For many, health and business appear to be incongruous. The characteristics of healthcare organisations (HCOs) appear to be social and not business-like in nature as portrayed by peoples healthcare needs. Yet, Charles Handy (1994) in his book, The Empty Raincoat describes, Every organisation is, in practice, a business because it is judged by its effectiveness and judged against its peers.
By implementing a systematic approach to project development, the author will prepare the business plan of a 28 bedded operational Care Home in Glasgow that is being purchased from the Council.
The private home sector in Scotland is a major industry employing over 100,000 people and an annual turnover of 1bn. Thus, it is vital to the national economy and has potential for investment and growth (Scottish Care manifesto for Care, Nov.2010). Currently, the private sector runs 66% of all care homes for adults and older people nationwide (NHS Care Home census, 2010).
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The present economic climate raises challenges ahead but prospects for the industry are still promising (Colliers International, 2010). There is opportunity for new players as the market is characterised by a large number of small players with the top-ten providers representing only 25% of all bed spaces (Ellis, R. 2008) and 78% owning only one home (Hancock and Hviid, 2010). Although annual profit margins (as a proportion of total revenue) have been under pressure, they were around 26% in 2009 in Scotland (Colliers International, 2010). Scotlands population is ageing somewhat more rapidly than the other UK countries (Scottish Govt. report, 2010) and life expectancy have improved because of a trend towards healthier lifestyles and advances in healthcare (Scottish Govt. Report, 2011). According to figures available from Registrar General office (2010), the number of people aged 60 and over in Scotland is projected to rise by 50 per cent, from 1.17 million to 1.75 million and 25 percent more older people (=23000) will need some form of care in just the next six years. The Healthcare Quality Strategy of NHSScotland (2010) recognises the significance of mutually beneficial partnerships with high quality care providers including those in the private sector.
The author will review and critically examine appropriate theories and principles of business planning and project management techniques that will ensure successful planning and execution of the business plan. The mission, objectives and key strategic plan and management plan of the business project will be proposed. In addition, a review of the industrys background and existing market and of the potential impact of the current economic situation on it will be presented.
This will follow a discussion of theories and models that currently exist for quality and performance measurement management of healthcare services.
Key words: Healthcare organisation, business plan, strategic planning, quality, performance measurement management.
Business culture and strategic planning in healthcare
Compassionate care must be at the heart of healthcare; however, rising healthcare costs, demographic shifts, the pace of medical technology and changing customer expectation have driven the application of business practices to healthcare industry (Bell, McNaney and Jones, 2006).
Early reports (Donaldson and Gray, 1998; Koeck,C. 1998) emphasised the importance of organisation culture and clinical governance in health services to manage the change that is required to improve quality of services. Subsequently, there has been increasing recognition of the need for accountability and develop a business culture in health services, including within the NHS (Scotland's Health White Paper 2003). Such a culture enables the HCO to define quality standards, deliver services matching those standards and subsequently monitor quality and performance. In addition, it helps to identify factors that facilitate or hinder performance as well as predict and measure impact of strategic interventions (Mallack et al 2003; Davies, Nutley and Mannion, 2000). Waldman, Smith and Hood (2003) prefer the phrase corporate culture to organizational culture and argue that by creating an effective corporate culture, healthcare professionals and managers can improve performance and quality in both medical and financial outcomes.
Strategic planning as defined by Brooks and Weatherston (1997) is the effort to match organisational capability with environmental opportunities. Armstrong (1982) emphasised the need to gain commitment all stakeholders during the entire planning process, to have alternative strategies in place and a system of monitoring of results.
Although strategic planning is designed to lessen the risk of failure, promote efficient use of resources and enable it to communicate its vision and values (Hyde and Cooper 2001), earlier reports questioned its benefits (Greenley 1986, Porter 1987) and companies commitments on its implementation and evaluation (Glastair and Falshaw, 1999). Modern healthcare management considers strategic planning as a live, ongoing process (Grobmeyer 2001; Zuckerman 2000) and emphasises on aspects of implementation and evaluation (Bossidy, Charan, and Burck 2002) and meaningful stakeholder involvement in the planning process well illustrated in the Equally Well Implementation Plan of NHS Scotland (2008).
