Change Management in Healthcare Organizations

Change Management in Healthcare Organizations

Summary of argument, Hypothesis

Literature Review/Survey/Requirements

182.2 Development of theories/current status

222.3 Assessing Change Management Models and Frameworks

342.4 Redefining Business Processes Using Change Management

402.5 How Does This Project Fit In With the Literature Review

423.1 Introduction: Hypothesis

494.1 Presentation and Description of Results

664.2 Discussion and interpretation of the results

705.0 Conclusion

725.2 Comparison of aims and objectives with achievements

735.3 Contributions of this Research

746.0 Limitations

Recommendations for Future Research

The Importance of Change Management in Healthcare Organizations: Strengths and Opportunities

Introduction

Healthcare organizations are undergoing a transformational change, driven by both economic realities and increased government regulation and intervention in westernized nations. Because of these market forces, consolidation of healthcare providers and rapid acquisition of healthcare facilities by private healthcare organizations is a certainty. The consolidation of the global healthcare market is forcing the privatization of previously nationalized healthcare organizations that failed to obtain funding and stay relevant to patients' needs. In devising a framework for the efficient integration of public government healthcare sector organizations and private firm from a business process, business management and change management perspective, this literature review integrates transformational leadership theories, concepts, change management theories, and frameworks.

The rate of change in the healthcare industry today in the U.S. specifically is accelerating, often forcing together the cultures of widely divergent companies within weeks, without a framework in place to navigate change management strategies (Swedish, 2009). Change management has several different dimensions, the two most integral to an organizations' performance being business process integration and business process re-engineering to gain greater efficiency from existing operations. Second, overcoming resistance to change in employees most affected by new initiatives including mergers and acquisitions is the most challenging aspect of a healthcare organizational change (Brinkmann, O'Brien, 2010).

1.0 Aims and Objectives

The primary objective of this research effort is to determine how effective for-profit healthcare providers are in integrating public-sector healthcare organizations after acquisition, alliance or merger. The focus of the research is on the management and leadership strategies that have led to the successful integration of public sector healthcare organizations into for-profit healthcare providers. The introduction of this dissertation discussed the economic factors that are contributing to the acquisitions, alliances and mergers between public healthcare providers and privately held, for-profit healthcare organizations. The research completed for this study also is predicated on the assumption that the for-profit healthcare organizations are more adept and capable of staying focused on the patient as a customer. Based on this assumption, it is further believed that the more effective a given leader is in a for-profit healthcare provider, the greater the success rate of acquisitions, alliances and mergers. The intent of this dissertations' research is to ascertain the factors, processes, systems and strategies leader specifically rely on in managing the transition of acquisitions, alliances and mergers between public or government-managed healthcare providers and their private-sector counterparts. Over and above the clear differences in how these organizations function, the focus of the research is on how the use of leadership strategies, styles and approaches keep the patient at the center of the organizational change to ensure quality of care does not diminish during the transition period of an acquisition, alliance or merger.

1.1 Background Information

This is in fact the most important facet of any change management strategy of organizations from public to privately-based operations: the transition must not allow patient care to drop or be degraded in any way. At the very center of this analysis is an assessment of what is at the center of state- or government-managed healthcare providers relative to those that are run for-profit and as a result have greater accountability to shareholders. This dissertation does not suggest that just having a customer-centric mindset on the part of for-profit healthcare providers ensures a high level of patient satisfaction and performance. Rather, it is an assessment of how effective the leadership approaches, strategies and systems are in sustaining this patient-based focus and having it permeate an organization so that its performance is by reflex, not by thorough evaluation and planning. In effect, how well does the leadership style of a for-profit organization drive the necessary change to keep the patient focus first, even in the midst of assimilating a public healthcare provider over time. This is the paradox and problem this research concentrates on and looks to determine the role of leadership consistency and focus over the duration of acquisitions, alliances and mergers between public and private healthcare organizations.

1.1.1 First Issue

Change management strategies have been shown to consistently increase the potential for greater levels of success in the integration of nonprofit or state-run healthcare organizations and those operated for-profit (Drummond-Hay, Bamford, 2009). The intent of this analysis is to evaluate to what extent change management strategies lead to greater levels of success with the integration of acquisitions, alliances and mergers.

1.1.2-Second Issue

To determine if there are financially measurable results of acquisitions, alliances or mergers being successful based on the use of process-based performance improvements. The methodology specifically focuses on Business Process Management (BPM) and Business Process Re-engineering (BPR).

1.1.3 Third Issue

To determine which causal factors support the Change Management Equilibrium Model from a statistically significant level of causality specifically in the area of leadership influencing performance.

The problem of making acquisitions, alliances and mergers more successful between public sector healthcare providers and privately owned ones often emanate from a lack of leadership and change management. When privately held healthcare providers acquire public sector organizations, often the patient's welfare is lost in the transition. The problem of how to successfully manage the transition between public ownership to private is multifaceted with employees often needing greater guidance on how their roles will change, and by what magnitude. Central to the problem is a focus on the transaction, not necessarily on the transition of each employee's role, responsibilities and needs during the transition. The needs employees have for greater insight and information as to their status in the new organization, their responsibilities, required new skill sets, and an overview of the new social structure of work all have a direct impact on the quality of care patients receive as well. Senior management often does not focus on the needs of the employees and their sustaining role in company performance when an alliance, acquisition or merger is in progress, as the transaction becomes all- encompassing in scope (Judge, Douglas, 2009).

When a transaction mindset pervades a company executives' focus and direction, the shift from the more difficult and time-consuming approaches to leadership that rely on social connections and creating new social frameworks diminish over time (Ross, Gray, 2006). These social networks and the connections they provide are what many consider to be the foundation of transformational leadership skill sets (Avolio, Yammarino, 2002). Leaders who are perceived as having a high degree of transformational skills in fact have the skills to create workgroups and social alliances quickly, creating interdependencies and trust in organizations rapidly (Russell-Bennett, Previte, Zainuddin, 2009). Transformational leadership skill sets are those that create an exceptionally high level of trust, which serves to accelerate organizational performance over time. Transformational leaders are those that are sensitive and perceptive to which socially-based strategies are the most effective in bringing groups together while also attaining exceptional results (Russell-Bennett, Previte, Zainuddin, 2009).

In the acquisition or merger of two healthcare organizations that are based on entirely different approaches to doing business (public vs. private ownership) the need for balancing transformational and transactional leadership skills is critical. Transformational leadership, and with it, the ability to create networks of trust throughout the merged organizations, often gets left behind in the midst of the transaction being completed. Instead the focus needs to be on how to best create a leadership strategy or approach that balances both transactional and transformational leadership attributes to create a unified strategy for managing organizational change (Al-Mailam, 2004). This is precisely the motivation for the creation of the proposed Change Management Equilibrium Model, which is discussed later in this dissertation. The focus on creating a balanced approach to managing transactional management strategies with transformational management requirements of organizations being acquired or merged is shown in this model. Further, the proposed model also shows a high level of consistency and focus across both transactional and transformational leadership, predicated on a high level of collaboration that serves to unify both types of leadership styles. The proposed model also concentrates on creating a customer-driven series of processes as the outcome of combining transaction and transformational leadership styles. It is the design intention of the proposed Change Management Equilibrium Model that through the combining of transactional and transformational leadership styles, that the customer (and patient) driven processes critical to sustain the quality of care be sustained throughout the acquisition, alliance or merger time period. Figure 1, Proposed Change Management Equilibrium Model, illustrates the conceptual model.

Figure 1: Proposed Change Management Equilibrium Model

The proposed model is discussed in greater depth in section 4.2 of this dissertation, which includes a discussion and interpretation of results.

