Stakeholder Analysis in health services management

 Mary C. Ruhe

                                                                                            

Introduction

Health services organizations in the United States have had to change in recent years as competition brought a new business orientation to the management of medicine. The traditional healthcare planning focus on public health, community needs and institutional program development had evolved to include a strategic planning orientation responsive to demand, markets and customers. What had been a relatively stable environment has become an environment of immense change and unpredictability. Health care organizations needed to become flexible, adaptable and knowledgeable in order to meet demands to decrease costs and errors and increase efficiency and quality. Health service delivery often involves the cooperation and integration of multiple stakeholders in a complex network or multi-provider system[1, 2]. Organizational management must include “stakeholder management,” where stakeholders are defined as “those key individuals (or groups of individuals) who have an influence over either decision-making or implementation (or both) either directly or indirectly, overtly or covertly.” [3] This influence can assist, hinder or alter the course of organizational change. Stakeholder analysis is a process, or set of tools and approaches, designed to seek out and systematically reveal a clear snapshot of the current landscape of an organization in order to inform the development and accomplishment of organizational plans[4, 5].

 

Overview

What is stakeholder analysis?

Stakeholder concepts and approaches originated in the business literature of the 1930’s and stakeholder analysis has since developed into a systematic tool with clearly defined steps and purposes for examining the organizational milieu.

Stakeholder analysis is designed to provide an organization with information to evaluate and understand stakeholders in term of their relevance to a policy or specific activity of the organization. Analysis can produce broad, general understandings which paint the landscape for potential change, or provide a focused lens to highlight concrete steps appropriate to the current situation. Stakeholder analysis is done to assist the evaluation, implementation, planning and management activities within an organization.

Stakeholder analysis is not explicitly one tool but a systematic process that can make use of a range of different methodologies for analyzing stakeholder interests, positions, interrelations, influence, networks and other characteristics relevant to the specific purpose of the inquiry. Stakeholder analysis is “an approach, a tool or a set of tools for generating knowledge about actors – individuals and organizations – so as to understand their behavio[u]r, intentions, interrelations and interests and for assessing the influence and resources they bring to bear on decision-making or implementation processes” [6].

 

History of Stakeholder analysis

            The term stakeholder and the concept of stakeholder analysis has historical roots in business management, development and policy literature. Organizations have approached the need to evaluate and understand those individuals, groups and establishments that have an interest (stake) in their performance and the potential to influence their actions in a variety of ways. A broad and extensive literature exists concerning stakeholders and how they impact policy, organizational behavior and decision-making processes[6-15]. The process of gathering and reviewing data can vary in the tools that are used and the time frame and intent of the analysis. The focus of this chapter is the description of a systematic approach to examining stakeholders and a discussion of the purposes for which it can be used, particularly within health services organizations.

 

History of Stakeholder analysis in the health care field

            Stakeholder analysis generates knowledge about individuals and organizations through a process of study and investigation. Systematic approaches have been developed and used in the health care field for three primary purposes. Analysis is done in order to understand and influence policy, to facilitate the implementation of organizational goals or objectives, both specific decisions and large scale projects, and to determine optimal ways of relating to key stakeholders. Each purpose can be directed toward current issues or as a part of strategic planning for the future.

            In health management, stakeholder analysis provides a tool for an organization to achieve an advantage in dealings with other organizations through building alliances or attenuating potential threats.[16] Stakeholder analysis fits neatly within the initial awareness phase of Smith and Kaluzny’s “stages of change” theory. “Awareness involves recognizing that there is discrepancy or gap between what the organization or work unit is currently doing and what it should or could be doing. This awareness may be sparked internally by the expectations of participants or externally by community or regulatory pressures affecting the performance of the organization.” [14] Stakeholder analysis, both internal and external, will uncover the perceptions and concerns of all those with a ‘stake’ in organizational behavior. Change that is in line with current organizational activities – and perceived as having a relative advantage over the idea, practice or tool it replaces – are more likely to be implemented. [14] And, because change is a continual process, continuous assessment of practices and perceptions are warranted.

