AN APPRAISAL OF BUSINESS POLICY MODELS IN THE MANAGEMENT OF MISSION HOSPITALS IN THE SOUTH EAST NIGERIA

Background of the Study 1

Business is an organized system aimed at delivering desired goods and services to customers, often with the goal of generating profit by ensuring revenues surpass operational costs While many businesses focus on profitability, some, known as nonprofit organizations, prioritize covering their operating expenses Nonprofits typically function as nongovernmental service providers, including social service agencies, foundations, advocacy groups, and mission hospitals (Redmond, 2009).

Every business organization relies on established rules, norms, principles, procedures, and policies to function effectively Without a clear policy, a business operates aimlessly, making it challenging to evaluate its performance and achieve its objectives Policies serve as essential guides for decision-making and can be defined in two key ways: as a specific goal or method of action that shapes current and future decisions, and as a framework of rules that govern the administration and management of network resources.

Business policies are essential guidelines that govern an organization's actions and decision-making processes, particularly in hospital management, where they outline strategies for effectively mobilizing and deploying resources to deliver quality health services These policies encompass critical functions such as planning, organizing, controlling, and leading, ensuring that organizational goals are met efficiently.

Organizations typically adopt one of two business policy approaches to achieve their objectives: a closed system perspective or an open systems view Traditional theories viewed organizations as closed systems, isolated from external influences, focusing solely on internal management, employees, and resources (Bola, 2011) However, by the 1960s, these mechanistic theories, such as scientific management, were largely rejected in favor of more holistic and humanistic approaches This shift acknowledged the significant environmental factors impacting organizational efficiency, leading theorists to embrace the open-systems perspective, which recognizes that each organization is unique and must adapt to specific challenges and opportunities Research from that era indicated that traditional bureaucratic structures struggled in rapidly changing technological and market environments and overlooked the role of regional cultural influences in employee motivation (Kahn, 2010).

An open business policy model in hospital management outlines the guidelines for how hospitals engage with their external environment, including patients, suppliers, competitors, and socio-political factors While various subsystems within the hospital, such as laboratories, nursing, and pharmaceuticals, require strict control and self-regulation, an effective open system must also be equipped to handle both predictable and unforeseen challenges in a structured manner.

An open business policy is intrinsically linked to the stakeholder business policy model, encompassing input, throughput, and output sources within an organization Corporate stakeholders are defined as parties that can influence or be influenced by the organization's actions The concept of stakeholders originated in a 1963 memorandum from the Stanford Research Institute, identifying them as essential groups whose support is vital for the organization's survival (Freeman, 2004) The Stakeholder Approach aims to create a framework that addresses the concerns of managers facing unprecedented environmental turbulence and change Freeman (1984) emphasizes that the focus has shifted from merely delivering products and services to recognizing the limitations of traditional management theories that prioritize efficiency and effectiveness within a product-market context.

The persistently low quality of health services in Nigeria's public facilities has forced consumers to turn to the private sector for care Issues begin with the unprofessional attitudes of doctors and nurses, who often display egoism and engage in confrontations with patients and their families In National Teaching and Orthopedic hospitals, patients are made to feel like burdens, with staff suggesting that it is their fault for seeking help This negative experience has led many Nigerians to view government hospitals as akin to mortuaries, resulting in a preference for chemists and private healthcare providers over public hospitals.

The Nigerian health system is in a critical state, with alarming health indicators and statistics There has been little progress in maternal and child health, and life expectancy remains below 50 years The doctor-to-population ratio is a concerning 3 per 10,000 The persistent issues of malaria, tuberculosis, and AIDS continue to plague the nation, while access to safe, clean water is severely inadequate in both urban and rural areas Additionally, road traffic accidents contribute significantly to the loss of life, particularly among young adults.

Nigeria faces a critical challenge in achieving the Millennium Development Goals (MDGs) four and five, which aim for a two-thirds reduction in child mortality rates and a three-quarters decrease in maternal mortality by 2015 Currently, the country is far from meeting these targets, with alarming statistics indicating that approximately 720 babies die daily—equating to about 30 deaths every hour This grim figure represents the highest newborn death rate in Africa and the second highest globally (Chukwu, 2011).

The decline in trust towards the public health system, due to mismanagement and ineffective business policies, has led to the expansion of the private healthcare sector, particularly the informal segment (Hanson et al., 2008) Many patients are turning to unregulated private healthcare providers, attracted by lower costs, despite the potential for inadequate treatment (Onwujekwe, 2005).

In southeast Nigeria, many Christian churches are actively addressing challenges in the public health sector, emphasizing the importance of both physical health and spiritual well-being The church believes that true salvation encompasses the whole person—body and soul—reflecting the healing ministry of Jesus, who healed the sick and restored hope (Mt 11:4-5) Mission hospitals play a vital role in this mission, offering comfort and a renewed sense of purpose to those suffering while invoking the mercy of Jesus, the ultimate healer As a significant player in Nigeria's health sector, mission hospitals provide over 40% of the country's healthcare services, with approximately 320 such facilities operating nationwide (Chukwu, 2011).

Anambra State is home to approximately 37 Catholic hospitals, maternity homes, and primary health centers that serve both urban and rural communities, providing care for the sick and comfort for the dying (Omutah, 2006) These institutions are founded on the principles of recognizing the inherent value of every individual and are dedicated to excellence in healthcare Their key objectives include delivering exceptional physical, emotional, and spiritual care to patients and their families, ensuring a commitment to the underserved while also offering specialized services to the wider community Additionally, they strive to create a respectful work environment that fosters personal and professional growth and to enhance health services education However, the failure to achieve these goals in many mission hospitals has prompted further investigation into the matter.

Concerns are escalating regarding the inadequate management of health institutions by both private and public providers in Nigeria The substandard quality of services in these hospitals has led many Nigerians, particularly those with financial means, to seek treatment abroad, while countless others are left to navigate a failing healthcare system.

Nigerians are increasingly accepting their circumstances as mission hospitals, intended to address the shortcomings of the public health care system, struggle to operate at their full potential.

The performance gap in healthcare institutions is primarily a management issue, stemming from ineffective business policy models Many mission hospitals implement policies that hinder effective interaction among employees, management, government, and other stakeholders Some models fail to foster team spirit, overlooking the collaborative nature of healthcare, while others are overly bureaucratic, lacking employee participation and empowerment This results in poor communication, with information flowing solely from management to staff, which discourages a two-way dialogue Such communication barriers lead to misconceptions, distrust, and low staff morale, ultimately contributing to labor unrest and decreased productivity.

Objectives of the Study 6

The study has the main thrust of critically evaluating business policy models in the management of mission hospitals with a view to achieving the following specific objectives:

1 To ascertain the extent to which the quality of service to patients in the mission hospitals is contingent on having appropriate open system business policy model.

2 To determine the extent to which stakeholder business policy model can improve the sustainability of operations in the management of mission hospitals

3 To examine the extent to which open system business policy model can promote competitiveness in the management of mission hospitals

4 To examine the relationship between open system business policy model and the management of human resources in the mission hospitals

5 To determine the greatest challenge of adopting business policy models in mission hospitals

6 To examine the influence of stakeholder business policy model on the supply chain management of mission hospitals.

Research Questions 6

Given the objectives of the study, the following research questions guides the conduct of the study:

1 To what extent is the quality of service to patients in the mission hospitals contingent on having appropriate open system business policy model?

2 To what extent can stakeholder business policy model improve the sustainability of operations in the management of mission hospitals?

3 To what extent can open system business policy model promote competitiveness in the management of mission hospitals?

4 What is the relationship between open system business policy model and the role of human resources management in mission hospitals?

5 What is the greatest challenge of adopting business policy models in mission hospitals?

6 How does stakeholder business policy model influence the supply chain management of mission hospitals?

Research Hypotheses 7

The following research hypotheses served as aids in finding answers to the research questions and in fulfilling the objectives of the study

1, Ho: The quality of service to patients in the mission hospitals is not significantly contingent on having appropriate open business policy model

H1: The quality of service to patients in the mission hospitals is significantly contingent on having appropriate open business policy model

2, Ho: Stakeholders business policy model cannot significantly improve the sustainability of operations in the management of mission hospitals

H1: Stakeholders business policy model can significantly improve the sustainability of operations in the management of mission hospitals

3, Ho: Open system business policy model does not significantly promotes competitiveness in the management of mission hospitals

H1: Open system business policy model significantly promotes competitiveness in the management of mission hospitals.

4, Ho: There is no significant relationship between open business policy models and human resource management in the mission hospitals

H1: There is significant relationship between open business policy models and human resource management in the mission hospitals.

