Email Address:

Password:

Performance Management In Relation to self

The concept of ‘performance management’ can be applied to many disciplines, from sports to companies, institutions, students, individuals and other areas. It constitutes a relatively new field in the annuals of management. Literature on this subject generally indoctrinates the reader in an understanding of the word ‘performance’ before delving into the subject matter at hand, thus this approach will be utilized here. It is described as:

1. The act of performing…or the state of being performed
2. the act or style of performing a work or role…
3. Something performed: an accomplishment.”

And so as to keep the context in perspective, the definition of management is:

1. The act, manner or practice of managing ……
2. The person(s) who control or direct a business or other enterprise
3. Skill in managing: executive ability”
   
   

It is interesting to note that individually many people have a misconception of ‘performance’ in that the act of doing is not necessarily the act of performing. The preparation of plans, billing, organizing and the like are generally done for the sake of doing them however, they do not necessarily contribute directly to the results of the operation or organization. In other words, “…being busy is not the same as producing results” . Performance management is the process that directs employee efforts from acts of being busy and channels them into being effective. The increasing challenges and competitiveness of today’s world means that organizations (business and otherwise), must increase their performance levels to remain competitive as their opponents keep raising the standard. To achieve the aforementioned “everyone (and everything) in the organization must be doing…”  what they need to do in consort with contributing to measurable performance.

And just as this (measurable performance) can be and is applied to organizations, it is equally important when utilized for and by individuals. Common sense should alert any employee of any company that if each individual is not doing their level best at their position each occurrence damages the reputation of the firm they are employed by in some small and possibly insignificant way. It is the accumulation of these instances that start to tarnish a company’s image and reputation thus opening the door for competitors. It could be something as small as the radio knobs on the car dashboard. The public likes ease, convenience and for things to work flawlessly (quality) each and every time. The preceding exaggerated example of one part and supposedly a few individuals who were not performed their jobs to the utmost of their ability is an important variable. This exaggeration can be applied to a number of companies who have suffered market position and reputation decline from such consumer disappointments. And in today’s society the Internet speeds word of mouth that is both good as well as bad. In reality if one is self-analyzing one’s individual performance, by measurable standards, it can become infectious and spread to other employees. Improvement moves at all angles, sideways, up, down and at various degrees in terms of the company’s organizational chart. Good ideas can come from any person and effective management has systems that allow people the access to contribute.

Chapter 1 - Introduction

1.1 Understanding the Context of Health Care Management

As the context in which the parameter, performance management in relation to self, is contained, nursing / hospital, the references and source materials will utilize same as the setting for discussion. The importance of the work performed within the health care / hospital system can not be overstressed as each individuals contribution has an impact upon their reasons for being, patient care.  The safety of both the patients as well as personnel are the utmost concerns to hospital management and administration. Governmental and public perceptions of health care institutions expect them to stay abreast of new developments in technology, patient care, medical procedures, and administration as they are in the business of saving and curing lives, the most noble of all professions making it one of humankind’s highest callings. And the foregoing makes the subject matter of this document particularly important on an institutional as well as individual level.

The discipline of performance management is usually organized and operates under the traditional performance management structure (model) whereby the focus is directed at the performance of an employee and their resultant contribution(s) to the organization’s mission.  Barter (2002)  stated that one factor which must be understood and addressed in the health care, hospital system is that “…patient care team leaders generally aren’t managers.”  The composition of most hospitals and health care facilities finds experienced as well as competent registered nurses as team leaders. They (RN’s - registered nurses) then report to managers. This arrangement is problematic in that RN’s are health care providers needed at the patient level. Given the acute shortage of nurses on a global scale, utilizing experienced RN’s in any type of capacity that limits or diminishes their patient involvement duties is a waste of an excellent source of health care expertise. Even more troubling is that in most  RN’s rotate between differing shifts thus limiting their ability to establish a managerial framework that allows them to provide more direct patient interaction and supervision time.

As the doctor’s right hand experienced RN’s can make on the spot decisions based upon the doctor’s guidelines and their understanding of what needs to be done at the onset of complications. As the extended doctor on the floor seeing to and ensuring that his (the doctor’s) patient instructions and monitoring are adhered to the responsibilities of the RN are enormous. Further exacerbating the problem is that these RN’s (team leaders) are also rotated within hospital teams as well as the personnel within these teams themselves. This creates a situation whereby they are managing and supervising a consistently changing staff with differing expertise and experience levels. This complicates the task of administering effective patient care as a result of consistent follow up and personal understanding of individual patient requirements which creates the potential for possible problems in reading the patient’s signs or other medical aspects. Limitations such as the RN’s not having much say or control, except in specialized units such as Acute Care, in the staff assignments, schedules, hiring, training, performance evaluation, discipline and other “…decision-making power…” , as well as budget authority further adds to the problem(s). These factors make ‘performance management’ a particularly difficult, if not almost impossible, task for the team as well as organization in achieving higher performance levels associated with quality care.