 

How to do a stakeholder analysis

Preparation: What is the purpose of your analysis?

The first step in approaching stakeholder analysis is determining the purpose of your inquiry; which in turn determines the time focus of interest and issues to consider in conducting the analysis. A systematic analysis can focus on the past, present or future and can be a short, rapid process or a long-term, more exhaustive process. When the goal is influencing policy, the focus is often broad, with either a retrospective or prospective lens. A retrospective focus is appropriate when the aim is learning from past experience, processes or patterns. Historical data helps gain an understanding of situations in their entirety, especially where there is a wide range of stakeholders involved and the situation is complex. A broad scope, long-term retrospective analysis is fitting for policy analysis. A prospective focus would be appropriate for policy development. A narrow, quick analysis might be all that is necessary to facilitate a specific policy.

Health services managers are well served when using a stakeholder analysis process to inform strategic planning for a specific short term objective or as an assessment activity to make long range plans. Stakeholder analysis for management purposes tend to focus on the present and future as the analysis is often issue or objective driven. In such instances helpful information describes the current environment and the opinions, interest and preferences of stakeholders in relation to a goal or project requiring expedient action. Often in management situations stakeholder analysis lays the ground work for building relationships that will foster success of a particular initiative or else identify information necessary to diffuse barriers toward a particular action.

For project planning and implementation doing a stakeholder analysis increases the chances of designing a plan that will be supported by and engage stakeholders in a mutually beneficial effort. Analysis reports can be used to develop a framework for projects and can uncover assumptions effecting the success or failure of project outcomes. Evaluating a project mid-stream or at completion using a stakeholder analysis approach can be both learning and rewarding experience as experience.  Project management incorporating stakeholder analysis usually requires a viewpoint that is both prospective and practical. Analysis for this purpose is frequently less complex and time-intensive than when used for policy analysis. Often a short period of time (days to weeks) is sufficient to grasp stakeholder interests on well defined topics. Time and resource availability will often instill a deadline for analysis and define the scope of the investigation.

 

What is the context of your analysis?

Consideration of the context and culture of the environments/individuals under investigation is also a key preliminary step in planning a stakeholder analysis. Planning ahead by studying the history and traditions of stakeholders and stakeholder organizations will ease the process of inquiry and access to valid input. One way of assuring a multi-faceted perspective of the stakeholder setting is by always including a wide range of key informants when gathering data. Without a balanced representation of opinions personal biases or interpretations may be construed as more or less representative of a context than really exists.

 

At what level will the analysis take place?

Depending on the complexity of the situation being assessed, stakeholder analysis can be done at a personal, departmental, organizational, system, community or even national or international level. The level at which analysis is carried out influences how to gather data and who to consider a stakeholder. In one situation, a system level stakeholder is treated as an individual while in another situation the entire system may be construed as one stakeholder, as in a large community based project.

 

Analysts and analysis teams

Analysis can be done by an individual, by a team or by an individual data collector and a support team. In most instances available resources and time will determine who conducts the analysis. A single analyst can ensure uniform data collection methods and higher reliability and cross-comparison validity of data. However, a team of analyst is particularly helpful with the qualitative data analysis where neutralizing individual biases and questioning assumptions assures a more balanced, objective approach. A single analyst can work with a support group or supervisor to whom they bring interim analysis conclusions and propose next steps for data collection or analysis.

Analysts can be insiders or outsider to the organization. Insiders may be part of the organization but not directly involved in the study question or be directly involved in the project. Notice should be taken of insiders who already have pre-existing relationships with stakeholders that may influence the data collection or interpretation or affect the behavior and responses of the stakeholder. A strength of an insider as analyst is that they know the common verbal and non-verbal communication patterns of the culture being studied.

A mixed team of insiders and outsiders offers both advantages, the contextual insights of the insider and the objective questioning of the outsider to check for biases and too quick assumptions.

