SEARCH

SEARCH BY CITATION

Keywords:

  • strategic planning;
  • hospital performance;
  • low-income and middle-income countries

ABSTRACT

  1. Top of page
  2. ABSTRACT
  3. BACKGROUND
  4. CONCEPTUAL FRAMEWORK
  5. METHODS
  6. FINDINGS
  7. DISCUSSION AND CONCLUSION
  8. ACKNOWLEDGEMENTS
  9. REFERENCES

Background

Strategic planning has been presented as a valuable management tool. However, evidence of its deployment in healthcare and its effect on organizational performance is limited in low-income and middle-income countries (LMICs). The study aimed to explore the use of strategic planning processes in Lebanese hospitals and to investigate its association with financial performance.

Methods

The study comprised 79 hospitals and assessed occupancy rate (OR) and revenue-per-bed (RPB) as performance measures. The strategic planning process included six domains: having a plan, plan development, plan implementation, responsibility of planning activities, governing board involvement, and physicians' involvement.

Results

Approximately 90% of hospitals have strategic plans that are moderately developed (mean score of 4.9 on a 1–7 scale) and implemented (score of 4.8). In 46% of the hospitals, the CEO has the responsibility for the plan. The level of governing board involvement in the process is moderate to high (score of 5.1), whereas physician involvement is lower (score of 4.1). The OR and RPB amounted to respectively 70% and 59 304 among hospitals with a strategic plan as compared with 62% and 33 564 for those lacking such a plan. No statistical association between having a strategic plan and either of the two measures was detected. However, the findings revealed that among hospitals that had a strategic plan, higher implementation levels were associated with lower OR (p < 0.05).

Conclusions

In an LMIC healthcare environment characterized by resource limitation, complexity, and political and economic volatility, flexibility rather than rigid plans allow organizations to better cope with environmental turbulence. Copyright © 2012 John Wiley & Sons, Ltd.


BACKGROUND

  1. Top of page
  2. ABSTRACT
  3. BACKGROUND
  4. CONCEPTUAL FRAMEWORK
  5. METHODS
  6. FINDINGS
  7. DISCUSSION AND CONCLUSION
  8. ACKNOWLEDGEMENTS
  9. REFERENCES

Strategic planning is the set of organizational processes that help an organization identify its desired future and develop its decision-making guidelines. When organizational decisions exhibit a logical consistency over time, the organization is said to have a “strategy,” which represents the means chosen to move from the current state to the desired future state. Using strategy, the organization can build on its strengths, address its weaknesses, exploit environmental opportunities, and avoid environmental threats (Swayne et al., 2006). Therefore, strategic planning is commonly believed to be a key ingredient for high performance and organizational success.

The empirical relationship between strategic planning and organizational performance is, however, not that straightforward. In general industry, numerous studies have reported a positive association between strategic planning and performance (Rhyne, 1986; Delmar and Shane, 2003; Glaister et al., 2008), whereas others argued that such a relationship does not exist (Shrader et al., 1984; Pearce et al., 1987). In healthcare, most research on strategic planning is limited to case studies and small samples and does not link strategic planning to organizational performance (Dubbs and Organization design consistency, 2002; Lemak and Goodrick, 2003; Wells et al., 2004). Still, there are few exceptions. A national study of the association between employing strategic initiatives and performance of rural hospitals detected no association between the two (Mick et al., 1994). However, more recently, Kaissi and Begun (2008) examined the association among Texas hospitals and reported a favorable finding, whereas Delgado and Langabeer (2009) found that cancer centers that deploy strategic control approaches have better financial performance compared with their counterparts that do not.

Evidence of deployment of strategic planning in low-income and middle-income countries (LMICs) is rare (El-Jardali et al., 2007). This is noteworthy because, relative to high-income countries, the healthcare environment in LMIC is more complex, dynamic, and challenging (Mills et al., 2002), whereas resources are generally more limited. As such, the perceived need for strategic planning should be high. Still, strategic planning in LMICs, if present, is set at the national governmental level, with limited evidence of its employment and use at the organizational level (Mostafa et al., 2004).