5, Ho: Environmental turbulence and uncertainties do not significant constitute challenge to the adoption of business policy models in mission hospitals.

H1 Environmental turbulence and uncertainties significant constitute challenge to the adoption of business policy models in mission hospitals.

6, Ho: Stakeholders’ business policy model does not impact positively on the supply chain management of mission hospitals

H1: Stakeholders’ business policy model does impact positively on the supply chain management of mission hospitals.

Significance of the Study 8

This study will be of immense significance to the stakeholders in the health sector such as the proprietors (legal owners), the government, the (patients), the workers, and scholars.

Proprietors of mission health care facilities must recognize that their active involvement in the formulation, implementation, and execution of business policy models is essential for achieving effectiveness and efficiency in operations.

The results of this study will support government agencies at all levels in developing policies that foster a conducive environment for the health sector Additionally, the findings will encourage the government to explore public-private partnerships to enhance healthcare delivery.

The Hospital Employees: The outcome of this work will bring about synergism among the different department of the hospital, thus increasing team spirit in the work place.

This study's findings will significantly benefit patients by evaluating business policy models aimed at enhancing the quality of service they receive.

The Scholar: The study will serve as reference point to any future researcher and in addition add credence to existing literature.

Scope of the Study 9

This study evaluates business policy models for managing mission hospitals in Southeast Nigeria, focusing on open system and stakeholder policies to assess service quality, operational sustainability, competitiveness, human resources, supply chain management, and the challenges of implementing these models A total of 27 mission hospitals were selected, with a recognition of the cultural and religious similarities in the region, making findings relevant across the geopolitical zone Specifically, the research included five hospitals in Enugu, twenty in Anambra, one in Imo, and one in Abia state.

The study was carried out within the period of three years from 2008-2011.

Limitations of the Study 9

In the process of conducting the research, the researcher was impeded by some constraints such as:

Financial limitations significantly hindered the research process, as obtaining essential information from various mission hospitals entails substantial costs Consequently, the researcher lacked sufficient funds to conduct a comprehensive study.

Due to time constraints, the researcher was unable to conduct a comprehensive study of mission hospitals across all states in Southern Nigeria, leading to a focused examination limited to the South East geopolitical zone Consequently, several locations that could have provided valuable data and information were not included in the research.

The attitudes of respondents significantly impacted the study, as many hospital staff and management were hesitant to share necessary information due to preconceived notions about the research This reluctance highlighted concerns regarding the privacy of information, posing a major constraint on the data collection process.

Profile of the Selected Mission Hospitals 10

Annunciation Specialist Hospital Emene, Enugu State

Annunciation Specialist Hospital, a mission hospital managed by the Daughters of Divine Love (DDL) Congregation, was established with the support of the Deutschorden Order in Germany through their Hospital project, Deutschorden Hospital Work (DOH) The generosity of this Religious Order has been instrumental in realizing the vision of Annunciation Specialist Hospital.

Annunciation Specialist Hospital Emene-Enugu was officially opened on the 9 th day of February, 1988, with a capacity of 100 beds, 2 theaters, modern analytic Laboratory, E C G.; Ultra/Sound, Gastroscopy and X – ray

Our mission is to participate in the healing ministry of Jesus Christ by offering health services that prioritize a holistic approach and uphold the dignity of every individual we serve.

Mother of Christ Specialist Hospital, Enugu State

Founded in 1958 as a maternity home, the Mother of Christ Specialist Hospital in Ogui, Enugu, evolved into a comprehensive hospital in 1971, addressing the health needs of civil war victims With a commitment to reducing maternal mortality and morbidity, the facility was upgraded to a 102-bed specialist hospital in 1995 Recognized as a baby-friendly health institution, it operates under the management of the Immaculate Heart Sisters (IHS) congregation.

St Theresa’s Hospital and Maternity, Abakpa Nike, Enugu State

St Theresa’s Hospital and Maternity, located in Abakpa Nike, Enugu, is a Catholic healthcare facility dedicated to the prevention, care, and treatment of various ailments Operated under the Enugu Catholic Diocesan Health Management Board, it is managed by a six-member committee Initially registered as a maternity hospital with 15 beds in accordance with the Enugu State Health Institutions Edict of 1988, the hospital has since expanded its capacity to 30 beds, with 23 currently available.

Ntasi Obi Ndi No N’Afufu Hospital, Trans-Ekulu, Enugu State

Ntasi Obi Ndi No N’Afufu Hospital, a non-governmental health institution owned by the Catholic Diocese of Enugu, offers essential healthcare services to the residents of Enugu and surrounding areas Officially opened on January 6, 1995, by the late Most Rev Dr Michael U Eneja, the hospital began full operations on March 1, 1995 Registered as a 100-bedded facility with the Enugu State Ministry of Health on May 8, 1996, it is overseen by a management board appointed by the Catholic Bishop of Enugu Diocese.

Bishop Shanahan Hospital Nsukka, Enugu State

Bishop Shanahan Hospital Nsukka is a private Catholic mission hospital built by His Grace Most Rev Dr Charles Heerey C.S.S.P of blessed memory It first operated as a maternity home from

From 1930 to 1948, the facility operated under various capacities until it was officially upgraded to a full-fledged hospital in 1949 by the Eastern Region Ministry of Health, becoming known as St Theresa’s Maternity Hospital Initially registered with 150 beds, the hospital expanded its services in 1952 by opening a School of Midwifery to train Grade A midwives.

The hospital expanded its services and facilities over the years, leading to the establishment of the School of Nursing in 1962 to train Nigeria Registered Nurses In 1964, the Midwifery Board of Nigeria upgraded the School of Midwifery to a Grade I institution However, both the training schools and the hospital suffered damage during the civil war from 1967 to 1970, but they were later rehabilitated.

In 1970, the Diocese, supported by the Caritas and Misereor organizations, initiated rehabilitation efforts On February 23, 1979, the Midwifery Council of Nigeria inspected the Midwifery school for its suitability as an examination center, which received approval in April.

1979 as an examination centre for the then Anambra State.

Following the war, the hospital was managed by the Sisters of Immaculate Heart Congregation until 1983 From 1983 to 1988, a dedicated team of doctors, seminarians, and administrators oversaw its operations The Sisters of the Daughters of Divine Love Congregation took over management from 1988 to 2000 Since 2000, the hospital has been under the administration of the Rev Fathers, with Rev Fr Bernard Eze currently serving as the hospital administrator.

In 2001, a third educational institution, the School of Medical Laboratory/Assistant Technicians, was established alongside the existing schools at the hospital to train Medical Laboratory Technicians and Assistants The hospital's motto emphasizes its commitment to patient care: "Your health is our concern."

St Charles Borromeo Hospital Onitsha, Anambra State

Archbishop Charles Heerey believed in the integral connection between physical health and spiritual salvation, envisioning a comprehensive healthcare facility dedicated to enhancing human health and alleviating suffering This vision materialized with the establishment of the Holy Rosary Hospital in Waterside, Onitsha, followed by the initiation of the St Charles Borromeo Hospital project, aimed at providing top-notch medical care Rev Fr Godfrey Okoye played a pivotal role in securing the hospital's site, with funding support from the Catholic Archdiocese of Onitsha, Cardinal Montini (later Pope Paul VI), and Misereor Germany.

The construction of St Charles Borromeo Hospital was completed in record time, with its blessing on June 5, 1964, and official opening in January 1965, commissioned by then Minister of Health Chief B C Okwu Registered with the Ministry of Health and relevant authorities, the hospital was initially administered by the Holy Rosary Sisters, with Sr Auscillia serving as the first matron from 1964 to 1967 Following the outbreak of the Civil War, the hospital suffered significant damage, but was reconstructed by Archbishop Francis Arinze in 1970 to serve the needs of the war-affected Igbo community The administration was subsequently handed over to the Immaculate Heart Sisters, with Sr M Chrysostom Okoye and Sr M Bide Njoku as the first post-war matrons from 1970 to 1983 The hospital was re-registered in 1984.

Mission: sympathy to the sick and the needy through Medicare and general health care delivery

Immaculate Heart Hospital Nkpor, Anambra State

This hospital was established by the Immaculate Heart Sisters Congregation in 1989 It started as

The maternity home in Nkpor, Idemili North L.G.A., Anambra State, has expanded from its original 8 beds to a 54-bed hospital, providing 24-hour healthcare services Officially approved by the Anambra State Ministry of Health in 1990, it was initially led by Sr Mary Emmanuel Ezeasor as the first matron.

