac¸ão
(quali a i a
e
quan i a i a),
que
pe mi iu
comp eende ,
a a és
do
es udo
de
caso,
como
se
a iculam
a
es a égia,
a
lide anc¸a
e
a
ino ac¸ão
nessas
cinco
o ganizac¸ões
de
saúde.
Tan o
o
modelo
de
Miles
&
Snow
(es a égia
o ganizacional)
como
o
modelo
dos
al-
o es
con as an es
de
Quinn
(cul u a
o ganizacional
e
lide anc¸a),
de idamen e
adap ados,
mos am-se
heu ís icos
e
p o am
pode
aplica -se
às
o ganizac¸ões
de
saúde,
apesa
a
sua
complexidade
e
especificidade.
As
o ganizac¸ões
do
se o
público
como
do
se o
p i ado
e
o ganizac¸ões
públicas
conces-
sionadas
(pa ce ias-público
p i adas)
podem
se
acompanhadas
e
moni o izadas
nos
seus
p ocessos
de
ino ac¸ão
e
mudanc¸a,
associados
aos
ipos
de
cul u a,
lide anc¸a
ou
es a égia
o ganizacionais
ado ados.
As
o ganizac¸ões
de
saúde
coabi am
num
con inuum,
onde
o
ambien e
(que
in e no
que
ex e no)
e
o
empo
são
a o es
decisi os
que
condicionam
a
es a égia
a
ado a .
Também
aqui,
em
unc¸ão
da
ealidade
dinâmica
e
complexa
onde
a
o ganizac¸ão
se
mo e,
não
há
ipologias
pu as.
Há,
sim,
uma
g ande
plas icidade
e
flexibilidade
o ganizacionais.
Quan o
aos
líde es
exe cem,
habi ualmen e,
a
au o idade
o mal
pela
ia
da
ci cula
no ma i a.
Não
são
pa es
(nem
p imi
in e
pa es).
Colocam-se
po
ezes
numa
posic¸ão
de
supe io idade,
quando
o
mais
adequado
se ia
a
elac¸ão
de
pa ce ia,
coope ac¸ão
e
p ocu a
de
consensos,
com
odos
os
colabo ado es,
a
fim
de
se em
eles
os
e dadei os
p o agonis as
e
acili ado es
da
mudanc¸a
e
das
ino ac¸ões.
©
2012
Escola
Nacional
de
Saúde
Pública.
Publicado
po
Else ie
España,
S.L.
Todos
os
di ei os
ese ados.
In oduc ion
O ganiza ional
pe o mance
is
mo e
and
mo e
based
on
e ec i e
knowledge
managemen
and
comp ehensi e
unde -
s anding
o
he
economic
alue
o
human
capi al.1Howe e ,
o ganiza ional
cul u e
unde pins
knowledge
managemen
by
influencing
he
way
membe s
lea n
and
sha e
knowledge.
O ganiza ional
cul u e
has
been
iden ified
as
he
main
obs a-
cle
o
knowledge
managemen .2
The e
a e
e y
ew
esponses
o
he
c ucial
ques ion
abou
how
o ganiza ional
cul u e
enables
o
obs uc s
knowledge
managemen .
A
g ea
challenge
in
he
esea ch
li e a u e
is
o
find
models
and/o
ypologies
gi ing
he
cha ac e is ics
o
o ganiza ional
cul u e,
like,
o
example,
he
O ganiza ional
Cul u e
P ofile3and
he
Compe ing
Values
F amewo k.4
Empi ical
esea ch
aiming
o
examine
he
ela ion-
ship
be ween
leade ship
and
o ganiza ional
cul u e
is
well
de eloped.5,6 In
spi e
o
his,
he e
is
a
lack
o
sound
heo y
o
elucida e
how
o ganiza ional
cul u e
can
impac
he
sus ainable
p ocess
o
knowledge
c ea ion
and
ans-
e .
The
Miles
and
Snow
(1978)
s a egic
choice
ypology
is
now
well
known.
In
he
las
25
yea s
his
model
has
been
widely
ci ed
in
bo h
he
managemen
and
ma ke ing
s a egy
li e a u es.7–11
The
ypology’s
longe i y
and
excellence
a e
due
o
i s
h ee
basic
ea u es:
(i)
inna e
pa simony,
(ii)
indus y-independen
na u e,
and
(iii)
co espondence
wi h
he
ends
in
business
and
managemen
ac oss
di e en
sec o s
and
coun ies.9
Acco ding
o
Miles
and
Snow
(1978),
s a egy
is
no hing
bu
a
se
o
decisions
by
which
a
c ucial
business
uni
aligns
i s
manage ial
p ocesses
wi h
i s
pe inen
en i onmen .
O ga-
niza ions
a e
hen
classified
on
he
basis
o
hei
decisional
pa e ns
in o
he
P ospec o –Analyze –De ende –Reac o
ame-
wo k.
(i)
P ospec o s
a e
echnologically
inno a i e
and
seek
ou
new
ma ke s,
(ii)
Analyze s
end
o
p e e
a
‘second-bu -be e ’
s a egy,
(iii)
De ende s
a e
enginee ing-o ien ed
and
ocus
on
main aining
a
secu e
niche
in
ela i ely
s able
ma ke
seg-
men s,
and
(i )
Reac o s
lack
a
s able
s a egy
and
a e
highly
esponsi e
o
sho - e m
en i onmen al
exigencies.
Theo e ical
backg ound
The
Compe ing
Values
F amewo k
The
Compe ing
Values
F amewo k
(CVF)
has
been
widely
used
in
heal h
o ganiza ions
s udies
and
esea ch
o
e alua e
hei
cul u e,
being
a
p edic o
o
such
ou comes
like
qual-
i y
imp o emen ,
eam
building,
o
pa ien
and
p o essional
sa is ac ion.
e
p
o
s
a
ú
d
e
p
ú
b
l
i
c
a
.
2
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1
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1(2):129–144
131
S abili y and
con
ol
Human
ela
io
ns
mode
l
Pa
icipa
ion
, con
lic esolu ion
and
consensus building
Coope a i
e eamwo k
Open
sys ems
mode
l
Adap
a ion and
inno a ion
Open sys em
Ra ional
goal
mode
l
P oduc i i y and p o i
Ra ional i m
In e nal p ocess mode
l
Flexibili y
Ex e nal Focus
and di e en
ia ion
In e nal
Focus
and
in eg a
ion
De ining esponsibili y,
mea
su emen
and
documen a ion
S able hie a
chy
• P odu
ce
• Di ec
o
• Mon
i o
• Coo
dina
o
• Men
o
• Facili a o
• Inno
a o
• B oke
Suppo
cul u
e
Mon
i o
c
ul u
e
Rule cul u e Objec
i e
cul u
e
Fig.
1
–
Compe ing
Values
F amewo k
o
Quinn
(1988).
Sou ce:
Re s.
12,13.
Adap a ion
om
Re .
4.