Lebanon is an LMIC located in the eastern Mediterranean region. The Lebanese healthcare system is pluralistic and fragmented because of the public–private mix involved in the financing and provision of health services as well as the lack of coordination among the multiple financing and delivery systems. By the end of the 15-year civil war that started in 1975, the government started strengthening the public hospital sector to match the significant expansion of the private sector during war years. Since then, efforts have been dedicated to expanding the number of public hospitals. As a result, the number of public hospitals increased from 12 in 1990 to 29 hospitals in 2011 (Ammar, 2009). This modified the public–private delivery mix that was predominantly private prior to 1990. In addition, serious concerns related to financial performance due to major inefficiencies, non-sustainable cost explosion (Lerberghe et al., 1997), and continuous modifications of reimbursement schemes exist. More specifically, the financing mechanisms of hospital care are fragmented. There is a mix of healthcare funding sources that include several public funds, as well as private insurance schemes and out-of-pocket expenditures. Each of these sources has its own benefit packages, fee scales, and individual agreements with healthcare providers, tutelage authority, and financing intermediaries.

Although the Lebanese healthcare system, with its complex and mixed setting of private–public mix in delivery and financing, may share some similarities with the American healthcare system, it is still a very unique system, especially when the constant economic and political turmoil of the country is considered. Given this complexity, hospitals in Lebanon can arguably benefit from strategic planning to alleviate the adverse impact of uncertainty in their environments and steer their operations towards improved performance (Begun and Kaissi, 2004). It is important to note that as a requirement of the Lebanese national accreditation system which started in 2002, hospitals are required to have a “five-year strategic plan […] that indicates future directions/initiatives for the hospital…” with advisory input from the Senior Management (MoPH, 2009).

Although having a strategic plan is an overarching national health initiative, this study went beyond the requirement of having a strategic plan to assessing the actual process and identifying the stakeholders involved in the strategic planning within hospitals. The primary aims of this study are to explore the extent of use of these strategic planning processes in Lebanese hospitals and to investigate its association with financial performance. Although prior studies have examined this relationship, most were focused/based on industrialized countries.

CONCEPTUAL FRAMEWORK

  1. Top of page
  2. ABSTRACT
  3. BACKGROUND
  4. CONCEPTUAL FRAMEWORK
  5. METHODS
  6. FINDINGS
  7. DISCUSSION AND CONCLUSION
  8. ACKNOWLEDGEMENTS
  9. REFERENCES

Against this context, common strategic planning theories and hypothesis that are promoted in the health administration literature and/or supported by particular organizational concepts were studied. The first hypothesis relates to the organizational environment impact on the strategic plan. Structural contingency theory argues that organizational structures need to be compatible with changes in the environment (Donaldson, 2001). A thorough and accurate assessment of environmental factors is strongly enhanced by strategic planning. Institutional theory, on the other hand, posits that having a formal strategic plan is important because it allows the organization to gain legitimacy in the eyes of its important stakeholders, such as accrediting agencies and community organizations (Scott, 2000). Healthcare leaders seem to agree with these perspectives and argue that strategic planning is a key value-added function of leadership in their organizations (Begun and Kaissi, 2005). Therefore, we hypothesize that the existence of a strategic plan is favorably associated with hospital performance (Hypothesis 1).

The development of a strategic plan ideally involves a process that builds upon assessments of external and internal environments as foundations. On the basis of findings from these assessments, a strategic map is drawn with goals, objectives, and strategic thrust. The Baldrige National Quality Program (2006) criteria for strategic planning present a roadmap for ultimate strategic planning processes. Studies have shown that not conforming to a well-defined comprehensive process may lead to negative performance (Veliyath and Shortell, 1993). In addition, the strategic planning process should adapt an integrative approach, whereby the processes of planning and implementing strategies are combined in order to achieve long-term success (Kohtamaki et al., 2010). As previously mentioned, this is a main assumption in the structural contingency theory and has been highlighted by many (Bossidy et al., 2002; Begun and Kaissi, 2005). Implementation of strategic plans is obviously a key component in its success, which mirrors that of the organization. Therefore, we hypothesize that a more developed strategic plan is positively associated with hospital performance (Hypothesis 2) and that implementation of the strategic plan is positively associated with hospital performance (Hypothesis 3).