Chapter 2 - Enabling the Process

The ‘performance management’ process as it relates to one’s self is a part of the overall organizational plan that seeks to derive maximum actual performance from employees, department’s and all aspects of operations. When that machine is smooth and well oiled most problems or potential problems can be and usually are either avoided or caught in time. Accomplishing the task of managing one’s performance to meet organizational objectives requires additional guidance from supervisors to enable the process. For the purposes of example we shall select as our model the RN’s who are basically the individuals who run patient care on a 24 hour 7 day a week basis. The doctor’s role in health care management, utilizing a simplistic explanation, consist of knowing the nuances of his individual patient’s diagnosis and prescribing a course of care, surgery or other procedures, if required, that will cure said individual. From that point on the patient is in the hands of the hospital and thus the individual RN’s who run every department within that organizational structure.

2.1 Working Within the Constraints

It must be remembered that a health care environment is comprised of a high percentage of highly skilled professionals who by and large understand and perform their jobs and functions at a competent to excellent level. Given this high degree of innate professionalism these individuals “…expect the leader to coach, facilitate, and support…”  whereas technically trained or other unlicensed personnel might expect “… training, formal communication … close supervision and clearly defined authority”.  As a result of the aforementioned the leader who is unable to amend her supervisory and communication style to suit the needs of the team will not be effective. On the reverse side of the coin the leader who is able to master the communication and supervisory expectations will create an atmosphere that creates effective teamwork as well as increasing the productivity of the department.

And this is where the RN, as our example, must look inward to develop effective performance management skills recognizing the consistently changing variables and utilizing the proper skills to address each instance as they occur. The preceding does not mean that it is expected our even thought that the team leader (RN) should or can be perfect. It does mean that under the ‘performance management’ proviso the RN must understand the process and apply same to her role. The structure and constraints that accompany an organization are an outgrowth of how the hospital administration has elected to proceed and the prevailing culture that permeates the organization. These all have an influence on the quality of health care the organization provides as well as how those services are delivered, funded and other aspects that belong to the fiscal side. The bottom line, meaning profits, is a function of the ongoing performance of the organization in terms of the preceding and is what determines the public’s image and view of its reputation. The higher the perceived quality of care, hospital staff effectiveness, patient recovery, standards of the facility, and all other aspects that the public interacts with as well as the behind the scenes departments such as billing, cleaning, food service, etc. help to determine that reputation as well as image.

Higher performance levels also have a direct correlation on operating budgets. Efficient staffs are able to perform better and more work thus reducing the highest overhead cost associated with health care, which is the staff. In terms of health care service delivery, the following will provide a perspective on a global basis for which data is available:

1.    Comparative Health Care Costs
On a global basis, using the United States as the baseline, Americans spend 38 percent more on health care than their neighbor Canada, 39 percent more that the citizens of France. 53 percent higher that the residents of Germany, 42 percent more that the people of Sweden, 62 percent more that those of Italy, 78 percent higher that Australians do, 90 percent more than do the Japanese and 100 percent more that the citizens of the United Kingdom. The preceding figures become more meaningful when one understands that each of the indicated countries is rated as having a health care system that is either equal to or exceeds that of the U.S. Moreover, most of the hospitals in these countries are privately run institutions with doctors that have their own private practices.

2.    Socialized Medicine
The claims that this type of medical care is inefficient and provides a poor quality of health care, and the physician’s belief that it takes away their initiative as well as independence is generally accepted. However, a poll indicates that 87 percent of United Kingdom citizens indicated that they were satisfied with the system of health care provided as opposed to the United States where 70 percent expressed the same feelings.  The effectiveness and efficiency of socialized medicine is demonstrated in the fact that the infant mortality rate in Canada ranks 10th in the world, while in the United States it ranks at 21st, and Canadian citizens live an average of ten years longer than their American counterparts. Canadian citizens are able to obtain faster health care access and are less inclined to die from a malady such as heart disease. 

3.    Public Perception(s)
Studies have shown that the largely well cared for as well as satisfied citizens of the United Kingdom and Canada by and large have praise for their health care system, whereas those in the United States complain about their inferior health care.