CVF
is
one
o
he
mos
popula
and
heu is ic
concep ual
amewo ks
de eloped
in
he
ea ly
1980s,
o
in eg a e
he
main
dimensions
o
o ganiza ional
“e ec i eness”.5,6 “I
was
de el-
oped
in
esponse
o
he
need
o
a
b oadly
applicable
model
ha
would
os e
success ul
leade ship,
imp o e
o ganiza-
ional
e ec i eness,
and
p omo e
alue
c ea ion”.5,6
I
is
a
syn hesis
o
o ganiza ional
heo ies,
which
cha ac-
e ize
o ganiza ions
in
wo
dimensions
(1.
flexibili y
–
s abili y
and
con ol;
2.
in e nal
en i onmen
–
ex e nal
en i onmen ),
each
ep esen ing
al e na i e
app oaches
o
basic
challenges
ha
mus
esol e
in
o de
o
unc ion.5
The
fi s
dimension
o
CVF
is
he
deg ee
o
which
an
o ga-
niza ion
emphasizes
decen aliza ion
and
flexibili y
e sus
cen aliza ion
and
con ol
o e
o ganiza ional
p ocesses.
The
second
dimension
o
CVF
is
he
deg ee
o
which
he
o ga-
niza ion
is
o ien ed
owa ds
he
ex e nal
en i onmen
and
ela ionships
wi h
ou side
s akeholde s,
such
as
egula o s,
supplie s,
compe i o s,
pa ne s
and
cus ome s,
e sus
i s
own
in e nal
en i onmen
and
p ocesses.
C oss-classi ying
o ganiza ions
on
hese
wo
alue
dimensions
esul
in
ou
a che ypes,
e e ed
o
as
hie a chical,
a ional,
en ep eneu ial,
and
eam
cul u es
(Fig.
1).
In
he
CVF,
o ganiza ions
wi h
an
in e nal
ocus
and
emphasis
on
con ol,
labelled
hie a chical
cul u es
(also
some imes
e e ed
o
as
bu eauc a ic
cul u es),
adop
cen al-
ized
au ho i y
o e
o ganiza ional
p ocesses;
espec
o mal
hie a chy;
and
adhe e
o
ules.
They
ocus
on
s abili y
and
p e-
dic abili y.
O ganiza ions
wi h
an
in e nal
ocus
and
emphasis
on
flexibili y,
labelled
eam
cul u es,
encou age
b oad
pa ic-
ipa ion
by
employees,
emphasize
eamwo k
and
empowe -
men ,
and
make
human
esou ce
de elopmen
a
p io i y.
O ganiza ions
wi h
an
ex e nal
ocus
and
emphasis
on
flexibili y,
labelled
en ep eneu ial
cul u es,
exhibi
c ea i i y
and
inno a i eness;
hey
ocus
on
g ow h
and
expanding
esou ces.
Finally,
o ganiza ions
wi h
an
ex e nal
ocus
and
an
emphasis
on
con ol,
labelled
a ional
cul u es,
a e
cha ac-
e ized
by
cla i y
o
asks
and
goals.
They
ocus
on
e ficiency
and
measu able
ou comes.
These
ou
cul u es
a e
p oposed
as
a che ypes.
In
eal-
i y,
o ganiza ions
a e
expec ed
o
eflec
all
ou
cul u es
o
some
deg ee.
Acco ding
o
CVF,
he e
is
a
dominan
cul u e
(mani es ing
i sel
in
he
iews
o
employees
a
all
le els
o
he
o ganiza ion),
bu
he e
is
no
one
bes
o ganiza ional
cul-
u e:
all
ou
cul u es
can
ope a e
in
a
gi en
o ganiza ion
and
wi h
ela i e
s abili y
o e
ime.
Leade ship
is
ano he
key
concep
in
he
amewo k.
Eigh
ca ego ies
o
leade
beha iou
eme ge
om
Quinn’s
e iew
o
he
li e a u e.
Table
1
summa izes
hei
cha ac e is ics.
“The
p ocess
o
di e en ia ion
and
in eg a ion
is
also
ypical
o
esea ch
on
leade ship”.5,4 “Ano he
key
finding
in
o ganiza-
ional
s udies
is
ha
mo e
success ul
companies
a e
mo e
di e en ia ed
as
well
as
mo e
in eg a ed
han
less
success ul
companies”.5,4
The
Miles
and
Snow
ypology
Miles
and
Snow
ha e
had
pionee ing
e o s
a
linking
s a -
egy,
s uc u e,
p ocess
and
managemen
mindse .
I
is
a
model
o
oday’s
esea che s
who
seek
o
be
bo h
academically
espec able
ye
manage ially
ele an .
Based
on
empi ical
esea ch
conduc ed
in
ou
indus ies
( ex book
publishing,
elec onics,
ood
p ocessing,
and
heal h
ca e),
Miles
and
Snow14 p oposed
a
s a egic
ypology
classi y-
ing
companies
in o
ou
dis inc
g oups:
P ospec o s,
Analyze s,
De ende s,
and
Reac o s
(Table
2).
P ospec o s
lead
change
in
hei
indus ies
(e.g.
launching
new
p oduc s,
iden i ying
new
ma ke place
oppo uni ies).
De ende s
a e
mo e
engaged
o
main ain
a
secu e
ma ke
niche,
132
e
p
o
s
a
ú
d
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p
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2
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1
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1(2):129–144
Table
1
–
Compe ing
Values
F amewo k:
Leading
beha iou
cha ac e is ics.
Leade ship
pape
E alua ion
ques ions
Beha iou s
associa ed
Ex e nal/in e nal
Flexibili y/con ol
Men o
Shows
empa hy
and
in e es
in
he
beha iou
wi h
subo dina es;
ea s
each
pe son
sensi i e
and
a en i e
Pe son
commi ed
by
wo y
in
he
de elopmen
o
people
and
i s
o ien a ion
In e nal
Flexibili y
Facili a o
Fades
key
di e ences
be ween
g oup
membe s;
encou ages
he
pa icipa i e
decision-making
in
he
g oup
Pe son
who
de elops
collec i e
e ec s,
eamwo k,
gene a e
in e pe sonal
conflic s
and
build
cohesion
In e nal
Flexibili y
Inno a o Implemen
new
concep s
and
new
ideas
Pe son
who
expec ed
a
acili a o
o
change
Ex e nal
Flexibili y
B oke
Influences
o ganiza ion;
influences
decisions
Pe son
who
is
pa icula ly
conce ned
in
main aining
ex e nal
legi imacy
as
well
as
in
ob aining
ex e nal
esou ces
Ex e nal
Flexibili y
P oduce
Mo es
he
se ice
in
acco dance
wi h
he
p oposed
objec i es
Task-o ien ed
Pe son,
ocused
on
high
in e es :
mo i a ion,
ene gy,
and
conduc ing
Human
Resou ces
Ex e nal
Con ol
Di ec o
Makes
he
ole
o
se ice
e y
clea ;
cla ifies
he
p io i ies
and
di ec ions
o
se ice
Pe son
las s
in
i s
a i ude
o
leade ship
and
known
by
i s
u ili y
and
absence
o
ake
ials
Ex e nal
Con ol
Moni o
Main ains
a
igh
con ol
logis ic;
compa es
eco ds,
epo s
and
o he
ele an
in o ma ion
o
de ec
disc epancies
Pe son
who
knows
wha
is
happening
in
he
uni
and
see
i
con ibu o s
abide
by
he
ules
and
objec i es
o
he
same
In e nal
Con ol
Coo dina o
An icipa es
he
p oblems
o
wo k
be o e
c isis
began
Pe son
who
main ain
he
s uc u e
and
flow
o
he
sys em
In e nal
Con ol
Sou ce:
Re s.