1.3. Summary of argument, Hypothesis

The role of leadership styles and their applicability to the success or failure of mergers, acquisitions and alliances is the focus of this research. Any leadership study, to be relevant, must also focus on the needs of those served by the organizations studies. That is why in the proposed Change Management Equilibrium Model have customer-driven processes at their center or core. The focus of the research to either validate or refute the model is based on consistency and collaboration as two factors that also serve to create greater levels of integration between the two or more healthcare providers merging or changing their organizational structures to better serve the market. This market orientation is what many public-ally-owned and operated healthcare providers struggle with, as often the source of funding becomes their "customer" or whom they serve (Brinkmann, O'Brien, 2010). Studies by AMR Research for example show that nearly 60% of the members of a medical value chain have no idea who the real customer is for their services. This pervades the healthcare industry, as the sources of funding are often seen as the customer (Brinkmann, O'Brien, 2010). The for-profit healthcare providers often see the insurance companies, funding sources in the government, or even very large employers as their primary customer as that is where the majority of revenues accrue. In the public or government-run healthcare providers, the focus is entirely on the sources of government funding and the politicians responsible for keeping the organizations' funding viable and available over time. The actual patient is not in the highest priority of any of these organizations and as a result, accuracy and quality of care often suffer significantly during mergers, acquisitions and alliances (Drummond-Hay, Bamford, 2009).

The problem this dissertation addresses is a multifaceted one that concentrates on how to bring more effective change management strategies into public and private healthcare providers that are merging or changing their structures to acquisitions and alliances. This research also addresses the validity and reliability of the proposed Change Management Equilibrium Model from the standpoint of its scalability and applicability to mergers, acquisitions and alliances. This dissertation concentrates on leadership and its role in creating more effective change management strategies by combining transactional and transformational leadership mindsets and approaches. Making mergers, acquisitions and alliances between public and privately-run healthcare organizations succeed requires that leadership teams balance transformational and transactional leadership approaches, anchoring them in collaboration and fueling trust. Only when this triad of factors is taken into account can the integration of two or more desperate firms be successful, which is the design impetus for the proposed Change Management Equilibrium Model. Putting the patient and their needs at the center of any merger, acquisition or alliance will fuel the development of shared objectives of two most likely highly desperate and different organizations. The proposed Change Management Equilibrium Model specifically focuses on how organizations can accomplish this level of focus with regard to their organizational structures as they go through significant change. Mergers, acquisitions and alliances are all very turbulent and often leave entire industries completely re-defined and re-ordered as a result. The focus of this dissertation on how the effects of transformational vs. transactional leadership affect patient care and potentially influence for the positive the customer-driven processes in organizations is the focus of this research.

2.0 Literature Review/Survey/Requirements

The objective of this literature review is to provide a solid background of research and contextual analysis of the data presented to alleviate the lack of knowledge in the area of change management as it applies to healthcare organizations. Studies suggest that the more myopic or internally focused a government entity, the greater the lack of focus and accountability on the patients' welfare and satisfaction levels with treatment. The evidence of just how myopic and inward-centric government-run organizations had become is evident when merger and acquisition activity begins to their privatization. Mergers and acquisitions references in this analysis suggest that there is a lack of formal frameworks and structure for successfully transforming government-run healthcare organizations into privatized businesses. This is because the patient, their care, satisfaction levels and long-term needs are often ignored for the sake of internal process efficiencies. The streamlining of processes takes precedence over the quality of care to patients over time when state-run healthcare facilities have little to no accountability for their performance.

2.1 Background

This is a strategic issue for the healthcare industry, because the provisioning and quality of care delivered to patients is a heavily dependent on the quality of change management initiatives at both the business process and management levels of an organization. Factors that contribute to the greatest levels of dependency include cultural norms that reinforce resistance to change and the stability of the status quo over the ability to create significant and meaningful improvements on behalf of patients. Stability and the status quo are the most important values in these organizations. The concept of the patient as a customer is not considered or in public healthcare organizations decades in existence, even seen as part of among the most critical aspects of their operation. Successful change management initiatives reflect transformational objectives where the organization's employees can readily identify with the new direction and take ownership for their specific tasks to make the new organizational vision happen (Swedish, 2009). Therefore, included in my analysis are the concepts of transformational leadership (Avolio, Yammarino, 2002) which have shown to be a key success factor in successful change management initiatives and strategies throughout the healthcare industry (McCutcheon, 2009).

For public government healthcare sector organizations, change is likely to be exceptionally difficult. First, there is the issue of how different government healthcare sector organizations manage the patient experience through a multitude of different processes. Often these processes have little to do with actual patient improvement or much less satisfaction, but more about cot mitigation and process efficiency reporting. The perception of efficiency becomes more important than patients' health and continued improvement. Second, there is the factor of financing, which is often based on government grants, not customers and contracts with health maintenance organizations as commercial healthcare providers typically have. Third, there is the issue of standards of performance, which vary significantly between government-sponsored medicine and private practice, a point shown in the nationalization of healthcare in the United Kingdom (Drummond-Hay, Bamford, 2009).

The result is a practical contribution to the body of research of how organizations can better navigate the challenges and risk of integrating public sector healthcare organizations into the private sector. This research effort looks at how this can be accomplished from a pragmatic and focused standpoint without affecting the quality of care for patients who may be receiving treatment during the transition. Public government healthcare sector organizations' successful integration into private sector firms without adversely affecting the provision of care for patients is also included as part of the analysis. Taken together all of these factors make a significant contribution to the area of research supporting the model presented in this dissertation.

Integrating transformational leadership and change management is also pivotal in creating more effective communication strategies. For change management to have a lasting effect there needs to be a clear, overarching vision or direction of the organization, often defined by the leader, which seeks to galvanize the change as real and accomplishable (Brinkmann, O'Brien, 2010). In the following section, the practical implications of transformational leadership on change management are also discussed. Transformational leadership leads to greater trust, and with trust, more effective integration of organizations from the public healthcare and private healthcare sectors (Al-Mailam, 2004). This is also substantiated by analysis of how leaders that have transformational skill sets show greater restraint in using negative outcomes, choosing to create a culture of shared ownership and trust over time (Antonakis, House, 2002). This is also validated by the studies completed by Brinkmann and O'Brien (2010) that illustrate how transformational leadership in healthcare facilities lead to greater resiliency in organizational structures and the ability to overcome obstacles to growth. The studies of Brinkmann and O'Brien (2010) however did not differentiate between government-run healthcare organizations and those from the private sector. While the series of studies illustrate the importance of transformational leadership in managing healthcare organizations to patient-centric goals and objectives (Brinkmann, O'Brien, 2010) the study of leadership variation on financial performance is incomplete and often only cursory (Antonakis, House, 2002) (Avolio, Yammarino, 2002). The implications of transformational leadership on the long-term performance of healthcare organizations, either private or public, are incomplete as a result.

2.2 Development of theories/current status

A leader's impact on the success or failure of any initiative or strategy that requires exceptional levels of change on the part of employees is the single greatest factor in its success or failure (Tatli and Ozbilgin, 2009). Organizations must change to survive. If leaders are ever going to be trusted, they need to learn how to be transformational in scope. Taking a transformational vs. authoritarian mindset to the task of creating change significantly increases the potential for success (Chrusciel and Field, 2006). This may appear to be overtly positive or for the skeptical, naive, yet empirical studies suggest that leaders who have transformational skill sets are capable of managing uncertainty in organizations more effective than leaders who rely purely on transactional leadership styles as a result (Chrusciel, Field, 2006). Trust is the catalyst of lasting change, and even the most skeptical have to admit, they are more willing to change if they trust someone vs. not.