The responsibility of leading the strategic planning process and who should be involved in it vary by organization. It has been argued that strategic planning is primarily the CEO's job (Langely, 1988). Although in large organization, such a function is delegated to a Deputy Director/Vice President for planning or to a strategic planning committee, recent evidence shows that maintaining this function in the CEO hands is associated with better performance (Kaissi and Begun, 2008). Therefore, we hypothesize that CEO control of the strategic planning process is positively associated with hospital performance (Hypothesis 4).

The process of strategic planning would ideally involve all levels of management and operations within organizations. Nevertheless, the board of trustees of an organization has the primary responsibility of performing the strategic planning. The board should play an active role in this extensive planning process by establishing key policy targets (Cleverley and Cameron, 2007). Studies have shown a positive correlation between governing board involvement and hospital performance (Kaissi and Begun, 2008). As such, we hypothesize that the level of governing board involvement in the strategic planning process is positively associated with hospital performance (Hypothesis 5). In addition to the governing board, physicians are key stakeholders in any healthcare organization. Involving physicians in the strategic planning process from the early stages will engage them more as a group in its success. Many have advocated for a partnership with physicians in the strategic planning process to ensure success and enhanced performance (Alexander, 2006). Therefore, we hypothesize that the level of physician involvement in the strategic planning process is positively associated with hospital performance (Hypothesis 6).

METHODS

  1. Top of page
  2. ABSTRACT
  3. BACKGROUND
  4. CONCEPTUAL FRAMEWORK
  5. METHODS
  6. FINDINGS
  7. DISCUSSION AND CONCLUSION
  8. ACKNOWLEDGEMENTS
  9. REFERENCES

Study population

The study population comprised 119 private and 29 public acute care hospitals in Lebanon. Eight public hospitals were not eligible to participate because these facilities were still not fully operational (recently built/renovated and in the process of being equipped or governing structure has not been finalized). The total number of respondents was 79 hospitals (completing the strategic planning sections) representing a response rate of 56.4%. This response rate compares very favorably with other studies employing voluntary surveying of senior healthcare organizations' administration; the response rates of such studies ranged from 26% to 44% (Kaissi and Begun, 2008). Examining respondents and non-respondents revealed that both groups were similar on hospital characteristics examined with only one difference; all teaching hospitals in Lebanon (n = 5) responded to the survey and hence were included. Ethical approval for the study was granted by the American University of Beirut Institutional Review Board.

Data sources

The study has two main data sources. The first comprised a survey conducted between October 2009 and September 2010 that collected data on strategic planning activities and hospital performance measures and was completed by hospital administration. For the hospital performance measures, the data reported by the hospitals were validated (revenues-per-bed (RPBs)) by data from the Ministry of Public Health (MoPH). MoPH databases were also used to extract information on hospital characteristics (ownership, teaching status, accreditation status, and bed size).

The process of data collection was initiated by a letter faxed/e-mailed to the hospital CEO outlining the purpose of the study and associated activities. In the following 2 days, phone calls were made to the hospitals to ensure that the letter was received and inquiring whether they are willing to complete the survey. If the response was positive, hospitals were asked about the best day/time to deliver the survey to the hospital CEO. Upon delivering the survey, hospitals were asked about the time needed to complete the survey. On that pre-specified date, a call was placed to the CEO office to make sure that the survey was completed. Once informed of its completion, a private courier company was directed to pick up the survey. If the CEO indicated that she or he does not wish to complete the survey or 14 days passed without filling the survey (even after reminders), the hospital was considered as a non-respondent site.

