Background

In recent years, prompt public strategic planning has revolutionized, and public strategic planning has become more complex (1). Implementation of strategic planning is primarily defined as interaction and coordination (2, 3) and, practically, the collaboration between external and internal elements of the government body (4). On the other hand, the separation between politics and management has always been a controversial and undefined issue (5, 6). The traditional approach to management has caused the implementation of strategic planning to become a missing link (4). Today, the new approach to policy-making by policy-makers and its implementation by government managers is not a hierarchical relationship, includes mutual negotiation and collaboration (7), and can be considered as a facilitated interaction and collaboration between elected and governmental managers and has resulted in the dichotomy's evolution (1).

Several studies have been conducted to assess the effective implementation of strategic planning in health, including a study by Masoumi et al conducted to develop a template for assessing the effective implementation of health care policies. Their results demonstrated that the influential factors in implementing policies included popular culture, construction, awareness raising, strategy quality, style and implementation method, laws and legislations, budget allocation, competent human resources, and environment (8). Livani et al investigated key requirements of implementing strategic planning of medical tourism in Golestan Province, reporting
5 major factor categories: organizational design, capacity building, the quality of services, strategic planning system, and advertisement and branding (9).

Suppose the collaboration of stakeholders (those who are influential and the influenced ones) is not considered in strategic planning. This can lead to the inefficiency of strategies in addressing shortcomings. However, their contribution can lead to sharing knowledge and useful information, as well as establishing a foundation for long-term improvement and achieving the desired goals (10).

Recently, collaborative management has been hailed as an effective approach to minimizing conflicts (11). As a desired and efficient system, this management system has passed several theoretical and practical tests and is currently completely implemented in developing and developed countries (12). Euler and Heldt proposed that collaborative management can effectively lead to the democratization of processes and higher decision-making qualities beyond collaboration and the promotion of self-organization strategies (13). Collaborative management and democracy in work can promote the performance of employees. In this regard, several studies have demonstrated that collaborative management can minimize absenteeism and reduce the request to change the workplace (14, 15). Based on a meta-analysis, Petty et al demonstrated a significant relationship between staff job satisfaction and performance in collaborative management (16).

Collaboration is essential in organizations. The decisions made in organizations today are more complex and interlinked and demand teamwork. Moreover, staff contribution is not only confined to utilizing their information, but using the knowledge and experience of staff as advisory positions are crucial in any organization (17). Despite wide acceptance, there are several oppositions to collaborative management. Generally, research findings demonstrate that productivity increases by 30% to 40% with the collaboration of the employees. This approach is very popular in developed countries. Besides increasing productivity, this approach can promote 2 humane values: freedom and autonomy (18, 19). Considering the complete implementation of the strategic plans in health care, as well as the effect of multifactorial elements (such as different complexities in their implementation), it is necessary that involved teams need to collaborate for their effective implementation more than ever. Currently, although the importance of benefitting from the expert opinion and those who are prominent in health care in this field is clear, there is no template involving all necessary dimensions and elements. The objective of the current study was to reflect the participants’ opinions in defining the role of collaborative management in implementing health care strategies and defining a paradigm based on their input in the health system.

Objectives

This study aimed to define the roles of distinct elements of collaborative management in implementing health care strategies.

Methods

This qualitative research was based on the background theory. The primary objective of the background research theory is an in-depth analysis of individuals’ or groups' occupational behaviors, ideas, and attitudes. This can lead to better recognition of phenomena, dimensions, and related elements. In contrast to research methods designed to describe phenomena, the primary objective of the background theory is the development of theory (20). The rationale for using this approach in the current study was to illuminate defining elements and dimensions effective in implementing strategic planning in health care. This study was conducted based on the participants’ experience in their fields of activities in the health care system. Moreover, the research question “Which influential elements can be effective in collaborative management in implementing strategic health planning?” was considered. The current research was designed and implemented based on the background theory with Charmaz’s constructionist approach (21).

The field of study was the Kerman University of Medical Sciences and the Islamic Azad University of Kerman in Iran. Inclusion criteria were having experience and managerial positions in health care (including middle- and high-ranking managers). Moreover, they agreed to be interviewed, and written informed consent was obtained. Based on the qualitative research method, the sampling commenced with a targeted sampling and was continued based on the targeted snowballing sampling approach. It is noteworthy that in the analysis process, based on the theoretical sampling for addressing the identified gaps, several managers of the eighth region of Sistan and Baluchestan, and Kerman Provinces education were added to the study. Data gathering was continued until theoretical saturation was achieved.

Data Collection

Data were collected through 40 semi-in-depth
and semi-structured interviews (23 face-to-face and
17 online interviews), as well as through a review of overarching documents in the health care system's strategic planning field. The interviews were conducted in person or online using WhatsApp in Kerman. The interviews lasted 35 to 55 minutes. After analyzing the first interview, 12 participants were interviewed for a second time. Participants’ views were initially collected through open questions. Then, the explanations of the interviewees’ advantages and disadvantages, dimensions, influential and influenced circumstances, processes, backgrounds and frameworks, and requirements for the implementation of collaborative management in line with implementing health care strategies, organizations, and the involved units and their responsibilities were obtained through closed questions; the interviewees were given the opportunity for complementary explanations. Concurrent with data gathering and data analysis, notes and field notes played a key role in identifying the elements of collaborative management in implementing health care strategic plans.