There are many studies of transformational leadership that have empirically shown this to be true (Avolio and Yammarino, 2002). The greater the level of trust the more rapid the transformational change, especially when leaders take into account the inherent diversity of the employee base and their unique identities and needs (Tatli, Ozbilgin, 2009). These researchers (Tatli, Ozbilgin, 2009) have shown that transformational leaders deliberately look at how to use change management training and development programs to firmly establish an egalitarian mindset in their organizations before the actual change is attempted. This prepares the organization from an attitudinal and perception standpoint to adopt change more readily and see the value of the shared objectives of the new organization more readily. This differs from Lewin's Force field analysis in that it does not include unfreezing and refreezing specific aspects of the change management strategy (Mueller, 2009).

In the context of creating a change management framework to enable greater levels of collaboration between public government healthcare sector organizations and private firms its critical for there to be a strong focus on getting employee buy-in and ownership (Russell-Bennett, Previte, Zainuddin, 2009). This is essential to get the necessary level of buy-in from employees to transform short-term changes into long-term modifications to habits, processes and procedures.

Change management strategies that have as their catalyst training and development are more successful at imparting and gaining support for the vision of the combined enterprise. This is critical when mergers and acquisitions are being completed that integrate public-sector healthcare organizations into privately owned and operated ones. Transformational leadership is critically important for moving from short-term, often short-sighted initiatives to more all-encompassing strategies that make the merger or acquisition successful (Mueller, 2009)

What empirical studies of the effectiveness of transformational leadership show is that when the more positive aspects of transactional leadership are used, greater levels of short-term learning of behaviors happen (Mueller, 2009). When transactional leadership is used sporadically as a means of scaffolding and initiating change, long-term learning takes place on the part of employees, further supporting change to processes and procedures (Najjar, 2008). Transactional leadership is by definition when a leader takes a short-term view of how to motivate their organization, and as a result, often is effective only for specific strategies, not for long-term, permanent change to processes and systems. Transactional leaders rely heavily on short-term incentives and punishments to get the results they want completed quickly (Al-Mailam, 2004). The timeframes are often very short, and studies of this type of leadership style indicate that it is best used in organizations where there is low complexity of task and the need for rewarding repetitive labor over inspiring creative thought and process-centric innovation (Al-Mailam, 2004). The combining of a transformational vision and a series of transactional rewards however can be highly effective in motivating change (Al-Mailam, 2004). Including transactional leadership's more positive aspects in the change management frameworks also deliver more immediate rewards of performance and have a more profound effect on adoption of change (Judge, Douglas, 2009). Transactional leadership is therefore very effective as a means for initiating and sustaining long-term learning on the part of employees.

Transactional leadership is often used in change management strategies to drive a high level of compliance and conformity using authority as the means to get agreement as well. This is in the short-term effective, yet in the long-term extremely detrimental to the morale of an organization going through significant change. Enforcing compliance with transactional leadership only changes one side of the behavioral equation. It very often fails to change the perceptions and attitudes, beliefs and long-term perceptions of employees, as it is pushed on them instead of presented as a means to get to their goals as well (Kuhnert, Philip, 1987). These studies suggest that only modifying the behavior of an associate or employee does little to infuse a high level of ownership of tasks and a focus on internalizing objectives over time (Eze, Kuziemsky, Peyton, Middleton, Mouttham, 2010).

What is needed instead is a hybrid approach that takes the best of a leader's transactional and transformational skills so that results are achieved and the leader still maintains a high level of authenticity, trust and transparency (Ross, Gray, 2006). Often transformational leaders rely on training and development to get their organizations up to speed on how business processes and management will change as the two organizations go through a merger, acquisition or joint venture process. Studies of effective change management frameworks indicate that using training and development programs as the means to define the magnitude of the change and provide skill training for employees is highly effective (Antonakis, House, 2002). Training and development programs are useful for also creating a high level of autonomy of process ownership, mastery of a given area of study, and purpose in the context of an employees role in a company (Abbott, Ploubidis, Huppert, Kuh, Croudace, 2010).

There is little value to being entirely transactional-oriented as a leader in the context of significant change management projects, as the best attributes of transformational leaders are also required to enable lasting change management

(Antonakis, House, 2002). The hybrid approach that takes the positive reinforcement and tactically-based approaches of transactional leadership and the style of transformational leaders to create a compelling vision (Antonakis, House, 2002) and define the steps to attain it are critical for change management frameworks and strategies (Boyatzis, 2008).

This unique combination of talents is what makes finding leaders who can manage change so elusive and difficult to find. The best leaders who have this unique combination of skills can also create a foundation for making change last by concentrating on imparting a high level of autonomy, mastery and purpose to subordinates as well. This rejects the notion of the relational leader, or followership theories where the myth of the 'great leader' is exposed and emphasis is instead placed on networks, power and politics as the ingredients of so-called 'transformational leaders'. It is specifically these social skill sets that matter far more than the ability to provide or withhold immediate rewards (Russell-Bennett, Previte, Zainuddin, 2009). For public government healthcare sector organizations, the transition to collaborating with or entering into joint ventures with private firms is the basis of this literature review. The lack of empirically derived knowledge in this area has led to this research effort.

2.3 Assessing Change Management Models and Frameworks

In the introduction it was stated that the two most challenging yet essential aspects of any change management strategy are the integration of business processes and their management from a business model standpoint, and second, overcoming resistance to change. These two factors over the long-term most impact an organization's value chains (Davenport, 1992). Often when two organizations merge the customer management strategies and Customer Relationship Management (CRM) systems specifically need to be integrated from both a process and goals-based standpoint. The resistance to change based on varying goals between government and private firms can be particularly challenging to intermediate and solve (Dyche, 2002). The role of transformation leaders in unifying goals and setting a new common standard of performance has an impact on the performance of the organization immediately, as has been evidenced in studies of mergers, acquisitions and joint ventures (Beer, Nohria, 2000).

With the value chain and its performance, and the structure and execution of the business model dependent on how successful communication is between organizations merging or forming joint ventures, the study of change management models is imperative. The change management model and frameworks that have succeeded over time, proven through empirical analysis, are presented in this section.

A series of organizational frameworks that over time have proven to be empirically sound and effective at making change last in organizations are defined in this section. Theorists have been quick to define a series of equations to the concept of change management (Sirkin, Keenan, Jackson, 2005) yet this model does deliberately takes out the most critical components of long-term learning and internalizing of objectives, which are autonomy, mastery and purpose. The creation of the DICE Model is specifically created to show how project duration, performance intensity as measured by peer-reviewed questionnaires and interviews, management commitment, employee commitment and employee effort all combine to create a causal model of change management effectiveness. The DICE Model therefore using these attributes as variables: project duration (D); project team's performance intensity (I); management commitment (C1); employee commitment (C2); and employee effort (E). Ironically the researchers who created this model say that it is more attuned to "hard data" which is gathered and analyzed to present a realistic assessment of performance; the factors are based on peer-reviews and assessments by superiors and subordinates when it comes to performance. The researchers specifically created the DICE Model in response to nearly all previous change management frameworks organizations relying entirely focused on the soft factors of culture, leadership and motivation instead of attempting to quantify leadership performance (Sirkin, Keenan, Jackson, 2005).