Study variables

The main dependent variables measured hospital performance. The measures used included occupancy rate (OR) and revenue per bed (RPB). OR presents as an industry-specific measure, commonly employed in health services research as an indicator of hospital performance. High hospital OR, usually implying a high market demand, has been cited to increase prospects of profitability (Burns et al., 2000). Furthermore, a study by Younis et al. (2006), on hospital financial performance in the USA, reveals that OR is a factor influencing efficiency, profitability, and liquidity, within the hospital industry, and, thus, a key predictor of financial performance. Specifically in Lebanon, OR has been a focus of many hospitals in the past 10 years since the Lebanese MoPH has aggressively pursued the opening of public hospitals resulting in additional supplies of beds across high-demand regions of the country. This governmental intervention decreased the MoPH subsidized admission from 86% to 73%, causing alarm for the hospitals concerning efficiency and achieving economies of scale (Ammar, 2009). From that perspective, hospitals became concerned about the effect of strategic policy decisions on OR within the hospitals.

Net patient RPB, which is calculated by dividing the net patient revenue for a hospital by the number of beds, has been cited as indicative of an institution's competitive power in attracting patients and staffing its beds (Smith et al., 2006). In relation to OR concern (see preceding discussions) and the fact that most hospitals have a present revenue ceiling from the MoPH (the predominant payer of hospital services in Lebanon) (Kronfol, 2006), RPB became a key financial performance indicator for the financial wellbeing and survival of many hospitals especially in light of the decrease in number of contracts of hospitals with MoPH and limits on the yearly ceiling (Ammar, 2009). It is worth noting that outlier values on both financial performance measures were removed from the analysis. The other alternative explored was log transformation; however, this did not result in the normalization of the measures.

The strategic planning process characteristics were derived from those employed by Kaissi and Begun (2008). These included six domains, each measured with a single variable. They included (i) having a strategic plan; (ii) extent of strategic plan development (scale of 1–7, based on Baldrige criteria); (iii) extent of strategic plan implementation (scale of 1–7, based on Baldrige criteria); (iv) responsibility of strategic planning activities (CEO vs Other); (v) extent of governing board involvement in strategic planning activities (scale of 1–7) and; (vi) extent of physicians' involvement in strategic planning activities (scale of 1–7). Other study variables included hospital characteristics. These were ownership (public, private not-for-profit, and private for-profit), teaching status, bed size, and accreditation status. The latter is a classification employed by the MoPH, and it is indicative of the service and quality sophistication of the facility with classification A as the highest designation.

Data analysis

Univariate analysis was used to describe hospital characteristics and performance. The association between the independent variables and between these and the dependent variables was examined using Student t-tests and chi-square testing. Multivariate modeling was also employed to examine the effect of independent and control variables on hospital performance. Separate models were constructed for each of the two performance measures. The models were two levels. The first level included the availability of a strategic plan as the main independent variable whereas the second-level models included strategic planning characteristics and processes as main independent variables among hospital that had a strategic plan. Before conducting each of the models, tests examined the collinearity among all covariates in the model. If correlation among covariates was significant and higher than 0.40, a decision was made on which of the correlated variables are kept in the model. Collinearity was detected among the four variables: extent of strategic plan implementation, extent of strategic plan development, level of governing board involvement in strategic plan development, and level of physician involvement in strategic plan development. The authors decided to include extent of implementation in the model for three reasons: (i) the relation between extent of implementation and occupancy was significant in the bivariate analysis, and we wanted to investigate whether such a strong association would persist after controlling for other variables; (ii) including the variable on whether the CEO was solely responsible for strategic plan development versus with others can be considered as a proxy of level of governing board and physician involvement in strategic plan development, that is, if she or he is solely responsible, which may indicate a smaller role for the governing board and physicians; and (iii) we would have liked to include extent of strategic plan development variable to measure its independent effect on occupancy. However, the variable was the most correlated with extent of implementation at 0.69. Hence, the authors decided to include extent of implementation because of its relevance and the support of the literature of its critical role. It is also worth noting that almost all public hospitals had no accreditation classification, so public ownership was dropped from the regression models.