 

Identifying and defining stakeholders

            While remembering that the issue or aim of the stakeholder analysis is the primary defining parameter, stakeholders can be identified through several lenses and can include a wide array of individuals, groups or establishments. Connections to stakeholders can be found by examining the structure, function, vision or relationships that exist for an organization. When the issue driving analysis is large and complex the pool of relevant stakeholders may involve a wide range of actors. In such instances effective communication is required for “boundary spanning” [14] or obtaining critical information from external stakeholders. 

Analysis should identify actors within the organization who are decision-makers and as well as those impacted by the issue/action being considered; essentially all whose interests, actions and motivations influence the environment. While there may be debate as to the level of power or influence of internal stakeholders all members of an organization have a “stake” in the behavior of the organization.

To identify external stakeholders first one needs to scan the environment to identify strategically important relationships. Relationships can be complex and interdependent and include a large number and variety of actors. In some instances the level of analysis needed and the range and complexity of the issue of interest makes identifying and analyzing stakeholders a prolonged and iterative process and important stakeholders may emerge at a late stage.  Consequently, care should be taken not to prematurely limit the number of stakeholders considered so as not to be surprised by pitfalls later in the process.

A community health care system considering revising their immunization policies, may consider state and local governments influential stakeholders who warrant research and investigation. In settings where the question is clearly defined, such as where to procure a specific vaccine, the stakeholders may be readily visible and quickly identified. Familiarity with the issue of interest, through researching current literature, reports etc., also helps one identify stakeholders.

 

Conducting the analysis

Approaching stakeholders

When initiating contact with potential stakeholders it is important to consider how the analyst and the stakeholder came to be involved, any pre-existing relationships and the stakeholder’s interest in the issue.  The mode of entrée may be quite different if the analyst is invited to discussions through a well-respected colleague than if the analyst is asked to assess the stakeholder by the health care system or another more powerful entity.  Situations that begin with low trust take more time to establish reliability to consider who will have access to what information.  Confidentiality of sources may need to be negotiated up front with stakeholders.  Additionally, the potential for biased responses must be considered when either party has the potential to gain an advantage over the other, as with competitors or collaborators. The implications of who initiates contact, who performs the assessment, who has access to information, etc. are considered with any eye toward gathering the most valid and reliable information possible. An important goal of entrée is to begin the process of creating a sustainable and growing relationship among the stakeholders.

 

Data Collection Methods and data

The principle objective of initial data collection is to identify actors and subjects related to the aim of analysis, not to generate hypothesis of attitudes or levels of concern for particular issues. At this early stage it is important to avoid making premature assumptions or determining direction for the analysis. A too early narrowing of focus may result in missing important issues or questions, while a too broad a focus may cause stakeholders to question the justification for the inquiry and lead to decreased commitment or availability.

Once an entry strategy has been determined and negotiated, the analyst performs an appraisal of the stakeholder and their current situation.  This involves gathering information from multiple sources. The assessment begins with an evaluation of what relevant data are available; however, these data almost never provide in-depth insights for which original data are required. Primary data can be collected through interviews, observation, semi-quantitative checklists and surveys or using other qualitative data collection methods (more intricately described in a separate body of literature).Secondary sources of data include published and unpublished documents, reports, policy and procedure statements and internal papers related to an organization or an individual.

Qualitative approaches used to collect data from primary sources stress the importance of remaining open to new sources of information and framing data analysis as an ongoing, iterative process in order to avoid a premature focus that limits understanding of an issue.  When the issue in question is clearly defined and the analysis is around a pre-determined course of action (such as implementing a particular policy) the use of qualitative data collection methods such as observation and interviewing may be less essential than with a broad, complex issue (e.g. hiring practices for clinical staff).     A large body of literature exists on qualitative data collection methods and will not be covered in this chapter.[17]

Face-to-face interviews can be semi-structured or more of a dialog among parties. Dialogue can be intimate one to one conversation or large group structured information exchanges. Conducting interviews using pairs of interviewers allow one to take notes while the other leads discussion. This assures that non-verbal clues and interactions will not be missed. This advantage should be balanced by the possibility that a single respondent may be intimidated by the imbalance of interviewers to interviewee.

