A glance at the competing values framework of Quinnand the Miles & Snow strategic models: case studies in health organizations
Abstract
A B S T R A C T - The present research seeks to describe and understand how strategy influences leader-ship and how this in turn interacts in the process of innovation and change in healthorganizations.This is an exploratory and descriptive study that involved five health organizations: fourPortuguese and one Spanish. We used a mixed approach of research (qualitative and quan-titative), which enabled us to understand, through case study, how strategy and leadershipwere articulated with innovation in these five health organizations.Despite their complexity and specificity, both the model of Miles & Snow (organizationalstrategy) and the model of the Competing Values Framework of Quinn (organizational cul-ture and leadership), suitably adapted, have proven heuristic power and are able to beapplied to healthcare organizations.Public and private healthcare organizations, as well as public–private partnerships, can betracked and monitored in their processes of innovation and change in order to understandits kind of culture, leadership or organizational strategy adopted.Health organizations coexist in a continuum, where the environment (internal and external)and time are key factors which determine the strategy to be adopted. Here too dependingon the dynamic and complex reality where the organization moves, there are no pure types.There is indeed a great organizational plasticity and flexibility.Leaders usually carry the formal authority by circular normative. They are not pairs (orprimi inter pares). Instead they are, sometimes, in a position of superiority, when the bestthing is partnership, collaboration, cooperation, building consensus and cooperation withall stakeholders, in order that they are the real protagonists and facilitators of change andinnovation.
Full text
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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
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2
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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
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d
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p
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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
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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
leade ship
in
nu u ing
a
knowledge
suppo ing
cul u e.
Knowl
Manage
Res
P ac .
2003;1:39–48.
3.
G ay
JH,
Dens en
IL,
Sa os
JC.
Size
ma e s:
o ganisa ional
cul u e
in
small,
medium,
and
la ge
Aus alian
o ganiza ions.
J
Small
Bus
En ep eneu ship.
2003;17:31–46.
4.
Quinn
RE.
Beyond
a ional
managemen :
mas e ing
pa adoxes
and
compe ing
demands
o
high
e ec i eness.
San
F ancisco:
Jossey-Bass;
1988.
5.
Came on
K,
Quinn
R,
Deg a
J,
Thako
A.
Compe ing
alues
leade ship:
c ea ing
alues
in
o ganiza ions.
New
Yo k:
Edwa d
Elga
Publishing
Limi ed;
2006.
6.
Schein
EH.
O ganiza ional
cul u e
and
leade ship.
3 d
ed.
San
F ancisco:
Jossey-Bass;
2004.
7.
Miles
RE,
Snow
CC.
O ganiza ional
s a egy,
s uc u e,
and
p ocess.
New
Yo k,
NY:
McG aw-Hill;
1978.
8.
Conan
MP,
Mokwa
P,
Va ada ajan
R.
S a egic
ypes,
dis inc i e
ma ke ing
compe encies
and
o ganisa ional
pe o mance:
a
mul iple
measu es-based
s udy.
S a egic
Manage
J.
1990;11:365–83.
9.
Hamb ick
D.
Some
es
o
he
e ec i eness
and
unc ional
a ibu es
o
Miles
and
Snow’s
s a egic
ypes.
Acad
Manage
J.
1983;26:5–26.
10.
Cas o o
C,
Be ina o
L,
Baccaglini
U,
D ace
C,
McKee
M.
Configu ing
he
hospi al
in
he
21s
cen u y.
Copenhagen:
Eu opean
Obse a o y
on
Heal h
Sys ems
and
Policies;
2004.
11.
Sho ell
S,
Zalac
E.
Changing
gene ic
s a egies:
likelihood,
di ec ion
and
pe o mance
implica ions.
S a egic
Manage
J.
2006;10:413–30.
12.
Mo ais
L.
Lide anc¸a
e
es a égia
em
con ex o
de
ino ac¸ão
nas
o ganizac¸ões
de
saúde:
es udos
de
caso
[Disse ac¸ão].
Lisboa:
ENSP.
UNL;
2010.
13.
Mo ais
L.
Lide anc¸a
e
es a égia:
casos
de
ino ac¸ão
nas
o ganizac¸ões
de
saúde.
Lisboa:
Escola
Edi o a;
2012.
14.
Miles
R,
Snow
C.
O ganiza ional
s a egy,
s uc u e
and
p ocess.
S an o d:
S an o d
Uni e si y
P ess;
2003.
15.
Yin
RK.
Case
s udy
esea ch,
design
and
me hods.
London:
Sage;
1994.
16.
S ake
ER.
The
a
o
case
s udy
esea ch.
Thousand
Oaks:
Sage;
1995.
17.
Bax e
P,
Jack
S.
Quali a i e
case
s udy
me hodology:
s udy
design
and
implemen a ion
o
no ice
esea che s.
Qual
Rep.
2008;13:544–59.
18.
Fly bje g
B.
Fi e
misunde s andings
abou
case-s udy
esea ch.
Qual
Inqui y.
2006;12:219–45.
19.
G ac¸a
L.
Desenho,
edac¸ão
e
aplicac¸ão
de
ques ioná ios
e
guiões
de
en e is a.
Lisboa:
G upo
de
Disciplinas
de
Ciências
Sociais
e
Humanas.
Escola
Nacional
de
Saúde
Pública.