Always on Time
Marked to Standard
Hoshin kanri principles based strategy management allow organisations to bridge the gap between strategic vision and implementation (Witcher and Chou1973). In a review of an ongoing project to develop a strategy deployment framework for objectives for NHS North East is based on Hoshin Kanri principles, Kunonga, Whitty and Singleton (2010) note that successful implementation requires considerable investment and time.
Operational planning (O.P.) is a subset of the strategic plan and establishes goals specific on a particular unit or individual. O.P. often utilises a model known as critical plan method /analysis which represents activities and time scales between a beginning and endpoint of a project being delivered. Gantt charts (Mind Tools) can visually illustrate project planning.
Rational planning is a cycle of decisions that are made to achieve goals set by the organisation (Lawton and Rose, 1994). Features like assumption of control over the internal environment of the organisation and practice of top-down management make this model less relevant in present-day business planning.
Emergent planning: Particularly applicable to the healthcare sector, this model allows individual units and managers to develop and implement policies, negotiating skills, adaptability and ownership (OConnora and Netting 2007) and to develop the relatively safe option of incremental planning. However, the main risk of this autonomy-promoting method is that a fragmented approach to problems may lead to adverse effects on other units within the organisation.
The Business Plan
At the outset of starting a business, a written plan that describes how the organisation intends to meet the demands of its clients and develop the business is essential (Gray 1992). The business plan helps to identify and allocate internal resources judiciously (Barrow, Barrow and Brown,1998), and demonstrates the managements commitment to achieve realistic, sustainable goals to ensure long-term health and growth of the business (Deffenbaugh, 1991).
Preparing the plan
There is no one strategic planning model to suit all organizations (McNamara, C. 2003). Terminologies used to describe various models include basic strategic planning, issue-based or goal-based, alignment, scenario, and organic planning. Models can be integrated, e.g., using a scenario model to identify strategic issues and goals, and then an issues/goals-based model to address the issues and reach the goals.
Kotlers (1991) model of the strategic planning process provides a useful framework.
The model used for the proposed business is illustrated in Appendix 4 (figure 11).
Planning the business:
Scanning the external environment
To determine the relevant dynamic and complex factors in the external environment, PEST analysis (or its expanded forms, e.g., PESTEL) is a useful tool (McGee, Thomas and Wilson, 2005). Assessments of these factors, which are often beyond the control of a business organisation, help determine risks, position, potential and direction for an organization. The factors are categorised as:
P = Political, E= Economical, S= Social, T= Technological, E=environmental, L=legal
In addition, E= ethical is increasingly becoming relevant and not just in the business of healthcare as emphasised by the author in later discussion.
Although the PEST tool enjoys extensive usage, Burt et al (2006) have argued that the process of Scenario Planning is an alternative and superior tool than PEST for analysis of the macro environment.
To be effective, the Chartered Institute of Professional Development recommends regular review of PEST to detect changes early in the external business environment. The data analysed from this tool when used in conjunction with SWOT analysis (Valentin 2001) or other techniques such as Scenario Planning (Schoemaker, 1995), Porters five forces (Porter, 2008) or environmental scanning (Smeltzer, 1988) helps to implement initial business strategy as well as service planning, marketing, organisational change and for research purposes.
Mission and vision statements:
All business organisations including HCOs operate in dynamic and competitive settings and need an expression of their identity (who are they) and strategic direction (value statement - what does it aim to be) in the form of a vision statement. Such a statement serves as a navigational tool for the organisations decisions for a fixed period, usually for five or ten years (Zuckerman, 2000). It should be inspiring and motivational to the management and employees but also appear as achievable.
Coile (2000) proposes three different kinds of vision for a HCO:
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* The vision for health for all (emphasising inclusivity and accessibility, reduce inequalities).
* Strategic vision to define its role in the market place.
* Business vision to underscore the dual nature of a modern HCO: services with strategies for economic viability. This vision also lays the basis for strategic partnerships with key trading partners including other community-based healthcare providers.
A mission statement is not time bound. It describes the organisations purpose, why it exists and identifies the key measures of the organization's success (Drucker 1990). Sidhu, J. (2003) argues that an effective mission statement leads to better performance by aiding strategy formulation and implementation.
Philosophy, ethics and vision - form the fundamentals of modern business planning and determine the spirit and integrity of the business or organisation.
Solomon (1999) asserts that an honest, just and firm, robust approach helps an organisation to have a sound ethical foundation and Eiser, Goold and Suchman (1999) contend that healthcare is largely a moral enterprise and its management must examine an ethical perspective and not merely an operational one.