Tape recording of interviews and consensus on anonymity and attribution of opinions need to be negotiated. Confidentiality issues may be dealt with at the end of the interview when a level of trust has been established.

For efficiency, and in order to simultaneously assess and build relationships, a group process of inquiry can serve well as a format for information gathering. “Fusion technology”[18] and “Appreciative Inquiry” [19] are examples of egalitarian, inclusive group techniques for gaining an understanding of environments and planning for change. Both methods involve all members of an organization in sustained conversations for the purpose of sharing thoughts, desires and experiences that having meaning for individuals and/or the group. Focus groups or informal group discussions can engage groups of stakeholders, customers or potential customers in a dialogue to gather information on attitudes, relationships and support for issues.

            As issues and positions of the key stakeholders emerge, more structured tools can assist in quantifying and summarizing stakeholder positions and levels of support or opposition. Medical record reviews can be used to collect information on the process and outcome of patient care and information tracking.  They also provide insights into what is valued and how the processes of patient care operate. Surveys can elicit supplemental data on satisfaction levels, measures of the relationships, measures of quality of care, and health behaviors that are the target of health care interventions.  Surveys may also be used to validate data collected from other sources. The use of semi-quantitative checklists can be used to help quantify stakeholder positions and levels of stakeholder support or opposition. Checklist can also be used to gather and organize basic descriptive data on stakeholder’s organizational structures and processes.

Interview and observational data, focusing on the individual or organizational personnel, relationships, affiliations, customers and the community can be used to create an organizational chart, map or genogram.[17] This visual depiction of the key actors and their relationships evolves as it is refined during interviews with key people and observations of the organization and its affiliates.

 

Organizing and analyzing data

            Once stakeholders are identified, contact is established and the data collection ensues, data analysis also begins. The framework for analysis is, once again, determined by the aim or purpose of the stakeholder inquiry. Global assessments can inform stakeholders influence toward an organization generally, however, a more precise appreciation of stakeholder influence on and attitude toward the specific topic/issue under consideration is needed in order to inform management issues. Analyses first must evaluate of the level of stakeholder influence and then determine if, at the present time, the stakeholder is in favor of, opposed to, or uncommitted and neutral toward the issue in question.

During an iterative synthesis of multiple data sources, attributions which are confirmed by multiple sources are retained, whereas preliminary findings are deleted when they are refuted by multiple data sources.  Some findings that appear to be important, but which cannot be confirmed from more than one source are noted and discussed by the team.  Additional data that would confirm or refute these items are identified and subsequently collected if possible.  If there is not time to collect additional data, these items can be discussed with the stakeholder for further clarification.

Using quantitative tools can offer a reliable way of obtaining stakeholder assessments that allow for cross comparisons of rankings. Organizing incoming data into tables or maps can help quantify stakeholder interests, assets and/or influence, support or opposition toward change and provide a basis for ranking the level of importance of each. Using structured tools such as Delpi questionnaires, lickert scales or preferential rankings may be used to elicit further additional data by adding to earlier interview or observational qualitative data.[6, 14] The limitations of such tools lie in that they offer a real time interpretation in what may be a rapidly changing environment. The positions and influence of stakeholders are subject to change at any time due to internal or external pressures or events.

Interpretations of data are always provisional and open to ongoing revisions as incoming data dictate. Data collection and analysis are iterative processes, a continual building and refining of understanding until all stakeholders have been identified and assessed. A composite of stakeholder positions, relationships and potential for influence is continually evaluated for validity by triangulating results and explanations across data sources.  Analysis team members, supervisors or other neutral parties need to review assessments to check for bias and to seek consensus on rankings, judgments or scores. Explicit criteria for making such assessments should be established and defined in codebooks prior to analysis in order to reduce research bias.

In some cases feedback of interim data in the form of summary discussions or reports may help build trust and rapport and offer the opportunity for stakeholders to correct inaccuracies, give additional information or qualify earlier responses. The interactive presentation of the assessment findings serves to validate the experiences of the stakeholders and to facilitate a process of communication, learning and planning change.  In other instances feedback is not beneficial as it may influence or change stakeholder attitudes, or be inappropriate if stakeholders are in a position to influence the analysis or analysis outcome.