FINDINGS

  1. Top of page
  2. ABSTRACT
  3. BACKGROUND
  4. CONCEPTUAL FRAMEWORK
  5. METHODS
  6. FINDINGS
  7. DISCUSSION AND CONCLUSION
  8. ACKNOWLEDGEMENTS
  9. REFERENCES

Hospital characteristics and strategic planning processes

More than three-fifths of hospital respondents (62.3%) were private-for-profit with five hospitals (6.3%) classified as teaching hospitals (academic medical centers) (Table 1). The average number of beds was 106.5. The majority of hospitals were classified as C (44.6%)—classification is dependent on accreditation guidelines by the MoPH; “A” classification is for large general hospitals that have a clinical education component whereas “D” is for small hospitals with limited specialties. In terms of hospital performance, the average OR was 69.8% with average RPB of $56 200/year.

Table 1. Hospital characteristics and strategic planning processes in Lebanon
 Lebanon (N = 79)
Avg. (SD)/%
  • *

    In Lebanon, hospital performance data were obtained only for 55 hospitals; missing data were not counted in the percentage calculation.

Hospital characteristics
Ownership 
Public14.3%
Private not-for-profit23.4%
Private for-profit62.3%
Teaching hospital6.3%
Number of beds106.5 (114.7)
Accreditation status 
A26.8%
B10.7%
C44.6%
D17.9%
Strategic planning processes
Have a strategic plan89.6%
Extent of strategic plan development (1–7 scale)4.9 (1.2)
Extent of implementation (1–7 scale)4.8 (1.3)
Responsibility of the strategic plan 
CEO46.0%
Other54.0%
Level of governing board involvement (1–7 scale)5.1 (1.5)
Level of physician involvement (1–7 scale)4.1 (1.6)
Hospital performance*
Occupancy rate69.8 (16.6)
Revenue-per-bed per year56 200 (46 606)

Approximately 90% of Lebanese hospitals have a strategic plan. Strategic plans are moderately developed (mean score of 4.9 on a 1–7 scale) and moderately implemented (mean score of 4.8 on a similar scale). In 46% of the hospitals, the CEO has the responsibility for the strategic plan. The level of involvement of the governing board in the strategic planning process is moderate to high (mean score of 5.1 on a 1–7 scale), whereas not surprisingly the level of physician involvement is lower (mean score of 4.1 on a similar scale).

Association between strategic planning processes and hospital performance

The bivariate association between strategic planning process and hospital performance revealed that extent of strategic plan implementation was adversely related to OR, that is, the more a hospital implemented its strategic plan, the lower its OR (p < 0.05) (Table 2). A similar trend was observed with level of governing board involvement in strategic plan development. The multivariate modeling revealed no association between having a strategic plan and either of the two performance measures (Table 3). However, the findings revealed that, among hospitals that had a strategic plan, higher implementation levels were associated with lower ORs (p < 0.05).

Table 2. Association between hospital characteristics and strategic planning processes and hospital performance
 Hospital performance
Occupancy rate %Avg. revenue-per-bed
  • **

    p < 0.01;

  • *

    p < 0.05.

Hospital characteristics
Ownership  
Public69.735 762
Private not-for-profit74.363 210
Private for-profit68.655 786
Teaching status  
Teaching96.3**77 342
Non-teaching68.254 905
Number of beds  
0–5067.633 482
51–15069.063 064
151+75.0 
Accreditation status  
A71.782 830
B75.271 056
C67.646 641
D64.331 336
Strategic planning processes
Have a strategic plan (H1)  
Yes70.359 304
No62.033 564
Extent of implementation (H2)  
1–384.9*46 261
4–570.046 624
6–767.466 187
Extent of strategic plan development (H3)  
1–381.346 696
4–570.047 967
6–770.964 851
Responsibility of the strategic plan (H4)  
CEO73.655 433
Other70.560 197
Level of governing board involvement (H5)  
1–389.5**66 889
4–572.750 870
6–766.254 314
Level of physician involvement (H6)  
1–374.453 018
4–572.050 096
6–765.965 959
Table 3. Multivariate models
 Model 1 occupancy rateModel 2 revenue-per-bed
Unstandardized coefficientStandard errorUnstandardized coefficientStandard error
  • *

    p < 0.05;

  • **

    p < 0.01.