12,13.
Adap a ion
om
Re .
4.
o e ing
a
s able
p oduc
o
se ice.
De ende s
ocus
mo e
on
e ficiency,
and
manu ac u ing
cos s,
wo king
wi hin
a
limi ed
ange
o
p oduc s.
Analyze s
sha e
ai s
o
bo h
P ospec o s
and
De ende s.
Analyze s
a e
mo e
likely
o
ollow
a
second-bu -be e
s a egy.
In
he
wo ld
o
business,
an
Analyze
s a egy
com-
pe es
some imes
as
a
De ende ,
and
o he
imes
as
a
P ospec o ,
since
i
equi es
subs an ial
esou ces
o
be
able
o
do
bo h
Table
2
–
Miles
and
Snow’s
ypology.
O ien a ion
Desc ip ion
De ende
O ganiza ions
wi h
his
o ien a ion
end
o
ha e
a
na ow
p oduc /ma ke
domain.
They
will
y
o
c ea e
and
main ain
a
niche
wi h
a
limi ed
ange
o
p oduc s
o
se ices.
I
also
has
a
na ow
echnological
base
(because
o
i s
na ow
domain).
I
does
no
a emp
o
sea ch
ou side
i s
domain
o
new
oppo uni ies.
Hence,
i
becomes
highly
dependen
on
i s
na ow
p oduc /ma ke
a ea.
As
a
esul ,
i
ies
o
p o ec
i s
domain
h ough
lowe
p ices,
highe
quali y,
supe io
deli e y,
and
so
o h.
The
s uc u e
o
a
de ende
fi m
is
cha ac e ized
by
an
elabo a e
o mal
hie a chy
and
high
deg ee
o
cen alisa ion.
P ospec o
A
p ospec o
o ganiza ion
con inually
sea ches
o
new
oppo uni ies.
I
has
a
b oad
and
flexible
p oduc /ma ke
domain
and
hence
a
b oad
echnological
base.
They
usually
c ea e
change
and
unce ain y
in
he
en i onmen .
I s
s uc u e
is
cha ac e ized
by
a
low
deg ee
o
o maliza ion
and
ou iniza ion,
decen aliza ion,
and
la e al
as
well
as
e ical
communica ion.
Such
a
fi m
esponds
quickly
o
ea ly
signals
o
oppo uni ies
and
is
usually
he
fi s
o
en e
a
new
p oduc /ma ke
a ea.
I
is
no
necessa ily
success ul
in
all
o
i s
endea ou s,
no
is
i
e y
e ficien
since
p oduc /ma ke
inno a ion
is
a
majo
conce n
o
such
an
o ganiza ion.
Analyze
An
o ganiza ion
wi h
his
o ien a ion
has
cha ac e is ics
o
bo h
he
de ende
and
p ospec o
o ien a ions.
I
ends
o
main ain
a
s able
and
limi ed
domain,
while
a
he
same
ime
cau iously
mo ing
in o
a
new
domain
only
a e
i s
iabili y
has
been
p o en
by
p ospec o s.
Analyze s
a e
imi a o s
in
such
a
way
ha
hey
ake
he
p omising
ideas
o
p ospec o s
and
success ully
ma ke
hem.
They
seek
flexibili y
as
well
as
s abili y.
They
adop
s uc u es
ha
can
accommoda e
bo h
s able
and
changing
domains.
Reac o
This
o ganiza ion
does
no
ha e
long
e m
goals
o
a icula ed
s a egies,
and
hence
no
consis en
pa e n
o
beha iou .
The
o ganiza ion
is
passi e
in
dealing
wi h
a ious
issues.
I
does
no
a emp
o
main ain
a
defined
p oduc /ma ke
domain,
no
does
i
y
o
capi alize
on
iable
en i onmen al
oppo uni ies.
Sou ce:
Re s.
12,13.
Adap a ion
om
Re .
14.
e
p
o
s
a
ú
d
e
p
ú
b
l
i
c
a
.
2
0
1
3;3
1(2):129–144
133
The en
ep eneu ial
p ob
lem
The enginee ing
p ob
lem
The adminis a i e
p ob
lem
Fig.
2
–
Miles
and
Snow’s
adap i e
cycle.
Sou ce:
Re s.
12,13.
Adap a ion
om
Re .
14.
simul aneously.
These
h ee
s a egic
ypes
(P ospec o s,
Ana-
lyze s,
and
De ende s)
a e
consis en
in
hei
s a egic
selec ion,
and
will
pe o m
well
so
long
as
hei
implemen a ion
is
e ec-
i e.
The
adap i e
cycle
is
he
co e
model
o
he
Miles
and
Snow
(Fig.
2)
s a egic
choice
ypology,
and
defines
he
dynamic
p ocess
in
which
o ganiza ions
con inually
adjus
in e nal
in e dependencies
o
en i onmen al
oppo uni ies
and
isks.
“Miles
and
Snow
ca alyzed
subsequen
esea ch
on
he
accom-
panimen s
o
each
s a egy
ype
by
in oducing
he
idea
o
he
‘adap i e
cycle’.
This
insigh ul
me apho
po ays
busi-
ness
as
pe pe ually
cycling
h ough
se s
o
decisions
on
h ee
on s”.14,9
They
defined
h ee
majo
p oblems
ha
o ganiza-
ions
mus
con inually
sol e
in
o de
o
be
e ec i e:
(i)
En ep eneu ial
p oblem
(choice
o
p oduc
ma ke
domain);
(ii)
Enginee ing
p oblem
(how
o
de elop
he
echnical
and
o ga-
niza ional
sys em
in
o de
o
p oduce
and
deli e
hese
goods);
and
(iii)
Adminis a i e
p oblem
(selec ion
o
a eas
o
u u e
inno a ion
–
he
leading
aspec ;
a ionaliza ion
o
s uc u e
and
p ocess
–
he
lagging
aspec ).
Adap a ion
o en
occu s
by
mo ing
sequen ially
h ough
he
en ep eneu ial,
enginee ing
and
adminis a i e
phases,
bu
in
ma u e
o ganiza ions,
each
o
hese
h ee
managemen
p oblems
ends
o
occu
mo e
o
less
simul aneously.14
Ma e ials
and
me hods
Leade ship
and
s a egy
in
con ex
o
inno a ion
in
heal h
o ganiza ions
is
a
opical
issue,
and
he
bounda ies
be ween
he
phenomenon
and
con ex s
dese e
sc u iny.
I
we
wan
o
know
he
‘why’
o
he
‘how’
o
ela e
wo
a iables,
we
op
o
a
me hodology
ha
allows
us
o
explain
he
causal
links
in
in e en ions
o
eal
li e
si ua ions,
which
a e
oo
complex
o
ea men
h ough
expe imen al
s a e-
gies
and
da a
collec ion.15 The
in o ma ion
and
knowledge
abou
leade ship
and
inno a ion
a e
dispe sed
and
punc ual.
This
s udy
is
impo an
o
pa ien s
because
i
allows
echno-
logical
sophis ica ion
and
he
use
o
inno a i e
p ocesses
a
managemen
le el.
In
his
esea ch
some
impo an
ac o s
make
us
pon-
de
he
ques ion
‘how’,
as15 leads
o
a
s udy
ha
allows
unde s and
and
explain
phenomena.