Interim outputs of matrix tables or maps [6, 14, 20] can be constructed to quantify stakeholder interest in an issue, the resources and/or influences they may bring to bear, their support of opposition to moving in particular directions and what level of importance to give to each. A wide variety of tools and/or processes can be used to map, organize and/or prioritize the positions of stakeholders in relation to a particular issue and to each other. Stakeholder mapping creates a visual depiction of the connections between and among stakeholders; position held in regard to the issue at hand, availability of resources, level of control over decision-making, degree of motivation toward issue/project, etc.. Maps or chart can also reflect the level and degree of connections among actors in terms of responsibility or organization member assessments and feedback.

 

Presenting findings (outputs)

A variety of figures can be used to present data, including a variety of matrices, charts, position maps, network maps. These tools can function both as a place to organize data and a format for analysis and for understanding and planning future decision-making. Matrices can illustrate characteristics, interests, levels of influence; available resources etc. of each stakeholder and provide a format for cross comparison of traits. At times, with large numbers of stakeholders the maps and figures can become too complex and muddled.

            A forcefield [6] graphic illustration can track characteristics over time, allowing for predictions of future changes based on past decisions. This historical picture can be helpful when analyzing past policies, evaluating previous projects or for assessing and managing relationships with stakeholders for strategic advantage. A multi-dimensional diagram such as this can be repeated at later stages to see changes and new developments in stakeholder opinions and influence.

Analysis over time helps validate approaches to stakeholder management. Stakeholder analysis not only identifies characteristics of stakeholders with regard to the issue of interest, but can also be used to illustrate organizational relationships and predict or help develop stakeholder alliances. Understanding the nature and strength of these relationships can help develop strategies for managing stakeholders. Stakeholder mapping of relationships can show influence, potential influence, conflictual relationships, identify and current and future opportunities and threats and how best to handle them.[3]

The choice of tools or approaches will be determined by the characteristics of the issue or aim of the stakeholder analysis, the context or the environment in which the analysis takes place and the appropriate level of analysis. The goal of the synthesis and analysis is to create a summary description of stakeholders that begins the process of organizational planning, intervention or evaluation. 

 

Using the findings

            Stakeholder analysis is useful as a management and strategic tool. Best strategies for dealing with stakeholders can be identified and current and future opportunities or threats can be revealed, planned for or dealt with.  Successful stakeholder analysis identifies the “optimal fit” of the ideal level of attention and importance to pay to stakeholders.[9]. Managing stakeholders is best achieved by determining the potential level of threat and cooperation for each type of stakeholder and responding appropriately. For a supportive stakeholder, involvement is a best fit, for the non supportive, a defensive strategy, collaboration for ‘mixed blessing’ stakeholders, (those who exhibit elements of support and threat), and monitoring of marginal stakeholders who represent low threat and low cooperation. The consequences of finding or not finding an optimal fit are illustrated below in Figure 1. As illustrated, a poor fit can mean missed opportunities, facing unnecessary risk and wasted energy.

 

 

 

 

Figure 1 Strategies for managing stakeholders according to their organizational positions[6]

 

Optimal fit between diagnosed position and strategy

Suboptimal fit leading to excess attention to low potential stakeholder

Suboptimal fit leading to missed opportunities for gaining support

Suboptimal fit placing venture/organization at risk

 

Strategies

Positions

Involve

Collaborate

Defend

Monitor

Supportive

Optimal fit

Missed opportunities

Missed opportunities

Missed opportunity

Mixed

Risk

Optimal fit

Missed opportunities

Missed opportunities

And risk

Non-supportive

Risk

Risk

Optimal fit

Risk

Marginal

Resource waste

Resource waste

Resource waste

Optimal fit

 

 

For successful implementation of a project or policy the key relationship require careful management. Strategies for dealing with influential stakeholders with strong opposition to the project are necessary, while those stakeholders with considerable available resources but limited interest may need extra attention. Efforts to build strong alliances are critical in relationships with stakeholders who have both high interest and high influence toward a project.