4.    Labor
A study by the United States Department of Health and Human Resources found that “…changing patterns of use…”  as opposed to the aging population “…will account for a large portion of the nation’s health care costs…”  The preceding statement was based upon the “…magical new products that medicine has produced have a cost to society.”  The rising costs of labor are attributable to the structures in the industry’s institutions that create too much work that is not necessary.

The organizational and operational constraints mean that team leaders must be even more cognizant of ‘performance management’ for themselves and their team members.

2.2 Performance Management
As discussed, performance management consists of many varying elements that comprise the process. Marquis et al (2003)  delves into the aspects of leadership providing in depth analysis on its ‘historical development’, ‘evolution of leadership theory, ‘leadership and management for the future of nursing and ethical as well as decision making methodologies. Barter (2002)  concurs with the preceding stating that the team leaders who are successful utilize certain traits and attributes that enhance the quality of patient care. Barter adds that the preceding include the ability to coach, lead, teach and utilize effective strategies for delegation. In order to effectively lead others the RN must be cognizant of how to utilize teams in the care delivery system. In a paper prepared by the “Registered Nurses Association of British Colombia”(2001)  it set forth three aspects that it believes are important considerations in effective health care:

1.    Improved Effectiveness
The RNABC (Registered Nurses Association of British Colombia) indicates that for health care to be cost-effective more attention must be focused on the outcomes of varied services as well as the utilization of time proven strategies and methods. The document indicated that one of these strategies need to make more effective use of registered nurses.

2.    Reorientation of the Health Care System
The proposal went on to add that constructive changes to the system of health care means that there is a focus on the key principles inherent in primary health care. More emphasis on the promotion of health as well as the prevention of illnesses along with injuries were listed as important areas. In addition the RNABC believes that more nurses are needed to improve the quality of health care delivery by lessening the nurse to patient ratios that are at an all time high. By providing a budget for the prevention of illnesses and injuries they feel that the reduction in such occurrences will reduce the strain on the system.

3.    Meeting the Needs of Human Resource Health
Lastly, the RNABC indicated that as a result of the changing needs and demands of today’s society new forms of health care delivery need to be implemented. They pointed out that the starting point entails devoting serious attention to both the hiring as well as retention of registered nurses along with a long-term human resource planning initiative for health.

While the foregoing was prepared for the Canadian province of British Colombia the points indicated make sense across the board for any country. The basis for its findings are from the lessons learned in successful programs investigated in other locales and this evidence points to the need to revamp the system.

These factors as well as the indicated leadership aspects form the ‘performance management’ underpinnings that team leaders (RN’s) need to be aware of in understanding their own responsibilities under this process as well as in consort with the institutions strategic plan in this area. It is important that clear standards as well as objectives and targets be established to provide team leaders and staff with an understanding of the overall goals and objectives to be achieved. As a result, individuals should be able to answer the following:

1.    Roles and responsibilities, what are they? This forms the performance agreement.
2.    The standards that are expected of me, what are they? This indicates the performance minimums.
3.    Where and whom is going to provide me with feedback? Will such feedback come from a supervisor, manager or peers?
4.    What is the frequency in which I will receive said feedback? This asks what will be the frequency of such feedback information.
5.    How will I know how I am doing? This indicates the review process.
6.    Where do I go from here? This points to the targets and goals for the next period.
7.    And finally, how do I get there? This is a function of the development plan to attain the goals and objectives.

In order for the RN to achieve a level of ‘performance management’ pertaining to herself, she must be able to energize her team as the RN’s role is to motivate, supervise, guide, coach and lead by example. People are more inclined to follow the leader who does and shows how it is done rather than the individual who says how it should be done. This approach means that the RN must exhibit the traits and performance that she is looking for in others, thus helping to set the standard and fostering a climate whereby others will seek to improve upon this baseline. The RN must strive to stay abreast of not only the duties and responsibilities of her direct department, but also the defined goals and objectives as set forth by the institution.