And
hese
ac o s
a e,
among
o he s,
he
ollowing:
(i)
he
small
numbe
o
heal h
o ganiza ions,
(ii)
he e
is
no
a
uni o m
g oup,
and
(iii)
he
complexi y
o
he
p ocess.
So,
a
quan i a i e
and
quali a i e,
mixed,
app oach
seemed
mo e
app op ia e.
Tha
means
es ablishing
a
causal
ela ionship
be ween
leade ship,
s a egy
and
inno a ion
(socio- echnical
and
echnical-o ganiza ional).
This
s udy
p e-
ends
o:
(i)
be e
unde s and
he
dynamics
inno a ion
and
i s
dissemina ion
and
(ii)
unde s and
how
leade ship
is
exe cised
in
he
con ex
o
s a egy
and
inno a ion.
Gi en
he
esea ch
model
used,
he
complexi y
o
he
heal h
sec o ,
he
exis ence
o
di e en
legal
s a us
(EPE,
SPA,
PPP)
in
Po uguese
hospi als,
he
p oli e a ion
o
heal h
inno-
a ion
and
he
suppo
o
inno a ion
in
e ms
o
p ocesses
and
managemen ,
i
is
impo an
o
ca e ully
choose
he
bes
me hodology.
So,
he
desi e
o
unde s and
and
in es iga e
a
complex
social
phenomenon,
con empo a y
in
i s
eal
con ex ,
and
using
mul iple
sou ces
o
e idence,
led
us
o
choose
he
case
s udy.
Resea ch
ques ion
The
main
ques ion
we
wan
o
see
answe ed
is
he
ollow-
ing
one:
How
ha e
he
leade ship
and
s a egy
in
con ex
o
inno a ion
de eloped
in
heal hca e
o ganiza ions?
This
p oblem
is
ele an
o
heal h
managemen
and
he
ma e s
augh
in
he
pos g adua e
aining
cou ses
o
man-
age ’s
heal h
o ganiza ions.
The
ele ance
a ises
because
leade ship
and
s a egy
in
he
con ex
o
inno a ion
will
ha e
se e al
implica ions:
(i)
economic
ones
(di ec
cos
implica ions
in
he
case
o
ech-
nological
inno a ions,
and
mo e
indi ec
cos
implica ions,
o
example,
wi h
new
o ms
o
managemen ,
ega dless
whe he
we
wan
o
u he
imp o e
he
pe o mance
o
he
o ganiza-
ion),
(ii)
legal
and
bioe hical
( hese
new
echnologies,
including
new
he apeu ic
weapons,
a e
mo e
o
less
in asi e),
and
(iii)
people’s
heal h
( hese
inno a ions
can
imp o e
he
quali y
o
li e
o
he
ci izen/pa ien ).
Model
analysis
In
his
s udy,
i
is
conside ed
ha
o ganiza ions
and
hei
s a -
egy
a e
influenced
by
(i)
he
indoo
en i onmen
(s a /line
–
heal h
p o essionals/manage s;
double
hie a chy
–
medical
di ec ion/di ec ion
o
nu sing
s uc u e,
mo e
o
less
e i-
cal;
empowe men
–
bo h
o
pa ien s/s akeholde s
as
ce ain
heal h
p o essions/associa ions
o
pa ien s),
and
(ii)
he
ex e -
nal
en i onmen
(policies,
s akeholde s
–
p o essional
bodies,
pa ien s’
associa ions,
unions,
finally,
socie y,
he
bodies
ha
o e see/legisla e/finance
heal h
o ganiza ions).
The
inno a ion
equi es
a
s a egy
change.
Subsequen ly
e ol es
a
be e
o ganiza ional
pe o mance
by
using
quali y
ools,
and
ocusing
on
alues,
ision,
objec i es
and
p oce-
du es
o
heal h
o ganiza ions.
This
way,
heal h
o ganiza ions
achie e
a
high
deg ee
o
o ganiza ional
pe o mance.
These
o ganiza ions
a e
complex,
socio- echnical
sys ems,
and
so,
a e
open
o
con inually
adjus
hei
en i onmen .
Fo
he
p esen
s udy
a
la ge
numbe
o
a iables
we e
used
ha ,
di ec ly
o
indi ec ly,
influence
he
s a egy,
inno a ion
and
leade ship
o
heal h
o ganiza ions.

134
e
p
o
s
a
ú
d
e
p
ú
b
l
i
c
a
.
2
0
1
3;3
1(2):129–144
Design
o
s udy
The
case
mus
be
ea ed
as
an
in eg a ed
sys em.
This
means
ha
he
da a
e ie ed
he e,
al hough
cons i u e
new
o ms
o
knowledge
on
he
subjec ,
a e
no
ep esen a i e
o
he
whole
issue,
conce ning
he
case
s udy
in o
i s
con ex .16 The
case
s udy
goes
beyond
any
o m
o
his o y,
desc ip ion
o
e en s
o
ci cums ances,
since
he
da a
a e
collec ed
sys ema ically,
he
ela ionship
be ween
a iables
is
s udied
and
he
s udy
is
me hodically
planned.17
Howe e ,
he
case
s udy
as
a
esea ch
me hod
includes
se e al
c i icisms:
(i)
lack
o
accu acy,
(ii)
alse
e idence,
(iii)
isk
o
biased,
subjec i e
iews
o
he
esea che ,
(i )
p o-
iding
li le
basis
o
gene aliza ions
and
li le
con ibu ion
o
knowledge,
( )
e y
ex ensi e
and
ime
consuming
o
com-
ple e,
and
( i)
use ul
o
gene a ing
hypo heses,
whe eas
o he
me hods
a e
mo e
use ul
o
es ing
hypo heses.18
We
ha e
adap ed
he
me hodology
o
case
s udy,
whe e
some
o ganiza ions
will
be
s udied
and
obse ed.
This
me hod
is
used
when
he
ocus
o
esea ch
is
o
answe
he
“how”
and
he
“why”.19
The
aim
is
o
s udy
he
selec ed
ins i u ions
h ough
key
ac o s.
We
chose
a
su ey,
because
i
is
a
sui able
echnique
o
his
s udy.
Despi e
being
one
o
he
mos
widely
used
ech-
niques
o
empi ical
esea ch
in
a ious
fields
o
knowledge,20
i
should
only
be
used
o
ga he
ac s
abou
phenomena
ha
a e
no
di ec ly
measu able
o
obse able
om
he
ou side.
I
we
wan
o
iden i y,
desc ibe
o
e alua e
we
mus
see:
(i)
he
impo ance
gi en
o
inno a ion,
leade ship
and
s a egy
by
he
op
managemen ,
(ii)
he
ac o s
(inhibi o s/ acili a o s)
ha
influence
he
p ocess
leading
o
inno a ion,
and
(iii)
o
wha
ex en
he
o ganiza ional
s a egy
a ec s
he
exe cise
o
leade ship
in
he
con ex
o
inno a ion
in
heal hca e
o gani-
za ions.
I
is,
howe e ,
a
echnique
ha
has
limi a ions
ega ding
he
deg ee
o
dep h
o
in o ma ion
collec ed.