What makes the DICE Model relevant to the definition of the proposed change management equilibrium model is that it captures the quality and efficiency of communication by attempting to quantify the quality of peer review and collaboration of tasks. From this standpoint the authors of the DICE Model accomplished their goal as they were able to balance the theoretical aspects of their causal and equation-based design with the definition of a model that reflects organizational agility and speed of adoption to change (Sirkin, Keenan, Jackson, 2005). The DICE Model has captured the most relevant aspects of communication, clarity, collaboration and speed of process execution in change management scenarios. Attempting to quantify accuracy of communication, agility and value of collaboration over time can be attributed to the heavy influence on the models' design from the Boston Consulting Group and Harvard University, where the authors worked and graduated during the period of the time the model was created (Sirkin, Keenan, Jackson, 2005).

The implications of the DICE Model on the proposed change management equilibrium model is one of defining the 360 degree aspects of the peer, superior and subordinate influences on the balance of transformational vs. transaction leadership styles. At the center of the proposed model is the need for consistently, all based on collaboration and trust. The model is discussed later in this literature review. The DICE Model is used as a means to provide the quantification of the influences that impact the overall performance of the model.

It is readily apparent from the DICE Model's ability to quantify external factors that the use of its index and values would be very useful for defining the minimal levels of consistency and balance between outward-facing transformational leadership systems are essential for moving an organization forward, and the use of transactional leadership to get the immediate tasks and action items accomplished internally. It is a commonly cited statistic that 70% of the cost of modifying or changing an existing system is in providing guidance on how best to manage the business management and process-related problems first (Dyche, 2002). Dyche (2002) states that for effective change management to take place from a systems standpoint, the merging organizations must first align on shared customer definitions, goals, objectives, and benchmarks of performance. For the integration of public government healthcare sector organizations and private firms, this need for defining the customer focus is critical for lasting change management to happen. In the proposed change management equilibrium model, the customer is at the center. Customers must be the catalyst of all lasting change, galvanizing a firm to continually design and re-orient its strategies in their service. This is the unifying threat of all change management strategies that seek to unify public government healthcare sector organizations and private firms. In the context of the healthcare industry, the customer is the patient. Instead of technology, the financial structure and capital of a given firm, or even the incomplete and often cumbersome integration of systems uniting government and private firms, the one constant is customer centricity. Transformational leaders often rely on a very strong customer-centric message to unify and energize their organizations, often creating collaboration and trust quickly as divergent organizations find a common bond to attain greater results together (Antonakis, House, 2002). Sociologically all great leaders know that if they can find a common challenge, even an enemy to attack in a familiar market, this shared effort will accelerate the trust and process integration faster between two or more organizations. The alterative is to attempt through rhetoric and example to show why it is so critical to form a common bond and move forward. Yet the ability to energize and get a public government healthcare sector organization and private firms moving quickly to shared change management goals, the customer (patient) must be at the center, because accountability to them and their care is why the industry exists. Ion the discussion of the proposed change management equilibrium model this point of customer centricity is more fully defined.

One of the most important factors in evaluating change management models from the context of integrating at the process, business management and change management levels is the need for listening and responding to key market events. In the case of healthcare organizations, the need for managing turbulent and market-landscape altering events including mergers, acquisitions and alliances, the need for staying consistent with the leadership framework or model is critical. Often managers, when confronted with the magnitude and risk that change presents, often seek to mitigate these factors through the use of metrics and key performance indicators (KPIs) -- in short looking to quantify their value (Al-Mailam, 2004). The DICE Model quantifies the overall performance of an organization and defines which specific areas need to be improved to increase organizational performance. As a result, the DICE Model specifically aligns with the requirements of public healthcare organizations and their integration into private-sector healthcare providers. While the DICE Model was specifically designed to validate commitment and intensity and has over time evolved into a series of equations that can be modeled in rules engines, the basics of it are to measure collaboration while determining the impact of transactional and transformational leadership styles.

The Lewin Model centers on the observation that those affected by change move from one static state via a state of activity to another static status quo. Lewin specifically considers a three-stage process of managing change: unfreezing, changing and re-freezing. The first stage involves creating a level of dissatisfaction with the status quo, which creates conditions for change to be implemented. The second stage requires organizing and using the resources of an organization to bring about change. Stage three involves embedding the processes into the organization after change.

Clearly, the Lewin Model has many shortcomings specifically on the assumption that a status quo is again achieved. This is a fallacy as change in organizations redefines a new status quo over time, and the more intensely the change impacts a company, the greater the effort to retain "status quo." In reality, a new status quo is defined in the midst of every significant event that affects an organization. The Lewin Model is considered deficient due to this reason.

The Speed of Change Model Daryl R. Conner (2003) in his book Managing at the Speed of Change also has the potential to provide guidance to healthcare providers that are in the middle of merger, acquisition and alliance strategies as market dynamics change rapidly over time. The Speed of Change Model, which states that employees are designed by nature to move through life most effectively and efficiently at a unique pace that will allows for the meeting and overcoming of challenges. This resiliency to overcome challenges is what the author refers to as the speed of change. The model suggests that it is very critical for organizations to be aware of this inherent nature of people. Some people will be able to absorb change much more easily than others, and as a result, there needs to be a scaffolding strategy (Najjar, 2008) in place to support the change necessary for organizations to move forward to their objectives. Change management occurs when an organization can interpret the levels of change employees can tolerate and make the most of the organizational and market-driven shifts. This ability to interpret change and capitalize on in by combining the responses to it are also critical for ensuring all employees will be able to handle the stresses and requirements of it (Conner, 2003). These undesirable effects could vary in severity such as emotional burn out, inefficiency, sickness, destructive behavior, chronic absenteeism and other forms of behavior that distances employees from companies and leads to low productivity. Dr. Conner contends that for change management strategies to be effective, they must concentrate on the requirements and needs of the individual. The reliance purely on change management strategies for the sake of moving as quickly forward with a merger, acquisition or alliance will not be successful unless it takes into account the needs of individuals involved first, and second, the customers or those the organization serves. This is precisely the reason why the proposed Change Management Equilibrium Model is designed to have both transactional and transformational leadership supporting the customer-driven processes shown in its graphical representation. These customer-driven processes are actually those of patients, and their needs for consistently high quality of medical care throughout a merger, acquisition or alliance of public and private sector healthcare providers. From the Speed of Change Model perspective, the need for managing the many interactions with patients and the processes that support them further validate the structure and flow of the proposed Change Management Equilibrium Model, which is further discussed in Section 4.2 of this dissertation.

Dr. Conner (2003) further supports his Speed of Change theory with the fact that when employees reach a specific point in their levels of stress, they disengage from work and choose to redefine their own priorities. Task ownership greatly reduced and the overall focus of their activities is more orientated towards alleviating the stress and risk than in overcoming challenges and moving forward. The challenge of the Speed of Change Model is that it fails to take into account just how minute and varied the differences are between employees and how to address them in the context of en masse change efforts. For the strategist managing the integration of a public healthcare organization with its private counterpart (who is often the acquirer) the need for scaffolding (Najjar, 2008) the change management process is crucial to overall organizational success.

In his discussions of the model, Conner (2003) explains that there exists a point at which humans can no longer assimilate change without displaying dysfunctional behavior as well. Conner defines this point as Future Shock. The model also defines the single most factor necessary for individuals to increase their speed of change is human resilience. Human Resilience is the ability to absorb higher levels of changes while maintaining equilibrium. The model recommends that in order for change management efforts to be successful, resilient individuals should lead the change management efforts. There are powerful guidelines for the traits of resilient people defined by Conner.

Limitations of this model include the assumptions that people want to be resilient and not become apathetic, which is what many people resort to when it comes to managing significant amounts of change overall. Idealistically Conner sees those most capable or willing to change as having a strong sense of security and self-assurance, yet in the midst of major change, people's confidence is typically undermined and it makes them question it. Conner also makes some unrealistic assumptions about how people react to change, and doesn't focus enough on the challenges they need to overcome internally to succeed.