Sr Dr Virgie Onyeador was the first medical doctor to the hospital

The hospital is located in a two-storey main building alongside three additional bungalows, featuring essential facilities such as two theaters, a labor ward, four private room wards, a general ward, an emergency room, four consulting rooms, a pharmacy, two palpation rooms, and three administrative offices Additionally, there is a school for medical laboratory technicians affiliated with the hospital Offering 24-hour services, the hospital provides comprehensive care in obstetrics/gynecology, surgery, dental services, internal medicine, physiotherapy, X-ray, sonography, child immunization, and HIV/AIDS counseling and testing.

Fatima Catholic Hospital Awka –Etiti, Anambra State

Fatima Catholic Hospital Awka-Etiti was established by His Grace Francis Arinze, now a cardinal, following the successful completion of St Joseph Catholic Church in the community The hospital was created to address the pressing healthcare needs of the Awka-Etiti indigenes.

Definition of Terms 24

This study utilizes specific terminology that necessitates clear definitions, as these words may carry ambiguities or alternative meanings beyond their common usage To ensure clarity, precise definitions have been provided in relation to the context of this research.

Christensen (1982) defines business policies are the guidelines developed by an organization to govern its actions.

Olumide (1997) asserts that hospital management is process of mobilizing and deploying resources for the efficient and effective provision of health services

Mission hospitals are seen as non-government, non- profit making organizations that provide health services and owned by religious institutions (Omutah, 2006)

According to Redmond (2009), a model serves as a blueprint or framework that guides the execution of a specific task It exemplifies an ideal or superior example that is worthy of emulation.

An open system is a system that regularly exchanges feedback with its external environment (Katz and Kahn, 2004).

Stakeholder: Smith (2000) describes stakeholder (corporate), as a person, group, and organization, system who affects or can be affected by an organizational actions

Service quality: Lewis and Booms (1983) define service quality as a measure of the degree to which the service delivered matches customer’s expectations.

Business sustainability, as defined by Beller (2009), is a strategic approach focused on maintaining a firm's long-term health while enhancing profitability This involves minimizing negative environmental and social impacts through the delivery of innovative products and services, as well as optimizing business processes and resource management.

Environmental turbulences, as defined by Bower and Christensen (1995), refer to the accelerating pace of changes, particularly in technology, which complicates the identification of causes and makes it challenging to predict the outcomes of competitive strategies with any degree of certainty.

Supply Chain Management is defined by Cooper and Ellram (1993) as a comprehensive approach that oversees the entire flow of goods within a distribution channel, starting from the supplier and extending to the end user.

Theoretical Frame work 31

This study is guided by the following models:

In the 1960s, it became clear that the closed systems model was inadequate, as organizations actively exchange resources with their environments, contradicting the model's assumptions of isolation (Morgan, 2006) The increasing complexity and dynamism of technological, social, economic, and political factors necessitated a reevaluation of this model, prompting organizational theorists to explore new frameworks (Daft, 2007) This shift gave rise to the open systems model, which gained prominence throughout the 1960s and 1970s Pioneers like Daniel Katz and Robert Kahn highlighted in "The Social Psychology of Organizations" that a closed-system approach overlooks the critical interdependence between organizations and their external environments (Robbins, 2003).

Open systems must adapt to changes in their external environment to thrive Organizations that fail to adjust to these changes risk losing their competitive edge and ultimately facing failure or bankruptcy over time (Bertalanffy, 1951).

(1)Environment All the elements outside the system that have the potential to affect all or part of the system

(4) Output The work of the system, exported back into the environment

(2) Input Resources are taken or received from the external environment

A continuing source of information concerning the relationship with the external environment used to make the necessary changes in order to survive and to grow

The process of conversion or transformation of resources within a system

Fig 2.1: Basic Open System Model

Source: (Robbins, 2003, Basic open system model: Wikipedia, the free encyclopedia).

An open system engages with its environment to acquire essential inputs and economic resources necessary for survival In reality, no system is entirely closed or open, as organizations must obtain resources for their sustainability and cannot operate in isolation Additionally, individuals within these organizations allocate only a portion of their lives to work, spending the remainder in their surrounding environment.

An open system is characterized by its continuous interaction and feedback exchange with the external environment Key components of open systems include inputs, processes, outputs, goals, assessment, evaluation, and learning Crucial aspects that define open systems are their boundaries, the external environment, and the principle of equifinality, which emphasizes that multiple pathways can lead to the same outcome.

All systems possess boundaries, which can often be challenging to pinpoint due to their dynamic nature Open systems feature permeable boundaries that facilitate the easy exchange and comprehension of valuable feedback.

Closed systems, unlike open systems, have hard boundaries through which little information is exchanged Organizations that have closed boundaries often are unhealthy.

The external environment encompasses various needs and influences that can impact an organization, yet remain beyond its direct control These influences are often categorized as political, economic, ecological, societal, and technological factors.

An effective organization operates as an open system, consistently engaging in feedback exchanges with its external environment To enhance their understanding of this environment, healthy organizations utilize tools such as environmental scanning, market research, and evaluations Additionally, they actively seek to influence their surroundings through strategies like public relations, advertising, promotions, lobbying, and advocacy, while also educating industry and local leaders.

Equifinality refers to the concept that identical or similar outcomes can be reached through diverse methods and processes In management, this means that organizations can achieve the same results by utilizing different inputs or by applying various processes with the same inputs Ultimately, equifinality highlights that there is no singular correct approach to achieving significant results within an organization.

Closed systems prioritize a singular method for accomplishing tasks, often seen in bureaucratic organizations where individuals are required to adhere strictly to established processes This approach emphasizes completing procedures correctly, rather than focusing on achieving the most beneficial outcomes for the organization.

The principle of equifinality highlights that there is no singular correct approach to leading or managing organizations, nor is there a definitive method for facilitating organizational change This understanding is crucial when implementing diverse solutions-based practices, diagnostic models, and assessment tools.

Figure.2.2: Overview of the Open System of an Organization

Source: Robbins, 2003, Basic open system model ,http://www.authenticityconsulting.com accessed 15 th July 2011.

Standard materials and concepts used by the organization, for example:

Processes Subsystems to process the inputs and generate outputs for example:

Individuals Teams Projects Programs Products and services Processes (cross functional) Functions Etc

Outputs Tangible results from the organization, products or services, for example:

Trained customers Courses Books Revenue Fixed cars Patients Furniture Houses Etc

Outcomes Benefits to customers (in the external environment) from using the outputs, for example, customers who are more:

Happy Financially Strong Employed Literate Independent Healthy Mobile Etc

Feedback between all parts and external environment for evaluation, learning and adaptation.

Feedback in from the environment is especially from standard inputs, environmental scanning market research and evaluations

Feedback out to the environment is especially from outputs, public relations, advertising, promotions, and outcomes

Open systems utilize external resources to maintain themselves by transforming these inputs into outputs through technology They acquire necessary resources and implement technological processes that facilitate this transformation The effectiveness of these technical activities is crucial, as they enable the system's self-maintenance Ultimately, the degree of self-maintenance achieved by the system influences its classification as either open or closed.

The concept of entropy is employed when elaborating the difference between closed and open systems Entropy means energy loss or energy that cannot be turned into work.

The second law of thermodynamics states that closed systems inevitably progress towards entropy, characterized by a disordered arrangement and the breakdown of structured elements Conversely, open systems that can harness energy from their surroundings can achieve a state of negative entropy, also known as negentropy, allowing them to maintain order and organization.

Open systems enhance their energy and repair internal breakdowns by utilizing inputs that are more complex than their outputs According to Bertalanffy (1951), this allows such systems to sustain themselves at elevated levels and even evolve towards greater order and complexity (Scott, 1981).

Morphostasis and Morphogenesis are both system process They further help us in understanding the systems properties of entropy and negentropy According to (Scott,

Morphostasis refers to the processes that maintain a system's form, structure, or state, such as circulation and respiration in biological systems, and socialization and control in social systems In contrast, morphogenesis involves processes that change or develop the system, including growth, learning, and differentiation As open systems adapt to their environment, they typically become more differentiated and complex in structure In biological contexts, organizations with broad sensitivities to external stimuli evolve into more specialized receptors that can respond to a wider range of nuanced stimuli.

The environment serves as a crucial source of diversity and variation within systems, influencing their characteristics Organizations are shaped by their surrounding environments, and simpler environments necessitate simpler structural forms within the systems Consequently, open systems adhere to the law of limited variety, meaning that a system can only display as much variety as it has encountered in its environment (Pondy and Mitroff, 1979).