I
has
ce ain
disad an ages:
(i)
less
spon anei y
in
esponse,
(ii)
less
assu -
ance
o
comple e
esponse
o
he
ques ionnai e,
(iii)
ailu e
o
gua an ee
ha
he
sequen ial
o de
o
ques ions
is
espec ed
(as
i
is
a
sel -adminis a ion
o
sel - esponse),
(i )
possibili y
o
lowe
comple e
esponse
o
he
ques ionnai e,
and
( )
di fi-
cul y
in
concep ion.
The
ad an ages
will
include:
(i)
inc eased
co e age
o
popula ion
wi h
a
minimum
cos ,
(ii)
g ea e
assu -
ance
o
confiden iali y
and
anonymi y,
(iii)
g ea e
uni o mi y
in
how
he
ques ions
a e
pu
o
he
esponden s,
(i )
sys em-
a ic,
( )
simplici y
o
analysis,
and
( i)
as e
in
he
selec ion
and
analysis
o
da a.21
The
p oduc ion
o
knowledge
esul s
om
he
defini ion
o
ac o s,
aking
in o
accoun
hei
subjec i i y
and
hei
indi idual
expe ience,
i.e.
he
in eg a ion
o
quali a i e
and
quan i a i e
da a
in
a
single
s udy.22
Quali a i e
me hods
a e
be e
sui ed
o
explo a o y
esea ch,
which
migh
gi e
clues
and
gene a e
hypo hesis
o
esea ch,
while
quan i a i e
me hods
a e
needed
o
e ifi-
ca ion
pu poses.23,24 Quan i a i e
analysis
can
also
help
o
cla i y
and
shape
he
findings
in
quali a i e
analysis.
The
quan i a i e
esea ch
is
assumed
as
a
sys ema ic
p ocess
o
da a
collec ion
(obse able
and
measu able),
and
is
based
on
he
obse a ion
o
objec i e
ac s,
e en s
and
phenomena
ha
exis
independen ly
o
he
in es iga o .
This
app oach
eflec s
a
complex
p ocess
ha
leads
o
esul s
ha
should
con ain
he
lowes
possible
bias.25 In
he
quan i a-
i e
pa adigm,
esea che s
collec
da a
o
es ablish
ela ions
be ween
hem
( echniques
which
lead
o
quan i a i e
findings
can
be
gene alized).26
The
p esen ed
p oblems
and
he
heo e ical
basis
e iew
allow
he
de elopmen
o
a
s udy
wi h
he
ollowing
cha -
ac e is ics:
(i)
Explo a o y
–
because
i
is
a
case
s udy
and
he
in en ion
is
o
answe
‘how
o
exe cise
leade ship
and
o
define
he
s a egy
in
he
con ex
o
inno a ion
in
heal h
ca e
o ganiza ions’;
(ii)
Desc ip i e
–
since
i
is
p oposed
o
s udy
leade ship
and
s a egy
in
a
con ex
o
inno a ion
in
heal h
ca e
o ganiza ions.
Me hods
and
echniques
o
da a
collec ion
We
used
in ensi e
echniques,
such
as
he
applica ion
o
s uc u ed
in e iews
(membe s
o
he
Boa d),
documen
anal-
ysis,
di ec
obse a ion,
and,
in
addi ion,
he
applica ion
o
a
ques ionnai e
su ey
o
adminis a o s,
clinical
di ec o s
and
nu sing
di ec o s,
Di ec o s
o
Depa men
and
Se ice
as
well
as
chie
nu ses
and
coo dina o s,
in
o de
o
enhance
he
qual-
i y
and
quan i y
o
in o ma ion.
A
s a egy
was
hus
es ablished
which
ocuses
on
a
quali-
a i e
app oach
which
do
no
neglec
he
quan i a i e
aspec s,
aiming
o
cha ac e ize
he
leade ship
and
s a egy
in
he
con-
ex
o
inno a ion
in
heal h
o ganiza ions.
Explo a o y
in e iews
We
p epa ed
an
in e iew
guide
o
explo a o y
in e iews
o
se ice
di ec o s,
head
nu ses,
adminis a o s
and
some
mem-
be s
o
he
boa d,
in ending
o
add ess
he
issues
aised
by
he
h ee
majo
hemes:
(i)
leade ship,
(ii)
he
o ganiza ional
s a -
egy,
and
(iii)
inno a ion.
The
in e iews
ook
place
be ween
Ma ch
and
July
2007.
The e
we e
33
in e iews
o
membe s
o
he
boa d
o
18
heal h
ins i u ions
–
hospi als
and
holdings
o
wo
economic
g oups.
Di ec
obse a ion
Di ec
obse a ion
was
chosen
as
one
o
he
echniques
o
collec ing
e idence.
I
was
in ended
o
o e come
he
passi e
ole
o
he
obse e
and
hus
enable
he
aking
o
some
kind
o
pa icipa ion
in
some
si ua ions,
which
o he wise
would
be
inaccessible
o
esea ch.
Di ec
obse a ion,
when
compa ed
o
o he
me hods
o
obse a ion,
has
ad an ages
and
disad an ages.
The
main
ad an ages
a e
( he
au ho ’s
iew
o
he
expe ience):
(i)
allow
o
see
he
eali y
o
o ganiza ions,
(ii)
acili a e
quick
access
o
da a
on
ypical
si ua ions
in
which
membe s
o
o ganiza-
ions
a e
in ol ed,
and
(iii)
p o ide
access
o
da a
ha
he
o ganiza ion
conside s
o
p i a e
domain.19
The
disad an ages
o
di ec
obse a ion
e e
pa icula ly
o
he
es ic ions
se
by
he
assump ion
o
oles
by
he
in es-
iga o
as
a
heal h
p o essional.
The
in o ma ion
collec ed
his
way
eflec s
he
pe cep ion
o
a
eali y
seen
‘inside’.
Su ey
by
ques ionnai e
The
ins umen
o
da a
collec ion
consis s
in
di e en
ques-
ions,
which
we e
p epa ed
based
on
di e en
ins umen s
published.
e
p
o
s
a
ú
d
e
p
ú
b
l
i
c
a
.
2
0
1
3;3
1(2):129–144
135
As
such,
he
ques ionnai e
su ey
done
by
Sho ell
and
Zalac27 was
aken
in o
accoun
o
he
model
o
Miles
&
Snow.
Issues
abou
he
dominan
cha ac e is ics,
he
o ganiza ional
leade ,
in eg a ion,
clima e,
c i e ia
and
he
managemen
s yle
o
o ganiza ions
we e
also
aken
in o
accoun
o
he
model
o
Quinn’s
Compe ing
Values.
Ques ions
abou
s a egy
we e
based
on
he
S a egic
Capa-
bili y
Su ey
Ques ionnai e
d awn
by
Malcolm
MacPhe son,28
om
which
some
o
he
ques ions
we e
adap ed
o
he
case.
The
Pe manen
Inno a ion
Su ey
Ques ionnai e
was
used
o
inno a ion
issues
(Inno a ion
Labs).29
Finally,
leade ship
ques ions
we e
based
on
he
Heal hca e
O ganiza ion
o
Senio
Leade ship
Su ey
(RAND).30
Me hods
and
echniques
o
analysis
Th ough
his
analysis,
whe e
one
o
he
app oaches
used
is
quali a i e,
i
is
necessa y
ha
he
da a
collec ed
can
be
o ga-
nized
in
o de
o
each
conclusions.
The
echnique
used
o
analyse
he
in e iew
da a
was
con en
analysis.