Uni e sidade
No a
de
Lisboa.;
2009
(Tex os;
T
1069).
20.
Ghiglione
R.
Ma a on
B.
O
inqué i o:
eo ia
e
p á ica.
4 h
ed.
Oei as:
Cel a;
2001.
21.
G ac¸a
L.
Guião
pa a
o
desenho
de
um
p ojec o
de
in es igac¸ão.
Lisboa:
G upo
de
Disciplinas
de
Ciências
Sociais
e
Humanas.
Escola
Nacional
de
Saúde
Pública.
Uni e sidade
No a
de
Lisboa;
2009
(Tex os;
T
834).
22.
C eswell
J.
Resea ch
design
quali a i e
&
quan i a i e
app oaches.
London:
Sage
Publica ions;
1994.
23.
Poli
DF,
Hungle
BP.
Fundamen os
de
pesquisa
em
en e magem.
3 d
ed.
Po o
Aleg e:
A es
Médicas;
1995.
24.
Bogdan
R,
Biklen
S.
In es igac¸ão
quali a i a
em
educac¸ão:
uma
in oduc¸ão
à
eo ia
e
aos
mé odos.
Po o:
Po o
Edi o a;
1994
(Ciências
da
Educac¸ão,
12).
25.
Fo in
M-F.
O
p ocesso
de
in es igac¸ão:
da
concepc¸ão
à
ealizac¸ão.
Lou es:
Lusociência;
1999.
26.
Bell
J.
Como
ealiza
um
p ojec o
de
in es igac¸ão.
2nd
ed.
Lisboa:
Edi o a
G adi a;
2002.
27.
Sho ell
S,
Zalac
E.
Pe cep ual
and
a chi al
measu es
o
Miles
&
Snow’s
s a egic
ypes:
a
comp ehensi e
assessmen
o
eliabili y
and
alidi y.
Acad
Manage
J.
1990;33:817–32.
28.
MacPhe son
M.
S a egic
Capabili y
Su ey.
Alexand a,
New
Zealand:
Macphe son
Publishing;
2001.
A ailable
om:
h p://www.bald igeplus.com/su ey2.pd
[upda ed
23.09.07;
ci ed
13.12.10].
29.
Inno a ionlabs.
com
[In e ne ].
Sou h
Asia:
Inno a ion
Labs
Inno a ion;
2007.
A ailable
om:
h p://www.inno a ionlabs.com
[upda ed
06.08.07;
ci ed
13.12.10].
30.
RAND
Heal hca e
O ganiza ion
su ey
o
senio
leade ship.
San a
Monica:
RAND;
1999.
31.
Ba din
L.
Análise
de
con eúdo,
ol.
70.
Lisboa:
Edic¸ões;
1977.
32.
Pes ana
M,
Gagei o
J.
Análise
de
dados
pa a
ciências
sociais:
a
complemen a idade
do
SPSS.
Lisboa:
Edic¸ões
Sílabo;
2003.
33.
Boyne
G,
Walke
R.
S a egy
con en
and
public
se ice
o ganiza ion.
J
Public
Admin
Res
Theo y.
2004;14:231–52.
34.
OECD.
The
measu emen
o
scien ific
and
echnological
ac i i ies:
p oposed
guidelines
o
collec ing
and
in e p e ing
echnological
inno a ion
da a:
Oslo
manual.
Pa is:
O ganisa ion
o
Economic
Co-Ope a ion
and
De elopmen ;
1997.
35.
He zlinge
R.
Ma ke
d i en
heal h
ca e:
who
wins,
who
loses
in
he
ans o ma ion
o
Ame ica’s
la ges
se ice
indus y.
New
Yo k:
Pe seus
Books;
1997.
36.
OPSS.
Obse a ó io
Po uguês
de
Sis emas
de
Saúde.
Luzes
e
somb as:
a
go e nac¸ão
da
saúde:
ela ó io
de
P ima e a
2007.
Coimb a:
Ma
de
Pala a;
2007.
37.
Simone
D.
Medical
p ac ice
unde
managed
ca e:
cos –con ol
mechanisms
and
impac
on
quali y
se ice.
Public
O gan
Re
Glob
J.
2005;5:157–76.
38.
OECD.
The
e o m
o
he
heal h
ca e
sys em
in
Po ugal.
Pa is:
O ganiza ion
o
Economic
Co-ope a ion
and
De elopmen ;
2004
(Economics
Depa men
Wo king
Pape s;
45).
39.
Tidd
J,
Bessan
J,
Pa i
K.
Managing
inno a ion:
in eg a ing
echnological,
ma ke
and
o ganiza ional
change.
2nd
ed.
New
Yo k:
John
Willey
&
Sons;
2001.
40.
USA
Ins i u e
o
he
Fu u e.
Heal h
and
Heal h
Ca e
2010:
he
o ecas
he
challenge.
2nd
ed.
P ince on,
NJ:
Jossey-Bass,
a
Wiley
Company;
2003.
Suppo
o
his
publica ion
was
p o ided
by
The
Robe
Wood
Johnson
Founda ion.
41.
Länsisalmi
H,
Ki imäki
M,
Aal o
P,
Ruo anen
R.
Inno a ion
in
heal hca e:
a
sys ema ic
e iew
o
ecen
esea ch.
Nu s
Sci
Q.
2006;19:66–72.