Conceptual Framework 39

Business policy establishes the boundaries within which organizational decisions are made, empowering lower-level management to resolve issues independently These guidelines dictate the parameters for decision-making and address resource acquisition necessary for achieving organizational objectives Furthermore, business policy encompasses the analysis of top-level management's roles and responsibilities, alongside critical factors influencing long-term organizational success.

This comprehensive definition covers many aspects of business policy Firstly, it is considered as the study of the functions and responsibilities of the senior management related to those

Organizational problems within the scientific community can significantly impact overall success Addressing these issues involves outlining a clear future course of action for the organization It is essential to establish a defined purpose and identify necessary steps to shape the organization's character and identity Additionally, effective resource mobilization is crucial for achieving organizational goals.

2.2.2 Features And Elements of Business Policy

An effective business policy must have the following features: specific, clear, reliable, appropriate, simple, comprehensive, flexible and stable (Howard,2000).

Azhar (2002) identified the following elements of business policy:

Goals serve as the foundational guide for organizational activities, encompassing the organization's purpose, mission, objectives, and strategies Managers utilize the organization's purpose to establish distinct objectives aimed at fulfilling the mission Additionally, the term "goal" can refer to specific short-term targets set for lower-level employees, such as production, sales, and marketing goals.

The primary purpose of an organization is shaped by the societal context in which it functions, serving as a broad objective that is relevant not only to the specific organization but also to all similar entities within that society.

Objectives serve as the specific goals an organization must reach to fulfill its mission They translate the broader mission into concrete, measurable terms, allowing for easier assessment of actual results.

Strategies serve as comprehensive plans designed to achieve organizational objectives and fulfill the mission They provide a cohesive direction for the organization and facilitate the effective allocation of resources to reach established goals.

Values represent the shared beliefs of an organization's stakeholders, shaping its culture and guiding decision-making processes They establish a framework for priorities, such as emphasizing the importance of knowledge and skills for long-term success For instance, the value of teaching self-sufficiency, as illustrated by the saying, "give a man bread and feed him for a day, but teach him to farm and feed him for life," highlights a commitment to empowering individuals over merely providing temporary solutions.

A vision statement articulates the long-term aspirations of an organization, defining its fundamental objectives and strategic direction It reflects the organization's desired future state and the kind of world it aims to create, such as a charity envisioning "a world without poverty." This mental image encompasses the environment that individuals or organizations strive to develop over an extended timeframe, highlighting the conditions necessary for achieving this vision As noted by Kotter (1990), a vision describes the future of an organization, its culture, or its activities, while Miller and Dess (1996) emphasize that it encompasses broad, inclusive, and forward-thinking intentions.

A mission statement defines the core purpose of an organization, outlining its existence and the actions it takes to fulfill its vision It serves as a future-oriented snapshot of the organization, detailing its activities and answering the essential question: “What do we do?”

The mission of an organization defines its core purpose, highlighting its existence, the nature of its business activities, and the customers it aims to serve and satisfy (Thompson, 1997).

Business policies act as essential managerial guidelines that facilitate effective management within organizations As outlined by O’Bhaughnessy (1976), these policies serve five key functions that significantly impact all formal entities.

(1) It clarifies management viewpoints and philosophies within designated areas of operation

(2) Policy provides a pattern within which administrative delegation of authority may be expedited and controlled

(3) Policy establishes latitudes and guides within which authorized persons may make administrative decisions and effect actions

(4) Policy anticipates future conditions and situations and resolve how they will be dealt with

(5) Policy fosters a favourable management climate, produces a feeling of confidence in making decisions, expedites decisions, and encourages executive self-reliant, growth and development, and improvement of executive performance

Business policy implementation involves transforming policy into actionable practices, yet a noticeable gap often exists between planned objectives and actual outcomes Buse et al (2005) identify three primary theoretical models of policy implementation: the Top-down approach, the Bottom-up approach, and the Principal-agent theory.

The top-down approach distinguishes between policy formation and execution, with policies established at higher political levels These policies are subsequently communicated to lower levels, which are responsible for the technical, managerial, and administrative tasks necessary for implementing the policies effectively.

The top-down approach aims to establish effective structures and controls that promote adherence to organizational goals Nonetheless, it is important to acknowledge significant drawbacks associated with this method.

 It is very unlikely that all pre – conditions would be present at the same time

 It only adopts perspective of those in higher levels of government and neglects the role of other actors

 It is difficult to apply where no single, dominant policy or agency is involved

 Policies change as they are being implemented.

The bottom-up approach emphasizes the active role of individuals at lower levels in the implementation of policies, allowing them to influence objectives and modify execution methods This perspective views policy implementation as an interactive process that involves collaboration among policymakers, implementers across different government tiers, and various stakeholders.

The bottom –up approach over emphasizes the ability of the street-level bureaucrats to frustrate the goal of the top policy makers.

Service Quality and Open Business Policy in Hospitals 44

Service quality, as defined by Lewis and Booms (1983), measures how well delivered services align with customer expectations Consistently meeting these expectations is crucial for service providers, who share the same goal as tangible goods producers: to create offerings that fulfill customer needs and ensure economic viability To succeed, service providers must comprehend how customers assess service quality, their criteria for selecting one organization over another, and the factors influencing their long-term loyalty.

Service quality has emerged as a key focus in research within service organizations, initially drawing from consumer behavior and the confirmation/disconfirmation paradigm This framework posits that customers assess the quality of a product by comparing their actual experience with prior expectations, resulting in emotional responses reflected in their satisfaction or dissatisfaction Instead of applying manufacturing quality concepts, service marketing researchers have developed a distinct service quality model rooted in consumer behavior Extensive studies have shown that customers gauge service quality by contrasting the actual performance of service providers with their expectations, highlighting the importance of perceived service quality in shaping customer experiences.

The main goal of service providers mirrors that of tangible goods producers: to create and deliver offerings that meet customer needs, ensuring their economic viability To accomplish this, service providers must grasp how customers assess service quality, the criteria they use to select one hospital over another, and the factors that influence their long-term loyalty.

Customers commonly desire personalized and close relationships with service providers

Customers increasingly recognize the importance of maintaining relationships with service organizations, valuing long-term relational benefits over short-term financial gains This shift in perspective emphasizes the relational value paradigm, which encompasses the interactions between customers and employees, customers and organizations, employees and organizations, as well as service providers and intermediaries Leading service organizations are adopting this changing philosophy, highlighting the significance of loyalty and interdependent partnerships, which have garnered attention from both academics and industry leaders.

It is suggested that today’s proactive hospital organizations operate on two fundamental strategies:

(1) To exceed the expectations of patients by anticipating their needs and subsequently surprising and/or delighting them.

(2) To maintain a long-lasting relationship with patients by offering loyal service.

The success of service organizations heavily relies on the quality of service, encompassing both technical and functional aspects (Gronroos, 1984) In healthcare, technical quality is primarily assessed through the accuracy of diagnoses and procedures, while functional quality focuses on how healthcare services are delivered (Bopp, 1990).

High-quality service provision is crucial for enhancing profits, market share, and cost efficiency, as evidenced by multiple studies (Devlin and Dong, 1994) In the face of competitive pressures and the growing demand for patient satisfaction, the importance of quality control, service quality, and effective medical treatment has become paramount (Friedenberg, 1997) Research indicates a significant gap between patient expectations of treatment quality and their perceptions of the actual service received, attributed to various factors influencing service delivery (Strasser et al., 1995; Butler et al., 1996).

Service quality is often assessed by how well a service meets customer needs and expectations (Lewis and Mitchell, 1990; Dotchin and Oakland, 1994) It is conceptualized as the overall impression of service superiority or inferiority (Zeithaml, Berry, and Parasuraman, 1990), typically defined as the gap between customer expectations and their perceptions of the service received (Gronroos, 2001; Parasuraman et al., 1988) Due to the intangible nature of services, measuring service quality presents challenges, particularly in the healthcare sector However, it can be defined from various perspectives, such as "the totality of features and characteristics of a product or service that bear on its ability to satisfy given needs" (Evans and Lindsay, 1996).

Patient satisfaction is crucial for quality assurance in medical services and hospitals, yet there is a lack of empirical data on consumer acceptance of healthcare practices, particularly in Nigeria Despite the rapid changes and growing competitiveness in the Nigerian healthcare industry, comprehensive studies on this topic remain scarce To address this gap, it is essential to implement an open system business policy model in hospitals, fostering interaction between the internal and external environments to enhance patient satisfaction and service quality.