Winkler, Gruen and Sussman (2005) suggest four essential principles to guide the ethics of business of healthcare - provide care with compassion, treat all stakeholders with respect, act in a public spirit, and spend resources responsibly. Similarly, NHS Scotlands corporate framework lists 10 service core values, which include respect, social responsibility, accountability and fairness. Additionally, National Care standards (2007) are based on six principles dignity, privacy, choice, safety, raising potential and equality and diversity. Further, Webley, S of UK Institute of Business Ethics lists transparency, fairness for all stakeholders and considering possible negative consequences of proposed actions as crucial.
Scanning the internal environment (Situational analysis)
SWOT analysis helps an organisation to ensure a fit between the external situation it faces and its own internal qualities or characteristics.
Internal to an organisation and within its control, are strengths that are positive (both concrete and abstract) attributes and weaknesses, which can be hindrances to attain the desired goal.
External to an organisation and beyond its control are opportunities that are stimulant factors (within identifiable times) and justify the organization to exist and grow and threats, which could place the organization mission or operation at risk.
The tool is popular in classical strategic business planning (Weihrich, 1982). However, there has been much debate about its precision and relevance resulting in interpretation of the acronym SWOT as meaning, significant waste of time and so WOT. In their review of use of SWOT by 20 UK based companies, Hill and Westbrook (1997) concluded that the process is obsolete and that it was time for a product recall. Menon et al (1999) found significant negative relationship between SWOT and market performance in their study of marketing strategies of Fortune 500 companies. Further Armstrong (1982) advises to stop using SWOT and proposes a formal strategic planning processes consisting of 5 steps:
Finally, Kangas et al (2001) have developed AWOT in which they have integrated the Analytic Hierarchy Process (AHP) framework into SWOT analysis. They propose that the hybrid method will improve the quantitative information basis of strategic planning processes and facilitate alternative strategy planning.
Key issues and critical success factors
Successful project management tools include identifying key issues and then critical success factors (CSFs) which potentially act as drivers for a successful business project (Pinto, 1989). Factors typically identified by Clarke (1999) as critical to the success of business projects include effective communication, clear objectives and scope, dividing complex tasks into smaller manageable actions and using project plans as working documents. Morris (2002) advocates the use of adopting the Pareto rule of separating out the important few from the trivial many'' to focus attention on the key factors. Yet, Clarke (1999) suggests a holistic approach, looking overall at project management. The CSF concept has been applied to health care (Johnson and Freisen, 1995). A SWOT analysis of each CSF can be undertaken to better understand the overall SWOT analysis of the plan.
Defining SMART objectives of the plan:
In a business plan, objectives are statements stating an intended outcome, which describe goals and enable the reader to envision results. These statements help determine if programs are elaborately linked and relevant to the business and are essential for survival of the business (Phillips and Phillips 2008). Objectives need to be specific (distinct) and measurable. They should also be achievable but challenging goals should be high but not so high that they are not realistic. Conditions and resources must be available to meet the objectives. Finally, they must be time bound (Annulis and Gaudet, 2010).
Quality and Performance measurement management
A wide range of initiatives based on various theories and models has been adopted to improve quality of services in healthcare organisations, including by NHS from the early 1990s. The evidence to assess their effectiveness and cost-effectiveness is scarce mainly due to methodological challenges faced by analytical research of this kind (Powell et al 2009).
In their assessment of the impact of quality initiatives, Shortell et al (1995) propose that irrespective of the model chosen to improve quality, successful implementation requires a culture that supports quality improvement work, strategic quality planning and empowerment and training of staff. Similarly, Walshe and Freeman (2002) assert that it is important to persevere with one carefully chosen model, understand how and why it works rather than measure whether it works and evaluate the program itself on a continuous basis to monitor its effectiveness. Further, optimum conditions must prevail to facilitate successful implementation - they include adequate practical and human resources, active engagement of professional staff and managers, use of coordinated multipurpose interventions at all levels of the health care system, substantial training and the availability of reliable, updated data (Powell, Rushmore and Davies 2009).