Level 1
Hospital characteristics
Ownership    
PublicReference Reference 
Private for-profit−5.89.0530914 021
Number of beds0.00.1−5890
Accreditation status    
A0.013.062 06320 301**
B9.112.543 10819 414*
C3.49.9604315 731
DReference Reference 
Have a strategic plan12.713.412 91220 979
R2 0.08 0.46
Level 2 (have a strategic plan)
Hospital characteristics
Ownership    
PublicReferenceReference 
Private for-profit10.18.1−456113 441
Number of beds−0.050.07−135110
Accreditation status    
A−19.113.865 955*23 113
B−14.513.639 43222 612
C−32.212.3*−964520 878
DReference Reference 
Strategic planning processes
Responsibility of the strategic plan    
CEO0.35.8−785810 450
OtherReference Reference 
Extent of implementation    
1–3Reference Reference 
4–5−27.29.7*−11 30418 591
6–7−22.09.9*940318 179
R2 0.40 0.70

DISCUSSION AND CONCLUSION

  1. Top of page
  2. ABSTRACT
  3. BACKGROUND
  4. CONCEPTUAL FRAMEWORK
  5. METHODS
  6. FINDINGS
  7. DISCUSSION AND CONCLUSION
  8. ACKNOWLEDGEMENTS
  9. REFERENCES

The goal of the study was to assess the association between strategic planning and hospital financial performance. However, the findings did not lend support to the hypotheses that argued for a favorable association between existence of strategic planning and its processes and financial performance. On the contrary, there was evidence of a negative relationship between the two, expressed by reduced occupancy associated with better implementation of strategic plans as shown in multivariate models (Hypothesis 2). Such a finding is noteworthy. The previously mentioned study by Mick et al. (1994) examining the association between strategic activities and financial performance in rural hospitals had revealed similar negative associations. Earlier studies have also questioned the potential effect of strategic initiatives on hospital performance (Shortell, 1988). The lack of association can be possibly explained by the nature of the strategic planning process itself, which can limit the flexibility of an institution's operation, add bureaucracy, and hence be detrimental to its performance (Bresser and Bishop, 1983). This view has some theoretical roots in complexity science, which argues that strategic planning may not be useful in complex adaptive systems where the dynamic unfolding of the system is uncertain, such as healthcare organizations (Begun et al., 2003). As surprises are inevitable, adherence to a pre-determined plan might result in adverse effects on the organization, which should be focusing instead on learning and creativity and on emergent and improvisational action (Downs et al., 2003).

These arguments are of relevance to the Lebanese healthcare system, which is greatly affected by the continuous political and economic instability in the country (Ammar, 2009). Functioning in such a system requires great flexibility and may penalize institutions that develop and adopt long-term strategic initiatives. Therefore, hospital administrators are advised to adopt a short-term flexible planning process with limited resource investments (and immediate returns), as it may be more suitable in such an environment and arguably associated with better performance. This is echoed in a recent study that showed that flexibility is an important mediator in the relationship between strategic planning and performance (Rudd et al., 2008).

Moreover, as previously discussed, hospitals in Lebanon are required to have a strategic plan in order to qualify for accreditation by the MOPH. Therefore, having a strategic plan may be more of an action to fulfill accreditation requirements than to actually improve hospital performance. This is highlighted by the fact that although the majority of the hospitals report having a strategic plan, the levels of development and implementation of the plan are moderate at best, which is critical for success and favorable outcomes.

Another possible explanation of the findings relates to the cross-sectional nature of the data. Given that the dependent variable (financial performance) and independent variables (strategic planning processes) were reported by the same respondents at the same time, it is possible that hospitals that are concerned about their negative financial performance have decided to develop a strategic plan in order to improve their performance and to obtain accreditation from the MOPH (with its added benefits of access to financial contracts). Therefore, a more longitudinal assessment of the relationship may be more appropriate in the future.