The literature reveals significant variability and confusion in the conceptualization and operationalization of quality, complicating managers' efforts to assess and enhance hospital quality amid increasing pressures Defining service quality in measurable terms proves challenging, as noted by Reeves and Bednar, who highlight the absence of a universal definition or model of quality This lack of clarity likely contributes to the unavailability of valid and reliable measurement instruments for hospital service quality According to the American Society for Quality, quality is a subjective term, with individual interpretations varying widely In technical contexts, quality encompasses two meanings: the characteristics of a product or service that meet stated or implied needs, and the absence of deficiencies in that product or service.

Reeves and Bednar identified the roots of quality as excellence, value, conformance to specifications and meeting and/or exceeding customers’ expectations Quality is recognized as a multidimensional construct.

Parasuraman et al.’s SERVQUAL Dimensions

Time Timeliness Completeness courtesy Consistency Accessibility and

Tangibles Reliability Responsiveness Assurance Empathy

Concern Medical staff Technology- Equipment Specialization / Services

Efficacy Appropriateness Efficiency Respect and Caring Safety

Source: Sower, (2001) A Review of Twenty Years of SERVQUAL Research, International

Journal of Quality and Service Sciences 1 (2).

Table 2.3 outlines the evolution of quality dimensions, initially identified by Garvin, who proposed eight key dimensions of product quality According to Garvin and Stevenson (1989) and Chakrapani (1998), these dimensions are relevant for both products and services However, implementing these dimensions in the service sector presents challenges due to the inherent differences between services and products Services are characterized as "social act(s) which take place in direct contact between the customer and representatives of the service company" (Norman 1984).

Evans and Lindsay (1988) identify eight key dimensions of service quality, enhancing the application of Garvin’s product dimensions to the service sector Despite this advancement, the lack of empirical support for these dimensions remains a notable gap in the research.

Parasuraman et al (1988) identified five dimensions of service quality, which were empirically tested and included in their SERVQUAL instrument; however, these dimensions were primarily developed in industries such as banking and telecommunications, which differ significantly from healthcare In contrast, Chakrapani (1998) proposed a more streamlined service quality model with three dimensions, aiming for simplicity and broader applicability across various organizations This focus on simplicity and generalizability may limit the relevance of these dimensions to specific sectors.

Researchers have sought to define service quality in hospitals and create tailored measurement tools Carman et al (1999) and Fottler (1997) argue that additional service-specific dimensions should complement the five SERVQUAL dimensions to fully capture patients' perceptions of quality in healthcare Minjoon et al (1998) conducted group studies that integrated the SERVQUAL dimensions with those identified by Bowers et al (1994), highlighting the need for a comprehensive approach to measuring hospital service quality.

According to Coddington and Moore (1987), consumers perceive the quality of healthcare providers based on five key factors: warmth, caring, and concern; the competence of medical staff; the availability of advanced technology and equipment; the range of specialized services offered; and the overall outcomes of care The service quality initiative emphasizes the importance of the interaction between healthcare organizations and their customers, highlighting how consumer demands shape the services provided to ensure optimal satisfaction.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (2009) identifies nine quality dimensions for hospitals (see Table 2.3) The definitions of these nine qualities are very important to this work:

The efficacy of a procedure or treatment refers to its effectiveness in addressing a patient's specific condition It measures the extent to which the care provided achieves the desired or expected outcomes for the patient.

Competitiveness in management of Mission Hospitals 61

Hospital organizations today face significant challenges due to rising competition and increasing patient expectations As service quality improves, patients' demands intensify, leading to heightened scrutiny of the care they receive This critical perspective on service quality underscores the need for hospitals to adapt and enhance their offerings to meet evolving patient needs.

Change the dominant mindset (compelling need)

Alter the goals (visions and Principles)

Restructure the Rules of engagement (strategies)

Shift the flow of information (communication)

Correct the feedback loops (learning and motivation)

Adjust the parameters (policies and procedures)

The shift towards sustainability is compelling hospital organizations to move away from traditional patient satisfaction models Instead, they are adopting proactive strategies that enable them to lead in the marketplace.

The concept of quality management has become increasingly important in the service industry, as service quality is a key differentiator and a powerful competitive advantage for leading organizations (Berry et al., 1988) Success in the service sector is closely linked to the ability to deliver superior service (Gale, 1990; Rudie and Wansley, 1984), making high-quality service delivery essential for achieving long-term success (Parasuraman et al., 1988) To foster customer loyalty, top service organizations focus on maintaining exceptional service quality (Zeithaml & Bitner, 1996) Ultimately, a service organization's success is measured by its ability to cultivate and retain a loyal customer base, with customer retention serving as a critical metric for assessing the financial impact of service quality (Zeithaml et al., 1996).

Service organizations strive to build customer loyalty, while customers seek assurance of consistent, high-quality service as evidence of the organization's commitment to excellence Delivering superior service quality is essential for differentiating a company's offerings in a competitive market and serves as a strategic advantage for leading organizations Research consistently highlights the positive impact of superior service quality on profitability and market share, underscoring its importance for long-term success.

Customer perception of service quality hinges on the alignment between their expectations and actual experiences While meeting these expectations can lead to customer satisfaction, it often falls short of establishing a competitive edge To truly delight customers, businesses must strive to provide superior service and exceed expectations, as emphasized by various researchers This approach goes beyond merely fulfilling customer needs, aiming instead to create memorable experiences that foster loyalty and differentiation in the marketplace.

Customers will remain loyal to a service organization if the value of what they receive is determined to be relatively greater than that expected from competitors (Zeithaml and Bitner,

Service quality is crucial for attracting customers to a service organization, but maintaining consistent excellence is vital for fostering customer loyalty This shift towards a long-term service strategy emphasizes the importance of delivering on service promises In today's competitive environment, understanding the lifetime value of a customer highlights the necessity of cultivating long-term customer relationships.

In today's competitive landscape, customer delight has emerged as the key to success, surpassing traditional customer satisfaction (Brown et al., 1992) With rising expectations and rapid technological advancements, service leaders must differentiate themselves by exceeding customer expectations (Kandampully, 1997) According to Timmers and Van der Wiele (1990), merely satisfying customers is insufficient for gaining a competitive edge; organizations must strive to delight them through exceptional service Achieving this level of service requires continuous innovation, transforming an organization’s dormant assets—such as technology, service processes, environment, and personnel—into significantly enhanced value for both customers and the organization.

Customers often associate exceptional service with personal interactions from employees, highlighting the significance of the human element in delivering superior service Research consistently underscores this importance, indicating that continuous service innovation further enhances the ability to provide outstanding service Additionally, the integration of technology can transform service processes, impacting employee performance and customer satisfaction.

Figure2.5 Influences on the Delight Factor

Source: Kandampully, J (1993) Total Quality Management through Continuous Improvement in

Service Industries, Unpublished Doctoral Dissertation, University Of Exeter

Customer interaction enhances the significance of the human element as a competitive advantage for organizations Service excellence is now essential to delivering superior service, forming the core of the service promise rather than being a mere value-added feature Quality has been integrated into various industries as a critical factor for achieving competitive advantage.

Quality has evolved from being a peripheral value-adding aspect of services to an essential, uncompromising component of the service promise This shift signifies that quality is now at the core of service delivery, necessitating a fundamental reevaluation and redesign of services by managers As a result, the emphasis on quality within the service package has significant implications for effective service management.

In today's service economy, the significance of relationships surpasses that of physical products, impacting both our professional and personal lives (Albrecht and Zemke, 1985a) Business fundamentally revolves around relationships (McCormic, 1988), and in service industries, these connections are characterized by interactive processes (Booms and Bitner, 1981).

Figure 2.6 Quality as the core service

Source: Kandampully, J (1993) Total Quality Management through Continuous Improvement in

Service industries focus on offerings that assist and fulfill customers' personal needs, fostering relationships between customers and service providers (Parasuraman et al., 1991c) Emotion plays a crucial role in the service delivery process, significantly influencing customers' perceptions of service quality (Kandampully, 1993) This emotional connection is fundamental in establishing lasting relationships, encouraging customers to return or remain loyal to a particular service provider (Butz and Goodstein, 1996).

The challenge for today’s organizations is not merely to reach the top, but to stay there.

To achieve long-term success, organizations should prioritize building customer loyalty over merely attracting new customers This loyalty stems from a sustained relationship that relies on the organization's ability to nurture and extend connections with its customers As Levitt (1983) suggests, the dynamics of buyer-seller interactions resemble a marriage, where the relationship's quality and longevity are determined by how effectively the organization manages it Strong customer-supplier relationships are crucial for surpassing customer expectations, ultimately leading to 'service loyalty' and granting the organization a competitive edge in service excellence.