Assessing theories E. And O. Of change for an analysis of "Cracking the Code of Change" Michael Beer and Nitin Nohria describe change management from the standpoint of its economic value as defined by shareholder returns of whether the change is successful or not. Theory E Change focuses on the economic value as dictated by the shareholder returns. This is a drastic theory of change focusing only on the bottom line through financial incentives, restructuring and layoffs. Theory E is a set of concepts that together represent some of the worst layoffs in the history of business. All Dunlap's laying off 11,000 workers Scott Paper employees is an example, as is the firing of 5,000 employees from Oracle a year after the PeopleSoft acquisition so the company would not have to pay severance costs of the thousands of employees from the acquired company.

Theory O change is a softer, tactical and more human-centric approach that focuses on developing corporate culture and capability of the human resources. The focus of this theory is trust building and achieving emotional commitment through teamwork and communications. Hewlett-Packard is an example of a company that has built this level of trust with their employees and has often been recognized for "The HP Way" being an integral part to the company's culture. Theory O change management strategies are often useful during periods of rapid economic expansion, yet are not easily rationalized during periods of turbulent economic growth and change, which has become increasingly commonplace over the last decade. In addition, the drawbacks of using the Theory E approach are that trust is killed with employees, and as a result, the best and most marketable performers are quick to leave cultures that don't provide stability and a chance for growth. Theory E also creates pressure on the leaders to be unequivocal in their approach to change. Once this path is taken one can't deviate from it without a lack of credibility. The same holds true for Theory O Both of these theories are focused on the extremes of managing change and as a result are rarely used in isolation as the basis for defining strategies for change.

There are applicable parts of these two theories to organization's adoption of technology, as there needs to be a blending of Theory E and Theory O for the organization to accomplish its goals. For any organization to increase its financial performance and higher levels of compensation, employees need to feel a very high level of ownership for this strategy to pay off. Theory O-based organizations are much more prevalent when companies are profitable and there is a minimal level of perceived and real economic risk. At the center of Theory Os' success is the ability of an organization to accomplish its goals through mutual trust with employees.

The transformation of organizations' objectives into strategies that deliver lasting change is largely dependent on how companies approach changing everyday processes so they can be made more efficient. At the center of any successful business strategy, even irrespective of information technology or spending or investment, is the ability of leaders, some in management others de facto leaders, to initiate and sustain long-term change. For any change management program to be effective, leaders in an organization need to endorse and infuse trust in the change itself. In other words, leaders must change the concept of change in their organizations. To communicate this through an organization, leadership behaviors are need to be considered first to sustain momentum. The two articles analyzed in this paper are focused on change and the role of leaders in organizations to better enable its success. Bob Parker, Vice President of Research at International Data Corporation, points out that change management, especially from the standpoint of major shifts in the processes people rely on to do their jobs every day, requires senior management to fully engage in the planning, development, and launch of the initiative, whether it is IT related or not. In conversations with Mr. Parker, it's become clear that ownership is just the foundation, and the creation of trust has to come from the endorsement of senior executives of the change.

2.4 Redefining Business Processes Using Change Management

The most critical series of trade-offs that will need to occur in the integration of government healthcare sector organizations with private firms is the re-mapping and redefining of key patient-based processes meant to increase the accuracy, quality and speed of service to them. Redefining business processes through Business Process Reengineering (BPR) is a technique that was initially defined by Dr. Michael Hammer in a series of books he published including The Agenda (Agenda, 2003). He collaborated with Dr. Mike Davenport of Harvard Business School to create a Business Process Reengineering 9 BPR)-based series of methodologies and techniques for gaining greater efficiencies by cutting extra steps, extra time and costs from critical business processes (Davenport, 1992). BPR is considered comparable to Six Sigma, a popular efficiency strategy for getting higher performance from processes by making them more customers centric.

The approach of BPR is comparable to Six Sigma in that it places the customer at the center of change. Dr. Davenport defined a five-step approach for enabling change through Business Process Management. His framework has also been used specifically in the areas of mergers, acquisitions and joint ventures, where dissimilar organizations need to find a common series of processes and approaches to solve their goals. Davenport (1992) has prescribed the following five-step approach to the Business Process Reengineering model he authored with Dr. Michael Hammer (Agenda, 2003):

1. Create a shared business vision and define interprocess objectives. This is a critical first step in using BPR to create greater shared ownership of business processes and their management over the long-term. Creating a shared vision and series of shared objectives also creates the foundation for autonomy, mastery and purpose that also serves to bring greater ownership of shared tasks to the new organization. This is also critical for trust to be prevalent in the merged organization, as the commitment on the part of the new senior management team to deliver on the commitment of development is a powerful strategy against resistance to change (Judge, Douglas, 2009).

2. Determine with business processes need to be redesigned first and pilot them. This is the most pivotal point in any change management strategy between two firms who are relying on the BPR method to determine how best to integrate processes (Davenport, 1992). The reason is that this step requires intensive integration at the role-based, process, system and information reporting layers of the two organizations. For a government healthcare sector organization and the integration with a private firm, these pilots often lead to the development of entirely new systems and processes, and as a result, a strong focus on change management. For the government entities that may have seen their funding agencies as their primary customer, the shift to seeing the patient as the customer will be a major one. It is the intention of these pilots to force these perceptional changes over time so that both organizations can assess how best to make interprocess and intersystem communication more effective. Examples from the merger-intensive telecommunications industry (Barrett, 2007) illustrate how insightful a pilot program can be in finding out where apparent disconnects are immediately and where process-based disconnects will happen in the future. When a pilot is completed between a government healthcare sector organization and a private firm, there will be significant gaps in process coverage and process definitions. This is especially true in the definition of customer-centric processes as well. The development and continual evolution of the proposed change management equilibrium model is specifically focused on how to minimize these gaps and create a signal shared vision of the patient as customer. As is the case with successful transformational leadership, a pilot program with a common customer orientation and agreed-upon metrics stands a far greater probability of being successful over time.

3. Resist attempting to go for "big bang" process redefinitions right after a pilot; instead focus on the incremental smaller wins leading to the big win of more strategic processes being done first. This makes it possible to determine the best approaches to making process and organizational integration more transparent and focused on attaining share ownership. This step can actually contribute more to change management and doesn't necessarily have to be focused purely on getting processes completely redefined first. It can instead be focused on providing a foundation for autonomy, mastery and purpose so that shared learning can take place.

4. Use the merger or acquisition as means to get rid of processes known to be defective and broken while at the same time looking for ways to combine series of strategies more effectively. Getting rid of processes that may have been holding each organization back in the past, including the most critical to communication, are often deleted during this step after the pilot show limited results.

5. Benchmark performance and measuring existing processes religiously. The best organizations that undergo a merger, acquisition or joint venture are passionate about this step, and often create dashboards specifically to concentrate their attention on the areas needing the most improvement. How this fits with the concept of the acquisition of government healthcare sector organizations by private firms ties back to the first step of BPR, which is to define and stay focused on the same series of objectives over time. This has a powerful effect of making these factors known, and second, the shared metrics also serve to unify the direction of the new organization more effectively. Third, the selection of metrics that defines the shared performance of the new organization need to also be patient-centric, with a shared and common definition of just who the patient is. The lack of consistency in defining the patient or customer is can also derail pilots, which are used in this instance as a means to mitigate risk of completing entire process integration and not being clear on who it is interned to service. Pilots have the ability to define get to the point of what is leading to disconnects of the two organizations merging much faster than trial-and-error of attempting to accomplish strategies over time (Davenport, 1992). As a result the focus is on finding the best possible strategy to ensure consistency of customer focus first, and second, defining key performance indicators (KPIs) and metrics that allow for greater shared accountability and performance.