Two limitations for this study warrant consideration. The first lies in the fact that our results are based on the perception of hospital administrators. Although there is no reason to assume inaccuracy, underreporting of revenues remains a potential concern. Second, several private hospitals are family owned. A number of governing board members and medical administrators would be family members and concurrently involved in all aspects of the organization's operation. In these institutions, it would have been challenging to respond to survey items related to the level of involvement.

In conclusion, it remains true that organizations with the most environmentally adequate strategies usually perform best, both financially and operationally (Goldstein et al., 2002). This study has argued that the fixed element is sensitivity to the environmental context and the variable element is planning characteristics and processes. In an LMIC healthcare environment characterized by resource limitation, complexity, and political and economic volatility, flexibility rather than rigid plans seem to better allow organizations to cope with environmental turbulence. By staying flexible, organizations can anticipate changes in real time and allocate resources accordingly.

ACKNOWLEDGEMENTS

  1. Top of page
  2. ABSTRACT
  3. BACKGROUND
  4. CONCEPTUAL FRAMEWORK
  5. METHODS
  6. FINDINGS
  7. DISCUSSION AND CONCLUSION
  8. ACKNOWLEDGEMENTS
  9. REFERENCES

The authors have no competing interests, financial or non-financial, in relation to the publication of the manuscript. Funding was obtained through an American University of Beirut University Research Board grant.