Almost all business interactions are conceived as relationships between the firm and the customer; maintaining this long-term relationship is the true indicator of the firm’s success.

In many business scenarios, long-term relationships between service providers and customers are rare, as these connections often prove to be short-lived Companies, anticipating customer loss, focus on attracting more clients than they can realistically nurture This approach results in a system where only half of the customers receive services that meet their expectations, leading to dissatisfaction and eventual turnover among the other half.

Customers engage with businesses expecting reliable service and a positive experience, as they inherently value loyalty in their relationships When seeking services, they aim to establish connections due to the unique characteristics of services, such as intangibility, inseparability of production and consumption, heterogeneity, and perishability This desire for a relationship stems from the understanding that it ensures service reliability and meets both their current and future needs.

Environmental Analysis and Challenges of Adopting Business Policy Models in Mission Hospitals 86

BUSINESS POLICY MODELS IN MISSION HOSPITALS

Internal and External Environmental Analyses

The organizational environment encompasses all external elements that can influence the organization, highlighting its infinite nature beyond internal boundaries Understanding this environment is crucial, as it includes various factors that can impact the organization's operations and success.

The hospital business environment encompasses all external forces and factors that can influence the organization Understanding these elements is crucial for navigating the complexities of healthcare management and ensuring effective operations.

According to Churchman (1968), the environment is defined as the external factors that exist outside an organization or system, which significantly influence its performance He emphasizes that this environment is beyond the organization's control and serves as a fixed constraint, yet it plays a crucial role in achieving the organization's objectives Understanding the environment is essential for organizations as it shapes their operational effectiveness and overall success.

According to Farnhain (1994), the external organizational environment encompasses all elements outside an organization's boundaries that can influence its operations Kazimi (2005) describes this environment as complex, dynamic, and multifaceted, emphasizing that its significant impacts necessitate that organizations prioritize their environmental considerations to ensure long-term survival.

The environment of a hospital encompasses all external elements, institutions, systems, and forces that influence its operations, including customers, creditors, government entities, socio-cultural organizations, political parties, and both national and international organizations These environmental factors present both threats and opportunities, impacting the hospital's performance Organizations that can recognize and leverage these opportunities can enhance their strengths and achieve their objectives more effectively, while threats represent challenges that may hinder their ability to succeed.

Environmental factors influence organizations by imposing limits and presenting opportunities and challenges These limits can pose threats, highlighting the mutual dependency between organizations and their environments Organizations rely on external resources, while the environment depends on them for products and services.

Environment when considered on the basis of the extent of intimacy with the firm, the environmental factors may be classified into different types of internal and external environment.

The internal environment significantly influences a business, as it encompasses controllable factors such as personnel, physical facilities, and organizational structures Companies can adjust these elements to align with their operational needs Key internal factors impacting business policies and decisions, as outlined by Koontz (2004), play a crucial role in shaping the effectiveness of internal organizations.

The value system of founders and leadership significantly influences the selection of business ventures, the organization's mission, objectives, and its policies and practices.

A clear vision, characterized by imaginative and wise foresight, is crucial for an organization's success in achieving its objectives The mission serves as the pathway through which these objectives are realized, highlighting the interconnectedness of vision, mission, and goals in organizational development.

The management structure of an organization significantly impacts its business policy adoption and decision-making processes Factors such as the composition of the board of directors play a crucial role in shaping policy models and decisions, as these are internal influences Additionally, the organizational structure and style can either hinder timely decision-making or facilitate swift resolutions, affecting overall business efficiency.

 Internal Power Relationship: - The relationship among the three levels of the organization

The adoption of business policy models is influenced by the interactions at the top, middle, and lower levels of an organization Effective coordination among employees across these three organizational tiers is essential for successful implementation.

Human resources are crucial to an organization's success, as they significantly influence its strengths and weaknesses Essential characteristics of effective human resources include skills, quality, high morale, commitment to work, and a positive attitude The level of involvement and initiative displayed by employees can vary across different organizations, highlighting the importance of fostering a supportive work environment.

The external environment refers to the indirect factors that influence an organization, which are beyond its control (Johnson, 2000) Understanding this environment involves analyzing the organization's domain, which is the specific field of action it has chosen regarding its products, services, and markets This domain not only defines the organization's niche but also outlines the external sectors it will engage with to achieve its objectives.

The environment consists of various sectors, each containing similar elements that can be analyzed for any organization These ten sectors include industry, raw materials, human resources, financial resources, market, technology, economic conditions, government, socio-cultural factors, and international influences Understanding these sectors is essential for assessing the organizational domain effectively.

Source: Lynch, J.J (1997) Customer Loyalty and Success in an Environment, London: MacmillanPress

(a) Competitors, industry size and competitiveness, related industries,

(b) Suppliers, manufactures, real estate, services.

(c) Labor market, employment agencies, universities, training schools, employees in other companies, unionization,

(d) Stock markets, banks, savings and loans, private investors,

(e) Customers, clients, potential users of products and services,

(f) Techniques of production, science, computers, information technology, e-commerce,

(g) Recession, unemployment rate, inflation rate, Rate of investment, economics, growth,

(h) City, state, federal laws and regulations, taxes, services, court system, political processes,(j) Competition from and acquisition by foreign firms, entry into overseas markets, foreign customs, regulations, exchange rate

The micro environment, also referred to as the task or operating environment, directly influences a firm's operations and performance (Johnson, 2000) It encompasses the immediate actors that interact with the organization, such as suppliers, marketing intermediaries, competitors, customers, and the public, all of which significantly impact the organization's ability to achieve its goals Unlike macro factors, micro environmental elements are more closely linked to the organization, highlighting the importance of understanding this environment for effective business strategy (Griffin, 1996).

Influence of Stakeholder Business Policy Model in Supply Chain Management 106

There have been many definitions and variations of the term Supply Chain Management (SCM) in the literature, and some definitions include Supply Chain Integration (SCI)

Supply Chain Management (SCM) is defined by Cooper and Ellram (1993) as an integrative philosophy that oversees the entire flow of a distribution channel, connecting the supplier chain to the end user According to Bowersox et al (1999), the primary mission of SCM is to efficiently and effectively manage the sourcing, production, and delivery of products and services, along with relevant information, from the point of origin to ultimate consumption, thereby maximizing value for the end customer.

Morey (1997) highlights the essential management functions within supply chain management, defining it as the strategic process of planning, organizing, and controlling the flow of materials and services from suppliers to end users or customers This integrated approach ensures collaboration with suppliers to optimize efficiency and effectiveness throughout the supply chain.

G ov er nm en Te ch no lo gy C us to m er s E m pl oy ee s E co no m ic So ci et y

In today's competitive global market, companies are increasingly prioritizing their supply chains, which serve as the foundation for inter-network competition According to Mentzer et al (2001), a supply chain encompasses a network of organizations engaged in the flow of products, services, finances, and information from source to customer This intricate system includes both upstream suppliers and downstream entities, such as retailers and financial consumers, highlighting the complexity of modern supply chains (Desouza et al 2003).

Supply chain integration refers to the extent of interconnectedness among an organization and its suppliers, customers, and other members of the supply chain According to Kim and Narasimhan (2002), it establishes a cohesive link by unifying relationships, activities, functions, processes, and locations among all parties involved This integration is essential for enhancing collaboration and efficiency within the supply chain.

Internal and External Supply Chain Integration

To achieve long-term success, organizations must prioritize both internal and external integration, as highlighted by Daugherty et al (1996) and Bowersox and Closs (1996) They assert that sufficient integration is essential for meeting fundamental business objectives However, many experts recommend that companies should first focus on integrating their internal supply chains before attempting to pursue external integration with their business partners.

Internal supply chain integration refers to the level of collaboration among the internal functions of all trading partners within the supply chain, as highlighted by various studies (Stevens, 1989; Carter and Narasimhan, 1996; Narasimhan and Carter, 1998; Birou et al., 1998; Wisner and Stanley, 1999).

“the effort required to identify key functional activities and their interrelationships has caused many companies to change from integrating and managing supply chains by functions to

External integration involves the collaboration between an organization and its key suppliers and customers, as highlighted by Lambert et al (1998; 1996) This integration with suppliers refers to the level of coordination between manufacturers and their upstream partners (Stevens, 1989; Narasimhan and Jayaran, 1998; Frohlich and Westbrook, 2001) Similarly, external integration with customers pertains to the degree of coordination between manufacturers and their downstream customers (Kim, 2002; Frohlich, 2002).