In
quali a i e
analysis,
he
o ganiza ion
o
encoding
com-
p ises:
(i)
he
clipping
(choice
o
uni s
o
analysis),
(ii)
he
enume a ion
(selec ion
o
he
coun ing
ules),
and
(iii)
he
classifica ion
and
agg ega ion
(choice
o
ca ego ies).31
S a is ical
ea men
The
cha ac e iza ion
o
he
sample
was
obse ed
h ough
he
equency
dis ibu ion
(absolu e
and
ela i e
equencies),
and
when
app op ia e,
supplemen ed
wi h
hei
espec i e
modes
(measu e
o
cen al
endency).
The
answe s
o
esea ch
ques ions
wen
h ough
a
p ocess
o
s a is ical
analysis
using
nonpa ame ic
es s,
checked
o
non-no mali y
by
he
Kolmogo o
Smi no .
We
used
he
K uskal–Wallis
es
a
a
significance
le el
o
5%,
gi en
he
na u e
o
he
analysis
o
associa ion
be ween
a
ca ego ical
a iable
wi h
mo e
han
wo
ca ego ies
wi h
a
nume ic
a iable
o
compa ison
g oups
o
h ee
o
mo e
inde-
penden
compa ed
o
a
a iable
nume ical
as
well
as
o
hei
non-no mali y
(Kolmogo o
Smi no ).
The
in e nal
consis ency
o
he
ques ions
on
s a egy,
inno a ion
and
leade ship
using
he
C onbach
Alpha
was
e ified.32 Also,
he
homogenei y
o
a iance
was
checked
and
gua an eed
be ween
g oups:
s a /line
and
he
hospi als.32
Popula ion
and
sample
The
uni
o
analysis
is
a
collec ion
o
elemen s
o
indi iduals
who
sha e
common
ea u es,
defined
by
a
se
o
c i e ia:
(i)
be
a
heal h
o ganiza ion,
(ii)
p o ide
di e en ia ed
ca e
wi h
o
wi hou
p ima y
heal h
ca e
(in eg a ion
ca e),
(iii)
be
a
legal
pe son
wi h
adminis a i e
and
financial
au onomy,
(i )
in
he
public
sec o
o
p i a e
sec o ,
and
( )
be
conside ed
an
inno-
a i e
o ganiza ion
on
he
managemen
le el
(acco ding
o
selec ion
c i e ia
–
use
ools
ha
allow
managemen
flexibil-
i y,
bo h
in
he
ype
o
ca e
hey
p o ide)
o
on
he
le el
o
echnology.
Explo a o y
in e iews
we e
conduc ed
on
13
public,
2
p i-
a e,
1
PPP
and
2
Holding
heal hca e
o ganiza ions,
o
a
o al
o
33
explo a o y
in e iews.
Fi e
o
hem
we e
selec ed
o
adminis e ing
he
ques ionnai e
and
p o iding
in-dep h
in e -
iews.
This
selec ion
had
o
do
wi h:
(i)
heal h
o ganiza ions
ep-
esen ing
he
sec o s
whe e
hey
a e
in ol ed
(p i a e/public),
(ii)
no
being
o ganiza ions
which
en isaged
he
change
o
s a-
us
(i
he
“Hospi al
Fe nando
da
Fonseca”,
“Hospi al
San a
Ma ia”,
“Hospi al
de
S.
João”,
“Hospi ais
da
Uni e sidade
de
Coimb a”),
and
(iii)
ha ing
expe ience
in
inno a ion
in
e ms
o
managemen
o
echnology.
As
in
Po ugal
he e
is
no
expe ienced
PPP,
we
chose
o
s udy
a
heal h
uni
in
he
Heal h
Agency
o
he
Au onomous
Region
o
Valencia
(Spain),
which
is
one
o
he
ew
examples
o
inno a ion
and
leade ship
in
managemen
and
echnology.
The
obse a ion
uni
includes
elemen s
o
he
Boa d,
Adminis a o s,
Medical
Di ec o s
and
Nu sing
Di ec o s,
Di ec o s
and
Se ice
Depa men ,
as
well
as
head
nu ses
and
enginee s
om
ou
hospi als
in
Po ugal
and
one
hospi al
in
Spain,
whe e
a
ques ionnai e
was
passed
(applied
211
ques-
ionnai es
which
collec ed
165,
wi h
a
esponse
a e
o
78.2%).
Fi e
cases
These
fi e
cases
(Heal h
Ca e
Uni
–
HCU)
we e
selec ed
acco ding
o:
(i)
he
HCU2
and
HCU1
being
public
ins i u-
ions
and
being
he
fi s
heal h
o ganiza ions
o
use
ools
o
New
Public
Managemen .
The
HCU1
is
an
ULS
wi h
a
iew
o
in eg a ing
ca e
(p ima y
heal h
ca e/di e en ia ed
ca e),
a
model
ha
is
being
mul iplied
in
o he
egions
o
he
coun y;
(ii)
he
HCU3
and
HCU4
a e
hospi als
o
he
p i a e
sec o ,
and
belong
o
wo
p i a e
economic
g oups
ha
p o ide
Heal h
Ca e
in
Po ugal;
and
(iii)
HCU5
is
a
heal h
o ganiza ion
o
a
Spanish
au onomous
egion
(Valencia)
wi h
a
PPP
manage-
men
model
(which
will
be
implemen ed
in
Po ugal
in
u u e
wi h
he
necessa y
changes,
and
he e o e
i
is
in e es ing
o
s udy)
(Table
3).
Two
heal h
o ganiza ions
belong
o
he
public
sec o
and
wi h
legal
s a us
o
“En idade
Pública
Emp esa ializada”
(EPE).
Two
o
he
heal h
o ganiza ions
in
s udy
a e
p i a e
and
belong
o
wo
di e en
economic
g oups:
he
“G upo
Espí i o
San o”
and
“G upo
José
de
Mello
Saúde”.
As
in
Po ugal
he e
a e
no
PPP
models
in
hospi als,
i
was
conside ed
HCU5
in
Valencia
(Spain)
–
he
fi s
buil
unde
his
s a us
(concession)
in
Spain,
which
has
a
uni e si y,
in eg a -
ing
heal h
ca e
p ima y
and
di e en ia ed
ca e
and
which
has
a
high
deg ee
o
di e en ia ion.
The
fi s
poin
o
no e
is
he
p edominance
o
emale
gen-
de
(56%).
This
is
due
o
he
ype
o
o ganiza ion
ha
is
being
s udied
(heal h
o ganiza ions)
whe e,
in
ac ,
mos
employees
(adminis a o s,
doc o s,
nu ses
and
echnicians)
a e
emale
(wi h
he
excep ion
o
he
HCU5).
The
majo i y
g oup
was
aged
be ween
41
and
55
wi h
he
excep ion
o
he
g oup
aged
25
o
40
in
he
HCU4
and
HCU5.
Limi a ions
o
he
s udy
One
o
he
limi a ions
o
his
s udy
was
he
ime
o
pe -
o m
each
ac i i y.
The
geog aphical
dispe sion
o
heal h
uni s
and
he
agenda
o
he
esponden s
mean
ha
we
had
o
a el
se e al
days
om
no h
o
sou h
o
Po ugal
o
ca y
ou
explo a o y
in e iews,
in e iews
and
su ey
in
he
uni s
selec ed
as
cases.