REFERENCES

  1. Top of page
  2. ABSTRACT
  3. BACKGROUND
  4. CONCEPTUAL FRAMEWORK
  5. METHODS
  6. FINDINGS
  7. DISCUSSION AND CONCLUSION
  8. ACKNOWLEDGEMENTS
  9. REFERENCES
  • Alexander K. 2006. Advancing strategic planning. Front Health Serv Manage 23: 3941.
  • Ammar W. 2009. Health beyond Politics. WHO Eastern Mediterranean Regional Office: Beirut, Lebanon.
  • Baldrige National Quality Program. 2006. Health Care Criteria for Performance Excellence. National Institute of Standards and Technology: Gaithersburg, MD.
  • Begun JW, Kaissi AA. 2004. Uncertainty in health care environments: myths or reality. Health Care Manage Rev 29: 3139.
  • Begun JW, Kaissi AA. 2005. An exploratory study of healthcare strategic planning in two metropolitan areas. J Healthc Manag 50: 264275.
  • Begun JW, Zimmerman B, Dooley KJ. 2003. Health care organizations as complex adaptive systems. In Advances in Health Care Organization Theory, Mick SS, Wyttenback ME (eds). Jossey-Bass: San Francisco; 25388.
  • Bossidy L, Charan R, Burck C. 2002. Execution: The Discipline of Getting Things Done. Crown Business: New York.
  • Bresser RK, Bishop RC. 1983. Dysfunctional effects of formal planning: two theoretical explanations. Acad Manage Rev 8: 58899.
  • Burns L, Bazzoli G, Dyan L, Wholey D. 2000. Physician–hospital strategic alliances. Health Serv Res 35: 101132.
  • Cleverley WO, Cameron AE. 2007. Essentials of Healthcare Finance. Jones & Bartlett Learning: Sudbury, Massachusetts.
  • Delgado RI, Langabeer JR. 2009. Strategic performance evaluation in cancer centers. J Healthc Manag 54: 369381.
  • Delmar F, Shane S. 2003. Does business planning facilitate the development of new ventures? Strateg Manag J 24: 11651185.
  • Donaldson L. 2001. The Contingency Theory of Organizations. Sage: Thousand Oaks, CA.
  • Downs A, Durant R, Carr AN. 2003. Emergent strategy development for organizations. Emergence 5: 528.
  • Dubbs NL, Organization design consistency. 2002. The PennCARE and Henry Ford health system experiences. J Healthc Manag 47: 307318.
  • El-Jardali F, Jamal D, Abdallah A, Kassak K. 2007. Human resources for health planning and management in the Eastern Mediterranean Region: facts, gaps and forward thinking for research and policy. Hum Resour Heal 5: 920.
  • Glaister KW, Dincer O, Tatoglu E, Demirbag M, Zaim S. 2008. A causal analysis of formal strategic planning and firm performance: evidence from an emerging country. Manag Decis 46: 365391.
  • Goldstein S, Ward P, Leong G, Butler T. 2002. The effect of location, strategy, and operations technology on hospital performance. J Oper Manag 20: 6375.
  • Kaissi AA, Begun JW. 2008. Strategic planning processes and hospital financial performance. J Healthc Manag 53: 197208.
  • Kronfol N. 2006. Rebuilding of the Lebanese healthcare system: health sector reforms. East Mediterr Health J 12: 459472.
  • Kohtamaki M, Kautonen T, Kraus S. 2010. Strategic planning and small business performance. Entrepreneurship and Innovation 11: 221229.
  • Langely A. 1988. The roles of formal strategic planning. Long Range Plann 21: 4050.
  • Lemak CH, Goodrick E. 2003 Strategy as simple rules: understanding success in a rural clinic. Health Care Manage Rev 28: 179188.
  • Lerberghe WV, Ammar W, Rashidi RE, Sales A, Mechbal A. 1997. Reform follows failure: unregulated private care in Lebanon. Health Policy Plan 12: 296311.
  • Mick SS, Morlock LL, Salkever DG, Malitz F, Wise CG, Jones A. 1994. Strategic activity and financial performance of U.S. rural hospitals: a national study, 1983 to 1988. J Rural Health 10: 150167.
  • Mills A, Brugha R, Hanson K, McPake B. 2002. What can be done about the private health sector in low-income countries. Bull World Health Organ 80:325330.
  • Ministry of Public Health (MoPH). 2009. Lebanese National Hospital Accreditation System Standards. Standard GB1—Governing Body & Management. Haute Autorité De Sante (France) and Ministry of Public Health (Lebanon). http://www.moph.gov.lb/HospitalAccreditation/Old/Pages/LesGrillesdeDiagnostic.aspx Accessed on 28 June 2012.
  • Mostafa MM, Sheaff R, Morris M, Ingham V. 2004. Strategic preparation for crisis management in hospitals: empirical evidence from Egypt. Disaster Prevention and Manag 13: 399408.
  • Pearce JAI, Freeman EB, Robinson JRB. 1987. The tenuous link between formalized strategic planning and financial performance. Acad Manage Rev 12: 65875.
  • Rhyne LC. 1986. The relationship of strategic planning to financial performance. Strategic Manage J 7: 42336.
  • Rudd JM, Greenley GE, Beatson AT, Lings IN. 2008. Strategic planning and performance: extending the debate. J Bus Res 61: 99108.
  • Scott WR. 2000. Institutions and Organizations. Sage: Thousand Oaks, CA.
  • Shortell SM. 1988. The evolution of hospital systems: unfulfilled promises and self-fulfilling prophesies. Medical Care Review 45: 177214.
  • Shrader CB, Taylor L, Dalton DR. 1984. Strategic planning and organizational performance: a critical appraisal. J Manag 10: 149171.
  • Smith A, Houghton S, Hood J, Ryman J. 2006. Power relationships among top managers: does top management team power distribution matter for organizational performance? J Bus Res 59: 622629.
  • Swayne LE, Duncan JE, Ginter PM. 2006. Strategic Management of Health Care Organizations. Blackwell Publishing: Malden, MA.
  • Veliyath R, Shortell S. 1993. Strategic orientation, strategic planning system characteristics and performance. J Manag Stud 30: 359381.
  • Wells R, Lee SD, McClure J, Baronner L, Davis L. 2004. Strategy development in small hospitals: stakeholder management in constrained circumstances. Health Care Manage Rev 29: 218228.
  • Younis MZ, Younies HZ, Okojie F. 2006. Hospital financial performance in the United States of America: a follow-up study. La Revue de Sante de la Mediterranee Orientale 12: 670678.