Benefit of Supply Chain Integration

Supply chain integration offers several key benefits that enhance business operations, as identified by Fawcett and Magnan (2001) and further explored by Fawcett, Magnan, and McCarter (2008) The primary advantages include the ability to respond effectively to customer requests, ensure on-time delivery, and improve overall customer satisfaction Additionally, it contributes to reduced order fulfillment lead times and lower costs of purchased items, ultimately boosting firm profitability Furthermore, integrated supply chains enable companies to better handle unexpected challenges and manage inventory costs efficiently.

(9) overall product cost, (10) productivity, (11) overall product quality, (12) transportation costs,

(13) market penetration, (14) product innovation lead times, and (15) cost of new product development.”

Health Care Supply Chain Integration

Limited hospital budgets lead to supply chain inefficiencies that hinder the availability of crucial therapies According to Hersch and Pattigrew (2002), a more efficient supply chain can enhance financial outcomes while decreasing the administrative burden on healthcare workers, enabling them to concentrate on quality patient care Additionally, group purchasing strategies may lower hospital supply chain costs by 5% to 15%.

This study evaluates business policy models in the management of mission hospitals in South East Nigeria, highlighting the significant pressures these hospitals face to enhance productivity, innovation, and effectiveness To improve operational efficiency, it is crucial for these institutions to develop and implement appropriate business policy models, enabling them to achieve and maintain high performance A theoretical framework combining the open system model and the stakeholders’ model was established for this purpose The open system model illustrates the interaction between hospitals and their environment, emphasizing the importance of input reception and feedback mechanisms Conversely, the stakeholders’ model underscores the vital role stakeholders play in shaping organizational policies, implementation, and outcomes.

The article emphasizes the significance of understanding the external environment of hospital organizations, which encompasses all factors outside the organization that can impact its operations This environment is categorized into three segments: internal, task, and general environments, with a particular focus on the task and general environments The general environment includes four key components: political, economic, socio-cultural, and technological factors The literature review indicates that while these components are often treated as separate entities, their interactions and overlaps make it challenging to define clear boundaries among them, highlighting the complexity of the hospital's external influences.

The review identified key environmental factors that define the hospital setting, presenting both challenges and opportunities for business policy implementation It emphasized that organizations must adapt to environmental changes by either adjusting their resources, capabilities, and strategies or by influencing the external environment to better align with their needs.

This review revealed that while prior research in hospital management often points to corrupt practices, financial shortcomings, and embezzlement as the root causes of performance issues in the health sector, both public and private, this study identifies mismanagement and the inadequate adoption and implementation of business policies as the primary factors contributing to these inadequacies.

Previous studies have overly focused on bureaucratic management, neglecting the importance of hospital environments and stakeholder involvement, which has hindered the evolution of management practices This study introduces open system and stakeholder business policy models that foster communication, collaboration, and team spirit within hospital organizations Such collaborative efforts help manage environmental uncertainties and complexities, promoting a shift towards sustainability and high-performance management Key indicators, including service quality, operational sustainability, competitiveness, human resource management, and improved supply chain management, were evaluated to assess the effectiveness of these models Service quality, a critical measure of how well services meet customer expectations, encompasses efficiency, respect, timeliness, and availability of necessary treatments, making it a vital competitive advantage for leading organizations.

Previous studies on hospital management primarily focused on closed system models, which often resulted in bureaucratic bottlenecks, communication gaps, and a lack of involvement from various stakeholders In contrast, implementing open system and stakeholder-driven policy models has been shown to enhance communication and foster collaboration, both internally and externally This shift promotes competitiveness, leading to improved service quality, effective cost control, increased innovation capacity, and better human resource management By prioritizing collaboration, synergy, and team development, hospitals can achieve high-performance management and an enhanced quality of work life.

Albrecht, K and Zemke, R (1985a) Instilling A Service Mentality: Like Teaching An Elephant to Dance, International Management, November, 40(1).

Alade, et al (2004, March) Role of Supply Chain Management Decisions in Effective Inventory Control, Journal of the Academy of Business and Economics, 4(1).

Alter, C., and Hage, J (1993) Organization Working Together, Newbury Park: Sage.

Anderson, G and Sotir Hussey, P (2006) Influencing Government Policy, in Pencheon D, Guest C,; Melzer D; and Muir Gray J.A ( Eds) Oxford Handbook of Public Health, London: Oxford University Press.

Armstrong, M (2006) Human Resources Management, London: Kogan Page.

Baily, P., et al (1998) Purchasing Principles and Management, Essex: Financial Times/ Prentice- Hall.

Barratt, M (2004) Unveiling Enablers and Inhibitors of Collaborative Planning, International

Basu, R., and Wright, J.N (2008) Total Supply Chain Management, Oxford: Elsevier.

Begun, J W and Kaissi, A.A (2004) Uncertainty in Health Care Environment Myth or Reality?, Health Care Management Review, Vol 29(1).

Beller, J (2009) Adopting Sustainability for Better Workplace Performance, Bpoise Metro

Bell, C.R (1993) In Customers We Trust, Executive Excellence, (10).

Berry, L (1987) Big Ideas in Services Marketing, The Journal of Services Marketing, 1(1),

Berry, L.L and Parasuraman, A (1992) Prescriptions for a Service Quality Revolution in

Berry, L.L., Parasuraman, A and Zeithaml, V.A (1988) The Service Quality Puzzle, Business

Berry L.L., and Parasuraman, A (1991) Marketing Services: Competing through Quality, New York: Free press.

Bertalanffy, L (1951) General Systems Theory: A New Approach to Unity of Science, Human

Birou, L.M (1998) The Product Life Cycle: A Tool for Functional Strategic Alignment;

International Journal of Purchasing and Materials Management, 34(2).

Bloomberg, D.J (2002) Logistics, New Jersey: Prentice-Hall Inc.

Booms, B.H and Bitner, J (1981) Marketing Strategies and Organization Structure for Service

Firms, New York: Ama Services.

Booms, B.H and Nyqui St, J (1981) Analyzing the Customer/Firm Communication Component of the Service Marketing Mix In: J.H Donnelly and W.R George (Eds), Marketing ofServices, New York: Ama.

Brown, W.S., Bowen, D.E and Swartz, T.A (1992) The Future of Quality in Services, Paper

Presented At The Quality in Services Quis-3 Conference, Karlstad University, Sweden.

Brunell, K Kelley, E and R Amesan, J (1992) A Framework for Using the Voice of the

Customer to Design Services, Center For Services Marketing And Management, Florida

Bowers, M.(1994) What Attributes Determines Quality and Satisfaction with Health Care Delivery? Health care Management Review Vol 19 (4).

Bowersox, D.J and Closs, D.J (1996) Logistical Management – The Integrated Supply Chain

Process, New York: McGraw-Hill.

Bowersox, D.J.; Gloss, D.J.; and Stank, T.P (1999) 21 st Century Logistics: Making Supply Chain Integration a Reality, Oak BrokIL: The Council of Logistic Management.

Brinkerhoff, D W (1991) Improving Development Program Performance, Colorado: Lynne Reiner Publishers.

Brunell, J (1999) Technology should Support, not Lead, Automatic I.D News, 15.

Burns N and Groove S.K (2003) Understanding Nursing Research, Philadelphia: W.B. Saunders Company.

Burt, D.N., Dobbler, D.W.; and Starling, S.L (2003) World Class Supply Management- the Key to Supply Chain Management, New York: McGraw-Hill/Irwin.

Butz, H.E Jr and Goodstein, L.D Jr (1996) Measuring Customer Value: Gaining the Strategic

Buzzell, R.D and Gale, B.T (1987) The Pims Principles, Linking Strategy to Performance, New

Byrnes, J (2004) Fixing the Healthcare Supply Chain: Working Knowledge, Harvard Business

School Newsletter, retrieved April 12, 2011, from http://hbsek.edu/dispatch.jhtml? t=dispatch.

Cannon, J.P., and Homburg, C (2001) Buyers-Suppliers Relationships and Customer Firm Costs, Journal of Marketing, 65 (1).

Carman, J (1990) Consumer Perceptions of Service Quality: An Assessment of the SERVQUAL Dimensions, Journal of Retailing Vol 66 (1).

Carman, J.M (1970) Correlates of Brand Loyalty: Some Positive Results, Journal of Marketing

Caroll, A B (1989) Business and Society: Ethics and Stakeholder Management, Ohio: South

Carr, A.S., and Pearson, J.N (1999) Strategically Managed Buyer-Supplier Relationships and Performance Outcomes, Journal of Operations Management, 17

Carter, J.R., and Narasimhan, R (1996) Purchasing and Supply Management: Future Directors and Trends, International Journal of Purchasing and Materials Management, 32(4).