From the foregoing it is easy to see that the responsibility for performance management resides in the organization setting clearly defined goals and objectives that it disseminates throughout the various departments and divisions of the operation. These specifics now become the responsibility of the individual managers, supervisors and team leaders as well as each employee. The lines of communication as well as administrative oversight need to be clear in everyone’s mind in order for an effective improvement to take hold.  And this is where the ‘self - directed’ aspect of performance management comes into play. The team leader’s effectiveness in performance management is a combination of her direct work contributions in terms of the job responsibilities as well as the grading that the people in her team garner. The team leader’s job is not to dictate or direct, it is to guide, coach and supervise. The cornerstones of an effective leader are:

1.    that they get involved and are willing to spend time to aid and assist the team to reach their goals,
2.    lets other individuals entrusted with the responsibility for others to take responsibility,
3.    supports the decisions made jointly and that were/are put into action,
4.    is consistently looking out for anything that helps the team,
5.    values the qualities of individuality and diversity along with unity,
6.    is patient as well as organized,
7.    gets things done,
8.    informs the team regarding limitations and the reason(s) for their existence

Former American president Dwight D. Eisenhower stated “Leadership is the art of getting someone else to do something you want done because he wants to do it.”  And Lao Tzu indicated "A leader is best when people barely know he exists... When his work is done... they will say: we did it ourselves"  Both phrases provide a practical guide as well as insight concerning the manner in which an effective leader is perceived, not only by himself, but more importantly by others.

2.3 Leadership
Influencing people to get things done at a standard that causes them to perform and “… to a standard and quality above their norm. And doing it willingly”  defines leadership. It must be remembered that leading people entails social interaction and thus is an activity that constitutes:

1.    influence,
2.    people who are both followers and leaders,
3.    the achievement of preset goals and objectives as a result of the combined commitment of people to the preceding to enhance the group and the culture of the organization

Effective leadership molds a group of individuals into a team whereby their combined synergy exceeds the sum of their individual actions and efforts.  This synergy makes them as well as the team leader more effective, and efforts tend not to be duplicated thus opening the door for additional performance on an individual basis. This collaborative effort motivates the individual team members, provided the leadership example fits the described parameters, and in reality eases the workload for each while increasing performance output. A leader:

1.    creates followers,
2.    fosters constructive and necessary change,
3.    causes change in a manner that takes into account and is responsive to the goals and objectives of the organization, team members, patients and of course themselves as well,
4.    and, engenders trust from followers.

O’Toole (1995)  indicated that a new vision of leadership is ‘values-based’ which is just as well as fair and is based upon;

1.    the ideas and values of each individual leader taking into account what they adopt from the organization’s culture as well as their individual education,
2.    the understanding of the different as well as conflicting needs of followers,
3.    the ability to motivate team members to achieve higher goals than they believed were possible,
4.    and having the skills that are broad enough to encompass the diverse personal and professional views and values of team members and mold these into a focused common goal.

The most important aspect of performance management is that individual employees understand that they are individually responsible as well as accountable for their actions, performance and results. The process of self performance management entails one coming to grips with one’s behavioral patterns, thoughts and methods that we operate under as well as those which one exerts over others, when applicable. The highly demanding nature of the health care industry means that the highly talented and professional employees who comprise this industry need to be able as well as empowered to lead themselves and follow the dictates of their individual job responsibilities.

Chapter 3 - Literature Review

The process of ‘performance management’ as it relates to one’s self is larger than the individual as it includes the organization with whom they are employed as well as the various people with whom they interact and work with as well as for. The World Health Organization  supports hospitals in evaluating how they are performing and the results they are achieving and assists them in quality as well as performance initiatives. This organization’s report (World Health) in 2000 found that the performance achieved is impacted by accountability, patient satisfaction quotients, and quality improvement strategies. To this end the organization has assisted with the drafting of health care reforms in varied countries to bring the service delivery of care into a more standardized and universal format utilizing the inputs and insight gained from having this unique association with different health care systems in its member countries.

The University of California at San Diego  in its “Managing Team Performance Issues” document delved into the team aspect of ‘performance management’ as well as individual ‘performance management’. It stated that the responsibility for a self-directed team is by and large accomplished by the team itself and that this autonomy varies in different organizations as a result of the approach adopted by management. It also pointed out that a fully functional and empowered team will devise means to amend their jobs to fit the team concept, including personalities, and set their own standards being mindful of the minimum requirements as prescribed by the organization, self appraise their performance and determine which team members need assistance as well as training based upon their differing states of proficiency and development. The report stated that when the focus is on individual performance it fosters a climate of competitiveness which is counter productive to team goals and objectives. Team effectiveness as well as performance improves when the focus is on the group effort rather than the individual. As such the team performance standards should basically mirror the standards set for individuals in that they should be clear, realistic, measurable, consistent, specific as well as verifiable and developed as a collaborative effort including those to whom these standards will apply. This inclusion aspect is extremely important in garnering individual support through participation and agreement on the finalized standards and thus eliminate future goal conflicts.