Total quality management (TQM) philosophies/ Continuous quality improvement model (CQI)
Counte and Meurer (2001) define CQI as customer driven leadership approach based on continual improvement of the processes associated with providing goods or services. Although effective implementation of CQI can result in operational and strategic organisational benefits (Mahmoud et al 2011), its implementation has been difficult due to barriers such as traditional bureaucratic cultures, departmentalization with different leadership and operational style, complex process that dispense care, relationships between management and health professionals/unions and managements own understanding of quality strategies. Further, dependable data collection, frequent top-down reorganisations and program changes are additional challenges (Powell, Rushmore and Davies, 2009; Short and Rahim, 1995).
European Foundation for Quality Management business excellence model (EFQM): Developed in 1988 and approved by the European Commission (EC), EFQM has nine elements of the model (enablers and results criteria) which assess an organisation's progress towards excellence (Shergold and Reed, 1996). A key component is the self-assessment process, which uses a scoring matrix known as RADAR - Results, Approaches, Deploy, Assess and Review, to identify strengths and areas that need improvement.
There are reports of its use in various NHS trusts in England with positive results (Jackson, 1999; Naylor, 1999). Although this model claims to benefit customers, leadership, management, employees and stakeholders (Oakland, Tanner and Gadd, 2002), it has several drawbacks. McAdam and ONeill (1999) have questioned the validity of the process when performance assessment is out-sourced. Another concern is the debate between excellence and quality (Dale, 2000). Medhurst (2006) has posited that these pitfalls can be minimised through more flexible approaches. Further, Dahlgaard and Dahlgaard-Park (2007) note difficulties in the implementation of the model and Conti (2007) questions the extent of its usefulness for self-assessment purposes.
The fundamental concepts of the business excellence model:
Malcolm Baldrige Quality Award (MBQA) model: Developed by the U.S. based National Institute of Standards and Technology (NIST) in 1995 and based on the theory that Leadership drives the System which creates Results, the MBQA
Health Care Criteria have been widely utilized by hospitals for self-assessment purposes (Meyer and Collier, 2001). A study about the feasibility of this model in US hospitals found substantial evidence of the cause - performance relationships implicit in the model.
Chronic care model (CCM): This model identifies six elements, which influence the quality of care for chronic diseases. According to Wagner et al (2001), when used in collaboration with other quality improvement techniques, the model appears to be a viable method of improving quality across multiple chronic illnesses.
In a systematic literature review of integrated quality management models, Minkman, Ahaus and Huijsman (2007) argue that the EFQM/ MBQA models are experience-based, whereas the CCM is evidence-based. Although evidence is scarce to prove the efficacy of these three models, the authors suggest that CCM -based interventions may improve process and outcome measures in some situations; however, for EFQM/MBQA, the evidence found is less strong.
Six Sigma: A modified version of this model has been used in healthcare sector to improve financial and operational performance (Thomersen, 2001). The methodology defines, measure, analyse, improve and control (DMAIC) forms the implementation framework and is measured across cost and level of service, customer satisfaction and clinical excellence. Despite known disadvantages (training costs, need for strong leadership, lack of reliable data and difficulty in measuring indicators such as patient satisfaction), Antony et al (2007) argue it is useful for the NHS.
Business Process Reengineering (BPR) Developed as a new approach to organisational change, two three-year NHS pilot projects (Valerie, 1995) and projects in U.S. hospitals ( Urden and Walston, 2001) found mixed results.
BPR, along with TQM/CQI has been used to design of patient-centred care pathways.
Lean thinking is about realigning procedures to meet customer demands with minimal waste of time, effort and cost. In the healthcare setting, this approach has been found to be beneficial in support departments rather than mainstream clinical services. Antony et al (2007) expect use of the hybrid model, Lean Six Sigma in the NHS where lean thinking would first realign processes before the more meticulous tools of Six Sigma are applied.
Plan, Do, Study, Act (PDSA)
PDSA is increasingly being used by frontline health staff in the workplace as a tool to achieve improvement in patient care (PDSA, NHS quality and service improvement tools). The PDSA cycle of improvement asks three key questions:
* What are we trying to accomplish?
* How will we know that a change is an improvement?
* What changes can we make that will result in an improvement?