Chandra, V (2000) Supply Chain Analysis and Management, Management Review, Vol 12(1). Chrislip, D.D., and Larson, C.E (1994) Collaborative Leadership, San Francisco: Jossey-Bass Christensen C.R, (1982) Business Policy – Text and Cases, Homewood: Richard D Irwin.

Christopher, M., and Ryals, L (1999) Supply Chain Strategy: Its Impact on Shareholder Value,

The International Journal of Logistics Management, 10(1).

CIPS (2007) Supply Chain Management, Retrieved on April 15, 2011, from http://www.cips.org/ documents/supply_chain_management.pdf.

Coddington, D and Moore, K (1987) Quality of Care as a Business Strategy: How Customers Define Quality and How to Market it, Health Forum Vol 30(2).

Cook, C and Thompson, B (2000) Higher-order Factor Analytic Perspectives on Users Perceptions of Library Service Quality, Library Information Science Research, Vol 22.

Cooper, M C and Ellram, L.M (1993) Characteristics of Supply Chain Management and the Implications for Purchasing and Logistics Strategy, International Journal of Logistics

Cox, A (2004) The Art of the Possible Relationship Management in Power Regimes and Supply Chains, Supply Chain Management, An International Journal, 9(5).

Cox, A., Sanderson, J., and Watson, G (2001) Supply Chains and Power Regimes: toward an Analytic Framework for Managing Extended Networks of Buyer and Supplier Relationships, Journal of Supply Chain Management, 37(2)

Crosby B.L (1991) “Stakeholder Analysis: A Vital Tool for Strategic Managers”, USAID’s

Implementing Policy Change Project Publication, March.

Retention, and Prices in the Life Insurance Industry, Journal of Marketing Research, 24.

Delaney, B (1999) 10 th Annual ‘State of Logistics Report, St Louis, MO: Cass Information

Dershin, H (2000) Business Process Design-Completing the DNA, Supply Chain Management Review, Vol 4(2).

Devlin, S.J and Dong, H.K (1994) Service Quality from Customers Perspective, Marketing

Donaldson T And Preston L.E (1995) The Stakeholder Theory of the Corporation: Concepts, Evidence, and Implications, Academy of Management Review, Vol.20, No.1.

Doppelt, B (2000) Overcoming the Seven Sustainability Blunders, The System Thinkers, Vol.14 (5).

Dotchin, J.A and Oakland, J.S (1994a) Total Quality of Management in Services Quality,

International Journal of Quality and Reliability Management, Vol II (3).

Dessler ,G (1998) Human Resource Management, New Delhi: Prentice Hall.

Drucker, P (1954) The Practice of Management, New York: Harper and Row.

Effken, J (2002) Different Lenses, Improved Outcomes: A new Approach to the Analysis and Design of Healthcare Systems, International Journal of Medical Informatics, 65.

El-Namaki, M.S.S (1992) Creating a Corporate Vision, Long Range Planning, Vol 25, No.6. Ettorre, B (1994) Phenomenal Promises that Mean Business, Management Review, 83.

Evans, J.R and Lindsay, W.M (1996) The Management and Control of Quality, WestPublishing Company.

Fawcett, S.E., and Magnan, G.M (2002)The Rhetoric and Reality Of Supply Chain Integration,

International Journal of Physical Distribution and Logistics Management, 32(5).

Fawcett, S.E., Magnan, G.M., and McCarter, M.W (2008) Benefits, Barriers, and Bridges to Effective Supply Chain Management, Supply Chain Management, An International

Filley/House/Ken (1976) Management Process and Organizational Behaviour, Scott: Foresman Company III.

Description of Research Instrument 140

This study utilized questionnaires and oral interviews as data collection instruments, specifically designed to meet the study's objectives The questionnaire featured a five-point Likert scale and was divided into two sections: Part A focused on the respondents' profiles, while Part B contained questions aligned with the study's goals Additionally, oral interviews were conducted to gather more in-depth information from the management and staff of the mission hospitals.

Validity of the Instrument 140

Validity, as defined by Onwumere (2005), refers to how effectively a measuring instrument fulfills its intended purpose To guarantee the validity of the research instrument, the researcher focused on measuring the relevant concepts with input from management experts at four selected mission hospitals Their feedback and preliminary analysis were instrumental in refining and enhancing the instrument.

Reliability of the Instrument 140

The reliability of an instrument is assessed by its consistency in measuring target attributes To evaluate this reliability, a test-re-test method was employed, involving the distribution of 25 questionnaires to mission hospitals, which were then collected and redistributed The reliability analysis was conducted using Cronbach’s Alpha, yielding an impressive Alpha of 0.980 and an inter-item standardized coefficient of 0.993 Both values exceed the threshold of 0.7, confirming that the test instrument is highly reliable and valid (Refer to the Appendix for detailed results.)

Methods of Data Analysis 141

Data analysis involved both simple and statistical treatments, organized in tables and percentages Various statistical techniques were employed to test the hypotheses, including the Friedman Chi-square for hypotheses 1, 2, and 3, which compares observed and expected data Hypothesis 4 was assessed using one-way ANOVA to evaluate relationships between multiple variables, while hypotheses 5 and 6 were analyzed with the Z-test to compare sample and population means for significant differences.

All the test tools were applied using statistical package for social science (SPSS) windows software analysis.

Kumar, R.S (1976) A Manual of Sampling Techniques, London: Heinemann Limited.

Orji, J (1998) Business Research Methodology, Enugu: Meteson Publishing Company.

Uzoagulu, A.E (1998) Practical Guide to Writing Research Project Reports in Tertiary

Institutions, Enugu: John Jacob’s Classic Publishers Limited.

Yamane, T (1964) Statistics: An Introductory Analysis, London: Harper and Row.

PRESENTATION, ANALYSIS AND INTERPERTATION OF DATA

This chapter presents, analyzes, and interprets the data gathered for the study The findings are illustrated using frequency and percentage tables, along with pie and bar charts Statistical analysis of the collected data was conducted in line with the research hypotheses, and the results were interpreted accordingly.

Table 4.1 Questionnaire Distribution and Response

Unsuccessfully Filled and Not Returned 40 10.67

Source: Field Survey, 2010 copies of the questionnaire were distributed, out of which, 335 representing 89.33 percent were successfully filled and returned, while 40 representing 10.67 percent were unsuccessfully filled and not returned

Table 4.2 Distribution of Respondents by Gender

Figure 4.1: Pie chart representing respondent’s gender selected mission hospitals in the South-East, Nigeria

Table 4.3 Age Distribution of Respondents

Figure 4.2: Bar Chart of Age

Table 4.3 reveals the age distribution of respondents, indicating that 24 individuals (7.16%) are aged 20-30 years, 134 (40%) are between 31-40 years, 87 (25.97%) fall within the 41-50 age range, 58 (17.31%) are aged 51-60 years, and 32 (9.55%) are 61 years and older This data suggests that the majority of respondents belong to the 31-40 age group.

Table 4.4: Educational Qualification of Respondents

Figure 4.3: Bar chart representing qualification of respondents

According to Table 4.4, the educational qualifications of the respondents reveal that 8.66% hold senior school certificates, 22.69% possess OND or HND certificates, and 42.99% have a Bachelor's degree Additionally, 14.33% of the respondents have obtained a Master’s degree, while 5.07% hold a doctorate degree Furthermore, 6.27% of the respondents possess other health-related certificates.

Table 4.5: Marital Status of Respondents

According to a field survey conducted in 2010, 29.25% of respondents were single, while 26.57% identified as clergy, including Rev Fathers, Pastors, Rev Brothers, and Rev Sisters Additionally, 3.58% were divorced and 3.88% were widowed The data indicates that the majority of respondents were married.

Table 4.6: Work Experience of the Respondents

According to Table 4.6, a significant portion of respondents, 156 (46.57%), have served between 6 and 10 years in their positions Additionally, 79 respondents (23.58%) have experience ranging from 11 to 15 years, while 67 respondents (20%) have served less than five years Only 10 respondents (2.99%) have been in their roles for over 20 years.

Table 4.7: ORAL INTERVIEW RESPONSES were interviewed, out of which 20(15.3%) were doctors, 60(45.8%) were nurses and 51(38.9%) were other paramedical personnel’s.

Analysis of the Likert Scale Objective-Based Questions

The questionnaire utilized a five-point Likert scale for evaluation According to the guiding interpretations, a mean score below 2.5 indicates a strong agreement among respondents, reflecting a significant extent of consensus.