Data and analysis sources may remain as internal documents in the organization for internal management issues, but when the inquiry is for the purpose of evaluation results often become public. It is important to create a careful balance of private and public information to fit with the culture of the organization under review in order to avoid creating ill-will or confusion.

 

Stakeholder Analysis Matrices:

 

Figure 2   Stakeholder Assessment [11]

 

-         identified 4 kinds of stakeholders

-         rates stakeholder importance

 

 

Problematic

Stakeholders

 

 

Antagonistic

Stakeholders

 

Low Priority

Stakeholders

 

 

Advocate Stakeholders

 

   Oppose   -5

                                          

Stakeholder position

     on issue

 

 

                                                  Support  +5

                                                                       

                                                                            0                                       10

                                                                        Least                                 Most

 

                                                                                  Stakeholder Importance

 

 

 

 

Figure 3   Resource Assessment [11]                                                            

              

-         categorizes the kind of resource that could be available to support a strategy

-         rates relative importance of resource  

                         

        

Irrelevant   

 

 

 

Essential

Scarcity  

Auxiliary

Support

 

 

 

Core

Support

 

 

                                                      Never     -5

                 Potential

              Availability

              of Resources

 

 

                                                     

                                                 Always        +5

0                                                                                                10

Least                                      Most

 

 

 

Figure 4  Types of Organizations [11]

            -Where organizations are defined as one of 4 basic types

- Where successful strategy requires that buffeted organizations evolve towards proactive organizations

- Proactive organizations are distinguished by

            a. having a clear agenda tied to a generally acceptable vision

b. incorporating important stakeholders, even those who disagree, into the process

c. operating in a win-win context through cooperation rather than internal completion

            d. always maintaining political and public support

 

Political

organization

 

Proactive

Organization

 

Buffeted

Organization

 

Professional

Organization

                               High

 

External control

 

 

 

                                           Low

                                                                                    Internal capacity                         High

 

 

 

 

Figure 5   Issue Portfolio [11]

-         Assesses impact of issues on business strategy by identifying tractability

-         tractability is defined as the prospect that an issue can be attacked by an organization

-         Rates stakeholder (customer, supplier, distributor) support of issue

-         Successful business strategy requires some productive links to stakeholder concerns. Strategy should either reflect issues that are sitting ducks or should reflect issues management intends to make sitting ducks --- by increasing stakeholder support for dark horse issues or developing internal capacity to support angry tiger issues.

 

 

   Sitting

    Ducks

 

    Dark

   Horses  

 

  

   Angry

    Tigers

 

  Sleeping 

   Dogs

                                                    High

 

 

                          Tractability

 

                                     

 

 

                                                      Low

                                                                 High                                 Low

                                                                               

                                                                          Relative Stakeholder

                                                                                     Support

 

Figure 6  Stakeholder analysis [3]

 

 

For

 

 

Neutral

 

 

 

Against

 


                    Low                   Medium               High

 

 

 

 

 

 

 

 

Figure 7  The uncertainty/importance grid --- stakeholder application[3]

 

 

                                                             

Group will support project

 
                                                             Certain

 

 

 


Low importance                                                     Very important                  

 

 

 

 

 

 

 

                                                            Uncertain

 

 

 

Limitations, validity and reliability of the analysis:

            The limitation of stakeholder analysis lies in the fact that information is cross-sectional, or valid for a point in time. In light of the often quickly changing environment of the healthcare environment today care must be taken in drawing conclusions. The time frame of data collection and the time between data collection and data analysis can quickly affect the relevance of the analysis for informing management or decision-making.

            In conducting analysis careful attention needs to be accorded in attempting to interpret responses. Information should be considered in terms of the position of the source within the organization and how stable the position may be, the possibility that responses reflect individual views different than others in the organization or are influenced by implicit or covert positions not revealed to the analyst. It may not be realistic to fully establish the validity or reliability of responses but the careful progress of data collection and analysis can make determining positions more evident.