6. Identify strategy levers that can accelerate shared task ownership over time, using incentives to bring together divergent organizational cultures. This strategy concentrates on making the shared vision engrained into the mindsets of the employees involved in the integration part of their daily routine. As was mentioned in the beginning of this literature review, concentrating on this aspect of training and development as part of change management is highly effective. The creation of autonomy, mastery and purpose can be attained as a result of this strategy which leads to further organizational learning over time. With organizational learning comes more accountability for results and transparency in how they are achieved.

7. Definition and creation of a test prototype to evaluate the new process. Prototypes are very effective for evaluating the long-term effects of change management of the process and individual contributor role levels over time. A prototype can also successfully create a foundation for creating shared outcomes of entirely new processes. Organizations that rely on extensive use of mergers and acquisitions in the manufacturing sector have been successful in using this approach for distributed order management, ERP, supply chain and pricing systems of acquired companies over time. Prototypes also are invaluable for determining how resistance to change can be minimized and for study of how communication can be increased as well. The use of prototypes as nodes in a network for example has shown exceptional agility and accuracy of communication. The need is for using pilots not from just a technological standpoint, but from a patient-centered one as well.

8. Continually monitor and measure results towards objectives. The use of pilots and analytics from a BPR standpoint can be highly effective for determining the extent to which change management strategies will be successful over time for merged organizations. Pilots will not however provide complete certainly of change management strategies being effective in ensuring a high level of task and process ownership, or the internalization of shared goals on the part of employees most affected by the changed procedures. For public government healthcare sector organizations to share the same expectations as the private firms, there also needs to be a clear definition of metrics, their meaning, and the implications for evaluating collaboration and shared performance over time.

Despite the many benefits of BPR there are also several drawbacks, and these include the following. First, when process modifications are not working the natural inclination is to concentrate on quickly implementing cost reduction strategies to create more effective short-term financial gains with little insight into how long-term financial performance will be impacted. When this doesn't work often companies will resort to lay-offs to drive cost reductions instead of focusing on why BRP is not paying off. The downside is that BPR's quick exit as a strategy is to concentrate on creating more cost reduction purely through layoffs, as Oracle is doing right now with its Sun acquisition. While both companies are publicly held and from the same industry, it does illustrate the point of how, when mergers or acquisitions go bad and change management fails, that often companies will seek to quickly get results regardless of their impact.

The DICE and BPR methods illustrate the range of options available to private firms and public government healthcare sector organizations when they merge and attempt to create a new organization. What is missing from these models and other like them is a more customer-centric approach to attaining results. The proposed Change Management Equilibrium Model however seeks to alleviate this gap in leadership theories by showing how through collaboration that fuels trust through the effective use of rewards and consistency, customer-driven processes can be made more precise and targeted over time.

2.5 How Does This Project Fit In With the Literature Review

The proposed Change Management Equilibrium Model, which is at the center of this research, seeks to bring the gap between transactional leadership approaches on the one hand, and transformational ones on the other. The nee for creating greater agility in terms of response to market- and organizationally-driven turbulence is also shown in how collaboration becomes the foundation of the model, supporting both transactional and transformational leadership approaches. Consistency of strategy must unite both transactional and transformational leadership approaches as well. In fact consistency becomes the galvanizing link that keeps the entire proposed Change Management Equilibrium Model in balance.

Each of the change management theories and techniques mentioned in this section contribute to the linkages of the proposed Change Management Equilibrium Model from the standpoint of defining interlinking parts and integration points. The focus on how agile or flexible they are is also a key focus of the research contained in this analysis as well. Finally, the role of transformational and transactional leadership in the proposed Change Management Equilibrium Model serves to frame it from the standpoint of future growth and scalability of merged healthcare organizations over time. The fact that the proposed Change Management Equilibrium Model is designed to compensate for shifts in organizational reporting and leadership structures makes it particularly useful from the standpoint of managing healthcare organizations through mergers, acquisitions and alliances.

3.0 Research methods

3.1 Introduction: Hypothesis

Assessing the impact of transactional vs. transformational leadership on the financial performance of healthcare firms who have merged, been acquired or operate together in alliances is the focus of this research. Specifically focusing on how each of these leadership strategies affects the financial performance of a healthcare organization and its ability to withstand change is also a critical component of the overall analysis. The interrelationships of these factors, including the causality of their interrelationships are included in the proposed Change Management Equilibrium Model that is one of the outcomes obtained from this analysis.

In order to gain the necessary insights to complete this analysis, the use of research methods is critically important. Given the time and cost constraints of this analysis, it was not possible to interview the Chief Executive officers (CEOs) and Chief Financial Officers (CFOs) of healthcare providers who had gone through mergers and acquisitions. Interviewing these senior executives would have made it possible to quantify the value of transformational vs. transactional performance, and also made it possible to assess the structure of the proposed Change Management Equilibrium Model's structure and constructs. Much has however been written about the impact of leadership strategies and styles on the performance of healthcare organizations prior to mergers and acquisitions, specifically in both public and private healthcare facilities and hospitals (Al-Mailam, 2004). Studies that include the transformation of healthcare also illustrate that the foundational elements of this research, namely the role of cooperation and consistency being a counterbalancing factor in managing rapid change (Brinkmann, O'Brien, 2010) is a core element of the proposed Change Management Equilibrium Model as well. Validating these concepts and quantifying them with the assistance of senior management could have potentially created an Index of Change Management or Index of Healthcare M&A Effectiveness. Without this data however from senior management teams at healthcare companies globally who have merged public healthcare providers with private-sector ones, the research methods and methodology as defined in this chapter are focused on secondary research and the use of secondary data sets when applicable.

3.2 Background

How the mergers and acquisitions of government- and state-run healthcare companies are orchestrated, has a direct impact on the overall profitability of the merged organizations. The ability of senior managers and C-level executives to successfully manage the transition process has much more to do with their abilities to traverse leadership styles and networking expertise in creating shared ownership of critically important change. Research into change management at the UK Health Service has shown the need for balancing both transactional and transformational leadership for a state-run healthcare provider to stay relevant and responsive to patient's needs (Drummond-Hay, Bamford, 2009). The impetus for managing the trade-offs of transactional vs. transformational leadership was also made apparent in the study of combined state-run and privatized healthcare facilities in Kuwait (Al-Mailam, 2004). From these two studies and supporting analyses that indicate change management is more effective when implemented using a combined or hybrid approach o transactional and transformational leadership (Avolio, Yammarino, 2002). As a result of these studies and the implications of how effective change management strategies are when combined with a hybrid approach to leadership, the following three research questions have been defined.

Research Question #1: Does the use of change management strategies make a statistically significant difference in the integration of private sector healthcare organizations with public-sector providers to the process level.

Research Question 2: Are there are financially measurable results of successfully integrating public government healthcare sector organizations with private sector firms, attributable to process-based performance improvements that are quantifiable? Have any previous research studies specifically addressed this issue, and if so, what are the implications to the continued merger and acquisition activity of government-run and private healthcare providers.

Research Question 3: Are the causal factors that support the Change Management Equilibrium Model statistically significant, and support the framework of this proposed framework? Are the statistically derived relationships in the data statistically valid enough to base the Change Management Equilibrium Model on? The ability to measure how well or poorly a hybrid leadership model contributes to organizational change needs to be the central focus of the research.