Simila ly
we
had
o
go
o
Spain
o
ou
days
136
e
p
o
s
a
ú
d
e
p
ú
b
l
i
c
a
.
2
0
1
3;3
1(2):129–144
Table
3
–
Da a
om
heal h
o ganiza ion
case-s udys.
Indica o
Heal h
o ganiza ions
HCU1
(2007)
HCU2
(2007)
HCU3
(2008)
HCU4
(2008)
HCU5
(2008)
No.
beds 432
310
140
159
300
No.
doc o s
519
156
±200
419
317
+
231c
No.
nu ses
745
276 b152
594
+
257c
No.
echnicians
111
56 b56
54
+
14c
Ope a ing
income
83,753a65,407a
b81,852a114,807
Popula ion
430.000
383.050 bb245.000
Sec o
Public
Public
P i a e
P i a e
PPP
Legal
s a us
EPE
EPE
P i a e
P i a e
Managemen
con ac
aMillion
o
Eu o’s.
bThe e
a e
no
da a
ye .
cP ima y
heal h
ca e.
as
pa
o
fieldwo k.
The
echniques
o
ga he ing
da a
we e
e y
ime
consuming.
The
lack
o
unding
was
ano he
emba -
assmen ,
and
all
cos s
we e
suppo ed
by
he
in es iga o .
E en
mo e
impo an
han
he
di ficul y
o
accessing
da a
on
inno a ion
and
leade ship
is
he
ac
ha
he e
is
li le
com-
pa able
da a
be ween
he
heal h
uni s.
The e
is,
hus,
ano he
po en ial
limi a ion
o
esea ch,
which
is
ela ed
o
he
deg ee
o
knowledge
o
di e en
s akeholde s
on
he
ope a ion
o
he
o ganiza ion.
Public
hospi als
p o ide
se ices
wi hin
hei
geog aphic
a eas
o
influence,
while
p i a e
ones
ha e
a
mo e
open
ma ke .
Howe e ,
o
a ac
clien s/pa ien s,
many
a iables
a e
impo an
such
as:
(i)
he
a ailabili y
o
mul iple
se ices,
(ii)
he
eimbu semen
paymen ,
(iii)
he
medical
s a
o
hospi als
and
hei
pe cei ed
quali y,
(i )
accessibili y
o
in as uc u e,
and
( )
pe cep ion
o
he
quali y
o
acili ies
and
echnologies,
as
well
as
how
hese
o ganiza ions
a e
managed.
Howe e ,
heal h
o ganiza ions,
wha e e
hei
pu pose,
need
o
know
how
o
manage
esou ces,
seeking
o
sa is y
hei
cus ome s
and
ge ing
adequa e
e u ns.
I
is,
ega dless
o
he
impo ance
o
new
heal h
se ices,
associa ed
wi h
new
echnologies
and
impo an
o
combine
he
di e en
knowl-
edge
so
ha
pa ien s
and
all
ac o s
o
he
hospi als
ha e
an
adequa e
le el
o
sa is ac ion.
P esen a ion
o
esul s
Analysis
o
di ec
obse a ion
F om
he
analysis
o
field
no es
made
du ing
di ec
obse a-
ion
o
he
o ganiza ional
s a egy,
wha
was
mos
impo an
was
finding
ha :
(i)
HCU1
has
in eg a ion
and
ce ifica ion
o
heal h
ca e
se ices
which
need
es ablished
p o ocols
and
p o-
cesses
ha
would
o he wise
be
di ficul
o
accomplish
( he e
was
no
adi ion
in
eam
wo k
be ween
CSP
and
he
di e en-
ia ed
ca e),
as
well
as
he
in e naliza ion
o
addi ional
means
o
diagnosis
and
he apy,
using
he
ins alled
capaci y
o
HCU1;
he
p og amme
con ac
ha
was
in oduced
by
capi a ion
paymen
based
on
numbe
o
inhabi an s;
(ii)
in
he
HCU2
he
cos –benefi
analysis
is
pe o med
o
e i y
i
i
is
wo h
be -
ing
on
change;
and
i
he
answe
is
yes
hey
ad anced.
The e
is
a
g ea
cen aliza ion
and
con ol
by
op
managemen ,
hus
a oiding
la ge
de ia ions;
(iii)
in
he
HCU3
o
ecen
cons uc-
ion,
he
be
is
in
medical
oncology
and
pallia i e
ca e.
The e
is
a
ce ain
olun a ism
o
sol e
p oblems
and
seek
oppo u-
ni ies
o
do
be e .
In
e ms
o
logis ics,
economies
o
scale
is
one
o
he
s a egic
op ions
(in
he
pu chase
o
consumable
medical
and
o he );
(i )
in
he
HCU4,
he
ou pa ien
su ge y
esou ces
a e
used
in ensi ely,
lea ing
g ea
in e nal
con ol
and
a
p eoccupa ion
wi h
he
ex e nal
en i onmen
( o
ecog-
nize
business
oppo uni ies);
and
( )
in
he
HCU5,
whe e
he e
a e
p o ocols
o
ac ion,
he
Medical
Link,
he
single
elec onic
p ocess
o
he
CSP
and
di e en ia ed
ca e
and
he
ac
ha
he e
a e
only
wo
inpa ien
se ices,
whe e
medical
special-
is s
in e sec ;
all
hese
cons i u e
an
o ganiza ional
s a egy;
i
he
ime
o
su ge y
exceeds
mo e
han
nine y
days
he
o ga-
niza ion
will
be
sanc ioned.
The
p og amme
con ac
is
based
in
capi a ion
paymen
wi h
a
base
in
he
numbe
o
membe
inhabi an s.
The
HCU3
and
HCU4
ha e
in es ed
hea ily
in
new
ech-
nologies.
The
HCU3
has
in es ed
hea ily
in
medical
oncology,
in ending
o
sell
hei
se ices
o
he
NHS.
The
HCU4
has
in es ed
in
e ms
o
medical
special ies
(alle gy,
o ola yngol-
ogy
and
paedia ics)
in
o de
o
ha e
c i ical
mass
and
hus
be
ecognized
as
an
ins i u ion
o
pos g adua e
eaching.
Sim-
ila ly,
he
HCU5
became
a
uni e si y.
The
HCU2
and
HCU1
ha e
be
on
complemen ing
hei
a eas
o
influence,
in ending
o
mee
he
needs
o
he
popula ion
hey
se e.
As
o
leade ship,
we
can
see
ha
o ganiza ions
in
some
cases
we e
mo e
cen alized
and
flexible
han
o he s,
which
is
insepa able
om
he
o ganiza ional
s a egy
implemen ed.
The
HCU4,
HCU1
and
HCU2
we e
mo e
cen alize s,
con ibu -
ing
o
mo e
o mal,
mo e
cen alized
leade ship,
wi h
con ol
and
epo
(done
mainly
in
he
downwa d
di ec ion
–
op-
down).
The
o he
wo
uni s,
HCU3
and
HCU5,
we e
mo e
flexible
and
decen alized.
They
look
o
employees
(bu
also
o
hei
en i onmen ),
wi h
a
p edefined
s a egy
(sea ch
o
oppo uni ies
in
he
fi s
case
and
espond
o
pa ien s
in
he
second).