 

Future directions

Stakeholder analysis, though specific and defined for the purposes of this chapter, is similar to or embedded within process descriptions and objectives in current management literature. References to “shareholder or stakeholder impact analysis,”[21] “fostering generative relationships,”[13, 22] and “linkage analysis”[12, 14], are all representative of ways of evaluating and managing relationships with key stakeholders. “Alliance Development Metrics” is a stakeholder analysis tool that can be used to develop financial partnerships across organizations [23].

 A recently proposed updated version of a strategic planning model for organizations highlights a continuous cycling process in place of the static, linear formula of traditional strategic planning models.[21] In this new model the ‘shareholder impact analysis’ stage, as are all stages, is iterative and continuous, mimicking the ever changing real world. It is within such a framework that traditional stakeholder analysis can be updated in order to better meet the needs of a rapidly changing health care environment..

Some propose moving beyond mere stakeholder analysis toward “stakeholder synthesis” as a way of bringing business ethics into the decision-making process between stakeholders [24]

 

Summary

Stakeholder analysis is relevant for informing health services delivery and health services management. The systematic approach of traditional stakeholder analysis, with its emphasis on predicting and planning for the future may seem ill suited to a time of constant change and turmoil in health care. But, by highlighting the need for an iterative process and a concentrated time frame for analysis and use of data it remains a useful tool for generating knowledge, understanding behavior and assessing influence.

 

 

 

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3.         Grundy, T., Accelerating strategic change: the internal stakeholder dimension. Strategic Change, 1997. 6: p. 49-56.

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12.       Primozic, K.I., E.A. Primozic, and J. Leben, Strategic Choices; Supremacy, Survival, or Sayonara. 1991, New York: McGraw-Hill Inc.

13.       Senge, P.M., The Fifth Dicipline, the art and practic of the learning Organization. 1990, New York: Bantam Doubleday Dell Publishing Group Inc.

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15.       Walt, G., ed. Health policy: an introduction to process and power. 1994, Zed Publications: London.

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18.       Daft, R.L. and R.H. Lengel, Fusion Leadership. 1998.

19.       Cooperrider, D.L. and D. Whitney, A Positive Revolution in Change: Appreciative Inquiry, in Appreciative Inquiry, D.L. Cooperrider, et al., Editors. 2001, Stipes Publishing LLC: Champaign IL.

20.       Studin, I., Strategic Healthcare Management; applying the lessons of today's top management experts to the business of managed care. 1995, New York: Irwin Professional Publishing.

21.       Begun, J. and K.B. Heatwole, Strategic Cycling: Shaking Complacency in Healthcare Strategic Planning, in Health Services Management, A.R. Kovner and D. Neuhauser, Editors. 2001, Health Administration Press: Chicago.

22.       Lane, D. and R. Maxfield, Strategy Under Complexity: Fostering Generative Relationships. Long Range Planning, 1996. 29(2): p. 215-231.

23.       Segil, L., Partnering: metrics matter. Financial Executive, 2004. 20(9).

24.       Goodpaster, K.E., T.D. Maines, and M.D. Rovang, Stakeholder thinking: beyound paradox to practicality. Journal of Corporate Citizenship, 2002. 93(19).

 

 Informational Websites

http://msh.org/   Management Sciences for Health - a nonprofit educational and scientific organization to support public health decision makers in developing countries.

erc.msh.org/quality/ittools/itstkan.cfm  A Quality Guide from the Managers Electronic Resources Center

http://www.euforic.org/gb/stake1.htm

GUIDANCE NOTE ON HOW TO DO STAKEHOLDER ANALYSIS OF AID PROJECTS AND PROGRAMMES. Overseas Development Administration (http://www.dfid.gov.uk/)                         Social Development Department of the government of the United Kingdom
July 1995

http://www.isixsigma.com/dictionary/Stakeholder_Analysis-198.htm Reference Section on Stakeholder analysis from the business journal iSixSigma

http://www.ctg.albany.edu/publications/guides/and_justice_for_all?chapter=8&section=2   article from center for technology in government works with government to develop information strategies that foster innovation and enhance the quality and coordination of public services.