Small cycles of PDSA activity can summate into larger scale processes to cause the rapid cycle change and achieve improvements. Successful implementation demands specific training of clinical staff and management to enable new ways of thinking about improvement and understand the benefits and challenges associated with change.The tool has been used by NHS Scotland in the 'Safer Patient Initiative' pilot project (NHS Tayside, 2007) and delivery of primary care patient services (Scottish Primary Care collaborative, 2010). Although an independent survey of the SPI project reported no substantial improvements (Benning, A.et al, 2011), this view is challenged from the Scottish pilot side (OConner, 2011).
The Balanced Scorecard (BSC) Methodology: First published in 1992 and subsequently further developed by Kaplan and Norton (1992), BSC is regarded as one of the most important management innovations of the 20th century (Steele, J., 2001). The BSC strategic approach uses information systems to track a set of pre-determined balanced measures and indicators that are pertinent to achieve excellence in strategic objectives and measures performance across four key perspectives: financial, customer, internal processes, learning and growth (Voelker 2001).
With appropriate modifications, the BSC model can encompass the dynamic complexity of modern HCOs and help develop a systems-oriented approach to management. (Rimar 2000, Zelman et al,1999). However, there are challenges with regard to implementation and adaptation. Performance indicators such as medical staff relations, quality of care and value of long-term outcomes can be difficult to measure and interpret. Similarly, issues such as professional autonomy of physicians are unique to this industry (Zelman, 2003). Researchers agree that the theories and concepts of the BSC need to be tweaked to adapt to specific objectives of a particular HCO (Chow et al 1998, Inamdar, 2002). BSC-based strategic planning has been adopted successfully by HCOs of varying size, structure and scope including those in the public and not-for-profit sectors for purposes of adjustment and survival (Voelker 2001). The model has been used to measure performance at various levels, from a unit or department to group of hospitals (Bergman, R, 1994; Curtwright, Stolp-Smith and Edell, 2000; Mathias, 2001). Variants of BCS models have been adapted in diverse healthcare settings such as public information (Lowe and Baker, 1997) program and service planning (Schriefer, Urden and Rogers, 1997), managed care settings, accreditation (Kenkel, P, 1996; Sahney, V. K. 1998,) and developing incremental approaches to planning (Pineno, 2002). In addition, the healthcare sector as a whole has used this approach to address issues such as public accountability, cost-effectiveness and specific social and political concerns (Zelman, 2003).
The BCS has been used to measure outcomes as indicators of quality (West et al, 1997; Graumlich et al, 2000). However, Lilford, Brown and Nicholl(2007) argue that clinical outcomes are dependent not only on quality and outcome measures do not provide sufficient information about how to improve. They suggest that although outcomes are valuable for research, measuring the process itself is a more suitable way of measuring and rewarding quality.
Assimilating reliable, comprehensive and timely clinical, operational, and financial data with multiple components of the BSC facilitates complex decision-making (Oliveira, 2001) also illustrated by the NHS in its use of this framework for the national information for health (Protti, 2002).
Inamdar, Kaplan and Bower(2002) have proposed an holistic systems approach to the BCS system and underscore the challenges of adopting BSC cost, complexity, time consuming and the need for continuing evaluation and modification for example, incorporating new information systems when pertinent data inputs arrive. The NHS Performance Assessment Framework (PAF) in England (Chang, Lin and Northcott, 2002) and NHS Scotlands benchmarking project (2007) are based on the BCS approach. Yet, Chang (2007) contends that the use of the PAF in NHS England is symbolic and ceremonial and had little impact on improving performance.
Theory of Complexity thinking
Plsek and Wilson (2001) recognise that healthcare organisations are less like well-oiled apparatus and more like complex systems capable of adjustments and flexibility. They recommend the Complexity thinking approach, which suggests that relationships between components are more important than the components themselves and change in smaller steps may be more creative than elaborate plans. They argue that focus needs to be less on control or targets and more on exploiting the resourcefulness of staff and stakeholders through positive incentives and relationships and suggest that leadership based on this approach can bring about real change.
The PATH BALANCED dashboard
The World Health Organization (WHO) Regional Office for Europe initiated a flexible and comprehensive performance assessment tool for quality improvement in hospitals (PATH) in 2003 (Veillard et al 2005). Designed to measure performance in complex and multidimensional environments, it has two sets evidence-based indicators and aims to measure six dimensions of hospital performance: Clinical effectiveness, Patient centeredness, Efficiency, Safety, Staff orientation and Responsive governance. The framework is being piloted across various European nations.