Barter (2002)  explained that departmental productivity is a result of effective and productive team leaders (RN’s) who possess the ability to coach, teach, are proficient in patient care and understand delegation. She continued that these team leaders are not managers but a functioning part of a team unit that sees to the medical needs of their patients in consort with doctor orders as well as the broader goals and objectives of the organization. The constraints of the foregoing means that team leaders in the health care environment generally need more leadership skills than their counterparts in other industries. The aspect of human health care and the varied ramifications, complications and need to understand, be prepared for and respond to potential emergency situations amplifies the requirement to perform at top levels on a consistent basis. An RN’s (team leader’s) primary task is to check and double check that the doctor’s instructions for patient care are being adhered to as well as ensuring that the staff is aware of what signs or conditions to be aware of in monitoring patients. The extremely critical nature of providing health care means that the RN must have a hands on approach while actually delegating almost all facets of the work load to others.

Marquis et al (2003)  approaches leadership roles and management functions from almost every conceivable angle in bringing all relevant theories, concepts and practices to the nursing profession. She broaches such aspects as the positive as well as negative connotations involved in decision making and problem solving along with leadership and how this differs from management. This key assessment, the differences between leadership and management is summed up by the fact that a leader motivates, encourages, trains, teaches, instructs and participates with the group under their charge, whereas management entails thinking, drafting and implementing goals and objectives which others follow. Management assesses performance as well as routinely check on progress against pre-set objectives and goals. Leadership is by its very nature hands on, while management can or might not utilize this technique. Marquis et al (2003)   covers organizational structure and how leadership roles are integrated within these constraints along with personal and political power. Team building skill require a mixture of social, educational, staff development, motivational and the clarification of expectations through role models as well as instruction.

Data provided by the Institute for Economic Recovery (2005)  helped to bring some of the realities of global health care into perspective through varied statistical information that compared the costs of health care in the United States where costs are the highest, Canada, France, Germany, Sweden, Italy, Australia, Japan and the United Kingdom. The quality of care despite the differences in costs is basically the same. The United States ranks 21st in the world in infant mortality compared to Canada’s 10th, and on average Canadian citizens live ten years longer than Americans. The preceding is partially explained by the quality of health care as well as a different pace of living, differing food habits and other lifestyle variables. It was pointed out that a higher quality of overall care is perceived by the citizens of the United Kingdom as well as Canada in terms of patient satisfaction and they praise their health care system. In the United States, which has the highest patient cost ratios, the public voiced dissatisfaction on the quality of health care as well as the rising costs.

An article from the Washington Post  conducted by the United States Department of Health and Human Resources stated that the changing patterns of use in the health care system that places a heavy reliance on new medicines has caused costs to rise dramatically as the system utilizes these drugs in place of preventive medicine as well as other techniques. It also stated that the dietary habits and lifestyles of Americans along with lower staff performance were also contributing factors. This financial aspect of American health care has caused the cost of delivery of services to spiral out of control. This same view was shared by the Registered Nurses Association of British Colombia  which set forth three important areas that it believes are considerations in improved health care that must be focused upon more intently. These are:

1.    Improved Effectiveness
2.    Reorientation of the Health Care System
3.    Meeting the Needs of Human Resource Health

All three areas carry the same theme as their base foundation, improved service levels can be achieved through better performance management techniques to meet the increased demands of the system caused by the shortage of qualified nursing personnel and increased patient to nurse ratios. The manner in which performance management in relation to each individual (self) is incorporated into actual usage is primarily the responsibility of the RN’s who are the principle care providers in the health care system. As they administer treatment, medication and oversee patient recovery, they are uniquely positioned to have the greatest impact on overall health care system performance improvement.

Chapter 4 - Conclusions and Recommendations

The overburdened nature of today’s health care systems on a global basis has increased patient to hospital staff ratios to heights the industry has not seen heretofore. Three out of five hospitals  report that the high patient-to-staff levels are having a negative impact on the service quality they provide, and that the preceding is associated with higher mortality rates, more medical complications, errors, lowered job satisfaction and nurse burnout. So much so that three in five nurses , fully 62 percent, have or are considering leaving the patient care industry. Med-Surg nurses indicate that they average 8.0 patients per shift when they feel that a ratio of 5.2 permits them the time to perform adequately in this area. Fully 62 percent of the nurses surveyed believe they are caring for more patients than is medically safe in terms of allowing them to check all of the particulars such care requires. The problem is so pervasive that 82 percent of hospital nurses are in favor of legislation establishing a maximum number of patients they are required to administer care for.  Nurses also indicate that an increase in staffing levels on an immediate basis is the most important area needed to increase health care quality and reduce mortality rates along with the onset of patient complications and allied factors. The survey indicated that 59 percent, three out of five, state that understaffing negatively impacts patient care delivery and does not permit them the time to adequately care for patients in accordance with safe medical levels.