3.3 Methodology

The intent of this methodology is to define a reliable, statistically sound, and reliable research strategy for validating or refuting the factors that form the foundation of the proposed Change Management Equilibrium Model. Mergers, acquisitions, and joint ventures of public healthcare sector organizations with private healthcare organizations are the catalyst of new frameworks and models for ensuring two divergent cultures can be integrated together. The proposed Change Management Equilibrium Model requires the quantification of transaction- versus transformational management on the long-term financial and operational performance of healthcare organizations.

The proposed Change Management Equilibrium Model is based on consistency of transaction vs. transformational leadership, anchored in the positive aspects of transactional leadership (rewards and trust). The use of these transactional reward strategies to ensure a higher level of collaboration is integral for the proposed model to work. The tight vs. loose coupling of transaction-centric vs. transformational management to the customer-driven processes of a healthcare provider are also critical. It is the intent of this research methodology to take these factors into account and translate them into research problems, hypotheses, research methods, all accomplished with strong validity and reliability of data achieved.

Research Problem

The research problem is multi-faceted, as it requires a focus on the aspects of change management theories that can most significantly increase the financial performance of healthcare organizations after a merger or acquisition or is completed. Transactional and transformational leadership skill sets and styles also need to be taken into account, as there are significantly different cultural mindsets in public government healthcare sector organizations vs. private sector firms. The many facets of successfully managing change from public healthcare to private sector transition must however center on the patients' needs and the definition of a successful treatment plan. This is in fact the most important facet of any change management strategy of organizations from public to privately-based operations: the transition must not allow for patient care to drop or be degraded in any way. This is a core assumption of this research. The continual high quality care of patients is the most important metric in evaluating the performance of change management strategies.

The research problem is made more complex due to the need to isolate and quantify the effects of successful change management strategies on the financial performance of private-sector firms. This is the more difficult research problem to solve, as it requires the methodology to isolate the costs associated with change management strategies' effects over the long-term in private sector organizations. An ancillary factor in the development of the methodology is measuring the costs of processes within public government healthcare sector organizations vs. their private sector counterparts.

The comparison between public government healthcare sector organizations' performance on key process areas is beyond the scope of this analysis. The totality of them however is included in the customer-driven processes area of the proposed Change Management Equilibrium Model. The contributory effects of successful change management strategies are measured using benchmarks within the merged public healthcare and private firms. These series of benchmarks will then be evaluated using statistical analysis techniques including t-tests, nonparametric and parametric statistics and description statistics including measures of central tendency and mean, mode and dispersion measures including standard deviations.

Hypotheses

The following are the research questions of this research study.

Research Question #1:Does the use of change management strategies make a statistically significant difference in the integration of private sector healthcare organizations with public-sector providers to the process level.

Research Question 2: Are there are financially measurable results of successfully integrating public government healthcare sector organizations with private sector firms, attributable to process-based performance improvements that are quantifiable?

Research Question 3: Are the causal factors that support the Change Management Equilibrium Model statistically significant, and support the framework of this proposed framework? Are the statistically derived relationships in the data statistically valid enough to base the Change Management Equilbrium Model on?

Research Methods

The following are the research methods and the sequence they will be used to complete this study. First, a thorough literature review will be completed that includes secondary data on the topics of change management, financial impacts of transformation and transactional leadership in public to private sector mergers and acquisitions, and the financial impact of change management strategies on Return on Investment (ROI) of private sector firms who acquire public sector organizations. Included in the secondary data segment of this analysis will be an assessment of customer or patient satisfaction when mergers, acquisitions or joint ventures have taken place in the healthcare industry. All of these secondary data findings will be organized by their role in proving or retuning each of the research questions of this research effort. The findings from the secondary data by each of the areas of the proposed Change Management Equilibrium Model will also be assessed. Quantifying the performance of successful change management strategies also will either validate or refute the connections throughout the proposed Change Management Equilibrium Model as well.

Reliability and Validity of Data

Attaining validity and reliability in qualitative research is dictated by the stability of the cited research and its use in answering each of the research questions. For a study to be evaluated as statistically reliable and valid, the objectivity of both the qualitative and quantitative research must also be assessed. The intent of this study specifically is to draw from the body of research on the impact of transaction and transformational leadership on the performance of healthcare organizations after a merger or acquisition. The research model as defined by Lincoln & Guba (1985) states that any research, to be valid and reliable, must have the attributes of credibility, applicability, dependability and confirmability all must be present for a research study. Each of these aspects of the study have been specifically addressed through the design of the research methodology to ensure validity and reliability of the results. .

4.0 Results and Data Analysis

4.1 Presentation and Description of Results

Using Statistical Package for the Social Sciences (SPSS) datasets obtained from the Ministry of Health in Malaysia, comparison of patient satisfaction levels of state-run vs. privatized healthcare facilities in presented in this section. The state-run clinic is part of the Hospital Kuala Lumpur, a state-run medical facility that has an outpatient clinic. A privatized clinic is also located in the same region of Kuala Lumpur, and the analysis compares the performance of each from a customer satisfaction standpoint.

The approach to management varies drastically between each location. For state-sponsored center, which is an annex to the Hospital Kuala Lumpur is very transactional in scope, often relying on the total amount of inbound patients, their relative turn-around times, and the closure of specific cases. Unlike the cases shown from the work done on privatization in the U.S. (Pozniak, 2006) the skill sets did not include advanced areas of radiology, nuclear medicine or advanced forms of internal medicine. Instead, these clinics focused on triage techniques for treating emergencies.

To understand how the variation in ownership of the two locations influenced performance and either contributed to or detracted from the development of the proposed Change Management Equilibrium Model the focus on how Quality Management Systems (QMS) were implemented in each clinic was completed. Based on previous study it is apparent that to the extent an organization has more effective transformational leadership, the greater the extent of focus on quality management over time. The interrelationship and influence of outpatient service providers' processes on patient satisfaction levels therefore became a predictor of leadership direction and strategy in this study. The original intent of the research study was to specifically find those factors that contribute or detract from a patients' relative level of satisfaction with the outpatient services provided them. As the Ministry of Health, Malaysia, the assumption provided the dataset and further research to determine which leadership styles were used in which clinic was undertaken. Based on an analysis of the results and further study of the clinic system in Malaysia, the conclusion is drawn that the government-run clinics are more transactional in scope, while the privatized ones gained through acquisition from the government are somewhat more transformational as they focus on quality management. Yet there is not the wide chasm of differences between transformational and transactional leadership that is evident from the literature review completely previously.

The original survey instrument contained seven demographic variables and twenty-five attitudinal variables were used as the basis of this analysis. Gender, age, race, marital status, education level, occupation, and monthly incomes are the demographic variables. The twenty-five attitudinal variables are presented in a five-point Likert Scale and are specifically written to encompass the five generic dimensions as defined by Parasuraman, Zeithaml & Berry (1998) which include reliability, responsiveness, assurance, empathy, and tangibles. The questionnaire was originally written in English and then translated into Malay. This was done to increase the potential response rates and minimize sampling errors that may have been introduced through Social Desirability Response Bias (SDRB), as might have been the case if respondents had seen one group being excluded based on fluency in one language vs. another. Simple Random Sampling (SRS) was used to distribute 120 questionnaires to patients of the Hospital Kuala Lumpur, a state-run medical facility that has an outpatient clinic and to the private clinic in the same area of the city, who requested anonymity in the study.

Findings from Questionnaires

The primary intention of this research study is to ascertain which factors, to a statistically significant level, contribute to or detract from patient satisfaction levels for a healthcare outpatient clinic. The secondary objective is through the use of attitudinal variables define which intangible aspects of service are perceived as contributing to higher levels of patient satisfaction. The third objective is to determine through inferential analysis which clinic is performing better based on an analysis of their quality management procedures and processes. The ability of a clinic to sustain and grow the depth of their quality management initiatives and programs is a correlating factor to their ability to stay more transformational in their approach to leadership (Pozniak, 2006).