Analysis
o
ques ionnai e
Ques ions
abou
Miles
&
Snow
adap ed
model
When
we
look
a
he
answe s
o
ques ions
abou
Miles
&
Snow
adap ed
model,
we
lea n
how
he
o ganiza ional
s a egy
is
e
p
o
s
a
ú
d
e
p
ú
b
l
i
c
a
.
2
0
1
3;3
1(2):129–144
137
0
1
0
20
30
40
50
60
De ende
P ospec o
Analyse
Reac o
HCU2
HCU1
HCU3
HCU4
HCU5
Fig.
3
–
Analysis
o
he
esul s
o
he
ques ionnai e
based
on
he
model
adap ed
om
Miles
&
Snow.
de eloped,
and
wha
is
he
ypology
ha
eme ges
in
hese
o ganiza ions,
which
a e
he
ollowing
(Fig.
3):
HCU2
and
he
HCU1,
al hough
mo e
p ospec i e
(hospi-
als
wi h
a
apidly
g owing,
new
pa hs
and
new
inno a i e
me hods),
a e
also
analyze s
(gene al
hospi als,
communi y
o ien ed);
he
Adminis a o s
look
o
in e nal
se ices
(in e -
nal
con ac ing)
bu
a e
ocused
on
he
en i e
o ganiza ion,
in
o de
o
answe
he
ques ions
which
p og amme
con ac s
pose
(e ec i eness,
e ficiency
and
quali y);
i
has
a
mo e
e ec-
i ely
op-down
hie a chy.
HCU3
has
a
ypology
essen ially
p ospec i e;
his
may
be
due
o
i s
you h.
They
a e
ying
o
impose
hemsel es
on
he
field
(asse s
i sel
as
a
mode n,
inno a i e),
whe e
excellence
and
he
quali y
o
ca e
a e
o
g ea
impo ance,
and
a e
a
co ne -
s one
o
he
ins i u ion.
I
is
in ended
o
be
a
e e ence
uni ,
bo h
o
he
p i a e
sec o
whe e
i
belongs,
and
he
public
sec o
wi h
whoe e
also
wan s
o
collabo a e.
HCU4
and
HCU5
we e
p edominan ly
analyze s.
These
heal h
uni s
al eady
ha e
a
s o y
o
ell.
Since
hey
a e
con-
inually
moni o ing
he
ma ke ,
he
fi s
is
he
sea ch
o
new
pa ien s/cus ome s
and
new
business
oppo uni ies
(e.g.
Caesa ean
unde
spinal
anaes hesia);
he
second
is
finding:
(i)
new
pa ien s
expec a ions
in
heal h
ca e
se ices
(e.g.
oph-
halmology),
(ii)
no
allow
i s
pa ien s
o
seek
o he
heal h
uni s,
because
i
so,
hey
ha e
o
pay,
and
(iii)
lis s
o
su ge y
ha
do
no
exceed
90
days,
on
pain
o
penaliza ion
o
he
o ganiza ion
(i
necessa y
wo king
on
Sa u days).
HCU4
being
a
p i a e
uni ,
de eloped
in
e ms
o
obs e ics/gynaecology,
alle gy
among
o he s.
I
is
he e o e
some imes
a
uni
ha
has
aces
o
p ospec
(when
sees
oppo uni ies),
bu
i
is
also
de ensi e
(when
i
eels
i
has
o
consolida e).
Finally,
HCU5,
depending
on
managemen
model,
has
become
a
Uni e si y
Hospi al,
a
uni
ha
p esen s
a
s a egy
essen ially
analyze
(when
sees
oppo uni ies),
bu
which
is
also
de ensi e
(when
eels
he
has
o
consolida e).
0
10
20
30
40
50
60
Clan
Adhoc acy
Ma ke
Con ol
HCU2
HCU1
HCU3
HCU4
HCU5
Flexibili yIn e nal
Ex e nal
Con
ol
Fig.
4
–
Analysis
o
he
esul s
o
he
ques ionnai e
based
on
he
model
adap ed
om
Con as ing
Values
(O ganiza ional
Cul u e).
Ques ions
abou
he
Compe ing
Values
F amewo k:
o ganiza ional
cul u e
In
he
analysis
o
esponses
o
ques ions
abou
o ganiza ional
cul u e,
we
show
how
o ganiza ional
cul u e
de elops
acco d-
ing
o
he
model,
and
how
he
ypology
ha
eme ges
in
hese
o ganiza ions;
hen,
acco ding
o
Fig.
4,
he e
a e:
HCU2
has
a
p ofile
ha
fi s
in
cha ac e is ics
o
a
pa en
o ganiza ion
wi h
a
con ol
cul u e
( he
axis
flexibili y
and
con ol
shi ed
o
he
con ol
axis
and
axis
in e nal/ex e nal
shi ed
o
he
in e nal
dimension
–
in eg a ion).
HCU1
p esen s
a
p ofile
ha
fi s
he
cha ac e is ics
o
an
o ganiza ion
wi h
a
pa en
cul u e
( he
axis
flexibili y
and
con ol
shi ed
o
he
con ol
axis
and
axis
in e nal/ex e nal
shi ed
o
he
in e nal
dimension
axis
–
in eg a ion).
HCU3
has
a
p ofile
ha
fi s
in
cha ac e is ics
o
an
o ganiza-
ion
wi h
a
compe i i e
cul u e
( he
axis
flexibili y
and
con ol
shi ed
o
he
con ol
axis
and
axis
in e nal/ex e nal
shi ed
o
he
ex e nal
pa
axis
–
di e en ia ion).
HCU4
p esen s
a
p ofile
wi h
he
cha ac e is ics
o
an
o ga-
niza ion
wi h
a
pa en
cul u e
( he
axis
flexibili y
and
con ol
shi ed
o
he
con ol
axis
and
axis
in e nal/ex e nal
shi ed
o
he
in e nal
dimension
axis
–
in eg a ion).
HCU5
has
a
flexibili y
and
con ol
axis
shi ed
o
he
side
o
flexibili y,
and
an
in e nal/ex e nal
axis
o se
o
he
ou side
axis
–
di e en ia ion,
gi ing
i
cha ac e is ics
o
an
o ganiza-
ion
wi h
a
c ea i e
o ganiza ional
cul u e.
Ques ions
abou
he
Compe ing
Values
F amewo k:
leade ship
When
we
look
a
he
answe s
o
ques ions
abou
Compe ing
Values
F amewo k
model,
we
know
wha
ype
o
leade ship
i
is
(Fig.
5):
HCU2
has
cha ac e is ics
o
an
o ganiza ion
wi h
a
con-
olle
leade ship
( he
axis
o
flexibili y
and
con ol
is
shi ed
o
he
con ol
axis;
he
axis
in e nal/ex e nal
is
shi ed
o
he
in e nal
dimension
–
in eg a ion).
Leade ship
is
moni o ing
and
coo dina ing.
HCU1
p esen s
a
p ofile
ha
fi s
he
cha ac e is ics
o
an
o ganiza ion
wi h
a
con olle
leade ship
(axis
flexibili y
and
144
e
p
o
s
a
ú
d
e
p
ú
b
l
i
c
a
.
2
0
1
3;3
1(2):129–144
2.
Ribie e
VM,
Si a
AS.
C i ical
ole
o
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in
nu u ing
a
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suppo ing
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JH,
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