The preceding has been utilized to illustrate the importance of the ‘performance management’ process to increase staff effectiveness in light of this serious problem. The process, performance management, will not solve the understaffing ills facing the industry, but it does serve as a means whereby present staffing can increase the quality of care through an effective and efficient team oriented approach. And this means that the team leaders (RN’s) must exercise performance management skills along with leadership to govern their own individual performance as well as those under their supervision. This requires that communication, coaching goal setting, training and a hand-on approach combined with providing team members with clearly defined goals, objectives, responsibility, accountability and a place in the process is imperative. The inclusion of staffing personnel in the preceding process makes them a part of the overall organizational plan and fosters greater cooperation on an individual basis as opposed to the ‘do this’ management style. As the RN is in the trenches, so to speak, with the team members the lead by example as well as know your responsibilities approach is better suited to the educated professional composition of hospital staffing, rather than an iron hand.

Motivation and a willingness to adopt and personally take responsibility for their own performance management under a process whereby they understand the ramifications provides team members with a sense of accomplishment and a means for them to introduce ways in which to improve their performance as they think of how proceed as opposed to being given consistent orders which they might take exception to, thus lowering morale. Hospital administrators need to aid their staff members in an understanding of the overall objectives of the hospital as well as provide RN’s with the tools to implement this process through written materials, meetings, training, and follow up. By working with the staff for change and guiding them to higher performance management levels the quality of health care will increase and will set the tone whereby the staff and more importantly the patients benefit.

Bibliography

American Heritage Dictionary.2005. Definition of Performance. http://education.yahoo.com/reference/dictionary/entry?id=p0189500

American Heritage Dictionary.2005. Definition of Management. http://education.yahoo.com/reference/dictionary/entry?id=m0070600

Barter Marjorie.2002. Follow the leader. Nursing
Management. October . www.nursingManagement.com

CiteHR.com.2005. Performance Management. http://www.citehr.com/performance-management-vt2329.html

Hurwit, Cathy.1993. A Canadian Style Cure. May 1993. P.10. Dollars and Sense

idsa.2005. An Effective Leader. http://www.idsa-activities.org/files/effectleader.pdf

Marquis, Bessie, Huston, Carol.2003. Leadership Roles and Management Functions in Nursing: Theory and Application. Chap 3. Lippincott, Williams & Wilkins. ISBN: 078173794X

Navarro, Vicente.1986. What is Socialist Medicine. July - August  P. 64.Monthly Review

Options With Learning.2005. What is performance management. http://www.owlweb.co.uk/option7/samples/perform.shtm

O’Toole, James. 1995. The Executive Compass: Business and the Good Society. P. 1 - 15 Oxford University Press. ISBN: 0195096444

Peter D. Hart Research Associates.2003. Patient-to-Nurse Staffing Ratios: Perspectives from Hospital Nurses. AFT Healthcare, Washington, D.C.

Registered Nurses Association of British Colombia. 2001.  Better System, Better Health Care. Registered Nurses Association of British Colombia.

Navarro, Vicente.1986. What is Socialist Medicine. July - August  P. 64.Monthly Review

Ten3.2005.The Art of Effective Leadership. http://it4b.icsti.su/1000ventures_e/business_guide/crosscuttings/leadership_main.html

The Institute for Economic Democracy.2005. The Health Care Industry. http://www.ied.info/books/www/healthcare.html

The Archer. 2005. Dwight D. Eisenhower. http://www.peacearchrotary.ca/pdf/Nov.%201%20Issue%209.pdf#search='Leadership%20is%20the%20art%20of%20getting%20someone%20else%20to%20do%20something%20you%20want%20done%20because%20he%20wants%20to%20do%20it.%20–%20Dwight%20D.%20Eisenhower'

UCSD Human Resources Department.2005. Managing Team Performance Issues. http://www-hr.ucsd.edu/~staffeducation/guide/teams.html

Washington Post.1987. Nation’s Health Bill Expected to Triple. June 9, 1987, p 8. reprinted from The Missoulian

World Health Organization.2000.Hospital management / Hospital performance. http://www.who.dk/hosmgt/20030224_2