Survey results obtained from the Ministry of Health were tabulated and analyzed using SPSS Version 19 for Windows, with frequency distributions completed for all variables. Additionally correlation analysis was completed on all demographic variables relative to the twenty five attitudinal variables to test for statistical significance and the ability of demographics to predict levels of patient satisfaction based on the survey results. In addition, histograms that control of age, marital status and race relative to the perception of value of training materials as being sufficient (MATERIAL) and the use of A/V materials or not (AIDS) are included in the analysis.

The analysis shown that regardless of the ownership of the clinic, perception of time varied drastically across the respondent base. For example, those respondents in the 41 -- 50 age groups are particularly sensitive to time-based measures of satisfaction, including the wait time at the counter in the outpatient clinic, in addition to the cumulative time to see the doctor as well. This age group (41- 50) also negatively correlated with several of the attitudinal variables as well. The most noticeable result is the negative correlation of the attitudinal variable, "Clinic doctors always explain to patients about their medical conditions" having a -.387 correlation at the .01 level of confidence. Clearly this shows the 41-50 age group feels they are being ignored in the outpatient services in the clinic run by the government. This is in turn exacerbated by the negative correlation, -.341 at the .01 level of confidence for the correlation of age to "Waiting time to see doctor is very reasonable." The sense that respondents in the 41 -- 50 age group have of being initially ignored, then rushed through the visit and diagnosis has a weighting effect across the satisfaction levels of the entire respondent population. The -.301 correlation the at .01 level of confidence for the correlation of age and the variable "Clinic doctors always spend sufficient time with patients just underscores how much of the 41- 50 age group of respondents are by far have the lowest level of satisfaction across all age groups in the study. This dynamic of high levels of dissatisfaction does not apply however when age or income is used as an independent variable in the analysis. Race however is another demographic variable that has statistically significant ramifications on the customer satisfaction of respondents, especially in the area of health training and A/V materials. This finding will be discussed shortly in this analysis, yet it is clear that Malays are often dissatisfied with the quality of the health education materials, in addition to A/V aids.

Comparing the privatized clinic, there was not that much greater level of performance in terms of greet times by doctors and the ability to get in an see one. The privatized clinics however did have a higher level of correlation of materials and scheduling approaches than their state-run counterparts, to an .01 level of significance.

Another variable that specifically shows one of the attitudinal variables that contribute to a low level of satisfaction by race is the waiting time to see a doctor, which was the same across both state-run and private clinics. The following graphic is derived from an analysis of the research completed, showing that the Malay respondents have the highest count of all who strongly disagree with the statement that the waiting time to see the doctor is reasonable. When both race and age are combined with this variable, race is the most statistically significant predictor of dissatisfaction with the time required to see a doctor in the outpatient clinic.

Figure 1 is across both the state-run and private clinic, and shows that in both cases, there is much greater need for providing insights into how best ot manage perceptual bias of specific races who come to the clinics for treatment. Another interesting area of the analysis is the need for better management of the Chinese visitors to both clinics -- both are equally given longer lead times.

One of the most major sources of dissatisfaction however throughout the was the perceived quality of the health educational materials at the outpatient centers evaluated by the Malaysian government in this study. Malays, those in the 41 -- 50 age segment and men found these materials to be substandard and irrelevant to their needs.

The income variable was also tested in a correlation analysis to the variable "The health educational materials are sufficient" and did product statistical significance, yet did show trending to support the contention that the health educational; materials in the outpatient services office were not well aligned with the needs of the races or ethnic groups.

When the demographic variable of marriage status was included, the results also produced a very high degree of polarity between married couples relative to singles. Notice in the following graphic that those respondents who were married had a higher level of dissatisfaction with the health educational materials that those who are single. The assumption is that these respondents have family concerns including aging partners and younger children to take care of could be the catalysts driving the higher expectations for quality educational materials. Yet across many of the analyses completed, it's clear that educational materials are a source of dissatisfaction with the outpatient services center across race or ethnic groups and also for those respondents who are married.

The expectations of health educational materials are clearly quite high, and when the demographic variable for educational level was included in the analysis, additional findings showed the extent of those respondents with a more advanced educational background also seeing heath education materials as insufficient for their needs.

Apart from time required to see a doctor being excessive from the perspective of Malays and those in the 41 -- 50 age group, the levels of dissatisfaction with healthcare educational materials is statistically significant across income levels as well when stratified by each type of clinic they are offered through. The following graphic and table illustrate how significant the level of dissatisfaction is with health educational materials by income levels. Those with the highest monthly incomes for example show the greatest levels of dissatisfaction, while those with the second-most lowest income view the health materials as sufficient. The middle class income group is split, yet less more in their expectations to the upper-income group in terms of the health educational materials. When the SPSS Data Set was used to evaluating each of the types of clinics, the results were nearly identical. This shows that despite the level of income a patient has attained, transformationally-based vs. transaction-centric managed clinics do about the same in terms of performance.

When a Chi-Square plot is completed, it also shows the relatively high correlation levels of how health educational materials are perceived across race as well. This interpolates into the finding that while race is a predictor to a statistically significant level of satisfaction with outpatient centers in Malaysia, the factors of tailoring health educational materials to their unique needs is a critical priority for the healthcare service provider to work towards delivering.

The next two graphs illustrate the relationship between attitudinal measures of audio-visual aids and attitudes towards them.

One of the most critical aspects of customer's levels of satisfaction is the perception of time on the part of the service provider relative to the patient (Anderson, 1995). The varying perceptions of time, according to Barr, Giannotti, Sofaer, Duquette, Waters, & Petrilli (2006) the perceptional differences of time are by far the most critical in the development of effective patient satisfaction programs.

According to Tam (2007) and Twanmoh (2006) and supported by research completed by Scotti, Harmon, Behson, Messina (2007) significant variations in how time is perceived between patients and outpatient service providers is the foundation of dissatisfaction (Ramsaran-Fowdar 2008). The following table also illustrates the extent of dissatisfaction by race as well with doctors' timing of service.

To the extent that a clinic's management team can concentrate on delivering on-time performance and also seeing their visitors not as just patients but as customers, overall satisfaction increases over time (Barr, Giannotti, Sofaer, Duquette, Waters, & Petrilli, 2006). The role of transformational vs. transactional leadership then is one of respect for the varying perception of patients and not necessarily a focus just on the execution of tasks over time. The focus on how to gain the greatest value from each patient interchange appears from the SPSS analysis completed on the Department of health data set, to be relatively even. When the satisfaction scores or net SERVQUAL scores of each clinic were compared, the private healthcare provider actually had the greater levels of performance. The analysis showed that this was due to the fact that the clinic had to pay for each piece of collateral or material in the lobby, and also viewed the materials not as a means to just inform, but as a way to generate new opportunities or customers. The customer-centric nature of the one clinic is what led to a slightly higher level of satisfaction. Can this be extrapolated to a higher level of ROI or income over time? Only after more intensive research. Yet this orientation of seeing the patient as a customer increased overall satisfaction to a significant level.

The customer-centric orientation that the private clinic has been able to achieve is also reflected in satisfaction scores. The lack of focus on customers in the subsidized clinic leads to greater levels of dissatisfaction with higher-income, more educated patients as well. This lack of focus on customers gets communicated to patients as a perception of time not being that important overall, and at best a fungible or flexible resource. The following two tables are Chi Square Analyses showing how the satisfaction with wait times by income and educational levels make this point.