The business plan is presented in the Appendix 2 along with figures and charts (Appendix 4) depicting pertinent demographic data and market analysis. It includes a brief analysis of the industry background and market research analysis.
Factors that influence determining fees in a private Care Home are:
* Amount charged must cover all operating costs and make acceptable profit.
* Rates currently prevalent for similar type of services in the area
* Current National Care Home Contract (NCHC) Standard Rates for public-funded placements. Council rates are linked to measurable quality indicators.
Rates amongst independent providers vary according to the physical facilities and the level of care services provided. Nursing care fees are higher than residential care fees. Top-up fees are legitimate for special services when agreed upon mutually with the client and can only be taken from an agreed third party (NHFA, U.K.).
According to the report of the Office of Fair Trading (OFT, 2005), Councils use their buyer power to drive down the fees they pay for care services to private sector to sustain rise of their purchase costs below inflation rates. This leads to Care homes charging higher fees to self-funders in order to cross subsidise publicly funded residents (Laing and Buisson, 2009).
For Care Homes that have higher proportion of residents funded by Councils and NHS, keeping fees for self funders close to Council rates may help in attracting and retaining more self-funders. Homes that have a higher proportion of self-funders have higher rates for private payers while accepting clients on lower public funded rates. According to the UK Care Market annual review (Laing and Buisson, 2010), average annual fees in Scotland for nursing care and residential care for 2010 was 28642 and 24656.
The OFT report (2005) and National Care standards (2007) stress on the need for clarity, transparency, fairness and better information to customers. Petchs review (2009) of a toolkit developed for calculating prices for care in private homes provides useful guidelines for establishing fees.
Risks in present economic climate
The profitability of Care homes is highly dependent on scale and diversity of services offered and the proportion of contracts who are self-funders.
Public funding still supports 60 per cent of people in private homes (Laing and Buisson, 2010). The rate the public sector pays private homes is negotiated by Scottish Care within the framework of NCHC. Council funding is resource-based and more strictness is expected with need for more cost efficiency, savings, and best value. This will limit expansion within the public services sector - it costs councils more to place state-funded residents in their own institutions than in private care homes (800 versus 480 average) (Official report, Scottish Parliament 2010). The year 2011/12 will see further pressure on profit margins due to below-inflation fee rises by the Councils for both residential and nursing care. Additionally, privately funded individuals are finding it difficult to meet the rising cost of their care as their income is under pressure due to weak housing market and smaller disposable incomes (Colliers report, 2010; Laing and Buisson, 2009 and 2010).
Although average fee increases paid by councils across the UK to care homes for publicly funded placements had increased by 2.6% in 2009, they fell to just 0.8% in 2010. Yet, decline in council demands due to government-spending cuts in 2011/12 may be alleviated by increasing NHS demand for care in care homes (Laing and Buisson, 2010).
Staffing is the main element of care home costs and future increases in payroll costs due to minimum wage regulations will put additional squeeze on profits. A weak housing market, Government strategy on care pathways for older population in home and community settings and lack of bank loans to improve infrastructure to increase and retain occupancy rates is affecting profitability (Ellis, 2008). For operators with lack of self-funded contracts, development of specialised services such as dementia care will become increasingly crucial (Colliers, 2010). It appears that economic recession will continue to impact on the care home industry; however, profit margins on an operational level for providers with higher proportion of self-funders have not reduced significantly yet.
The proposed business addresses a growing market need care for elderly people. After a decline of this sector for several years, there has been an upward trend in the last 5 years. The market remains populated with numerous single-home owners. Evidence suggests that although there is potential for growth of this industry, the present economic climate presents significant cost pressures on operational costs, fees and consequently, profitability.
The aims, objectives, business environmental analysis and strategic plans of the business plan have been presented in accordance with principles of basic strategic planning model.
The author has examined the evidence and described key issues and factors that will favour long-term sustainability of the project and those that may threaten its financial viability and laid emphasis on the impact of the current economic downturn. It is suggested that in the current situation, the key to financial sustainability will be operational efficiency and retention of clients, and develop new services tailored to meet changing healthcare needs of the older population.
Quality improvement and performance measurement strategies are vital and a large number of models have been developed and adapted for healthcare industry. However, the complex nature of this industry poses significant challenges for successful application of any one chosen model. The author concludes from the evidence that some models are more resourceful than others are thus a dogged approach with one chosen model is important.