The data were analyzed using Charmaz’s constructionist approach (21). The analysis process was started by scripting the interviews and observations and continued by entering the information into Word software 2019 (Microsoft, Washington, US). Then, the interviews were reviewed line-by-line, and the primary free codes were extracted from them. These primary free codes were written in conceptual and meaning subgroups. Gradually, the recorded codes were expanded, and with the addition of each interview and observation, more diverse subgroups were formed. Subsequently, in the centralized coding stage, the researchers classified the subgroups under the main categories. Then, the results were presented to the interviewees to ensure all necessary amendments were made. Ultimately, in the last stage of data analysis, using fixed comparison methods, the collaborative management elements influential in the effective implementation of health care strategic plans in
5 dimensions, including 12 main areas, 42 subareas, and 396 free codes, were identified (Figure 1).

Validity and Reliability of the Study

The researchers used 5 criteria of Guba and Lincoln (credibility, transferability, confirmability, and dependability) to strengthen the data (22). In any subject, long-term collaboration is a suitable validation method. Analysis of the members is another suitable data validation approach. Therefore, the researcher
sent the scripted interviews to the interviewees using email or WhatsApp to ensure accurate descriptions
and similar comprehension of the concepts. Using a
3-dimensional approach in data collection (which included interviews, observations, field notes, and documents) increased the credibility of the research. Sampling with maximum diversity (age, gender, education, and related management experiences) was used to maximize the findings’ validity and develop more expanded information. For data analysis, first, the first researcher scripted, coded, and evaluated the interviews. Then, a second researcher analyzed these items independently. Next, a third researcher coded and analyzed the data as an expert in qualitative research.

Results

Forty participants participated in the interview; 38 were faculty members of medical universities, 14 were professors, 11 were associate professors, 10 were assistant professors, and 2 were non-faculty members. Twenty-four participants were male, and 16 (40%) were female. The mean age of the male and female participants was 46.0% and 36.5%, respectively. Moreover, 38 were married, and 2 were single. The participants’ educational background was diverse and included medical doctorate, pharmacy, dentistry, different branches of management, policy-making, pathology, economy, nursing, and medical engineering.

As tabulated in Table 1, 396 free codes, 42 subcategories, and 12 major categories were extracted.

Causal Conditions

Considering data analysis, 2 major categories of facilitators and inhibitors of the implementation were categorized as the causal subgroups (influential in the major category). There is a constellation of factors that lead to the effective implementation of collaborative management and facilitates its implementation. On the other hand, the resistance of managers and staff in implementing this approach, deviation of the goals and personal and organizational efforts, neglecting employment of clinicians when necessary, misunderstanding among the employees, and so on were obstacles hindering the implementation of collaborative management.

Participant 2 stated, “The current complex situation faced by the Ministry of Health and Medical Education is among factors that demand the contribution of diverse teams with unique skills.”

Also, participant 1 claimed that:

We should be realistic and flexible. Today, rigid and mechanical organizations cannot meet new demands. Considering future scenarios, it is necessary to be flexible based on the organization's strategic plan type and characteristics. We need to exploit the input of internal and external stakeholders and the latest technologies.

Participant 4 said, “The collaborative approach, which has different applications for financial, human, and information resources, should be exploited from higher to lower levels, but there are problems that managers do not accept.”

Strategies

Particular actions and interactions are necessary for implementing collaborative management. The first step for its implementation in health care organizations is to create the context. According to the analysis of interviews, “the provision of executive, information, communication, and cultural prerequisites” are among the subcategories identified in the provision of the context for implementing collaborative management.

In this regard, participant 13 said, “For implementing the plan, we need to employ skilled and experienced personnel, and without effective laws and legislations, it cannot be realized, as in that case, it has no robust foundation.” Participant 10 stated, “We need to identify successful models to exploit their experiences.”

The second stage in implementing collaborative management in health care organizations is the design and development of a comprehensive and documented plan for implementation of the collaborative management plan with subcategories of “designing strategies and legislations, designing of educational content for implementation, designing organization communications, designing a style for collaboration, designing the executing section, and the principles of collaboration principles design.”

Participant 13 claimed that “Short-term political considerations can undermine the implementation. Long-term overarching policies governing all strategies should not be conflicting, and they need to be in the same direction.”

Also, participant 10 said:

Based on the existing context, the best content should be included in the best process, and the achievement of the best outcomes follows. Similar to the current situation in which, although we know what we desire, it is still elusive.

Effective implementation using an expert team is one of the most important categories and the third identified stage in the achievement of collaborative management, which can be realized.  

“Proper classification, the contribution of experts in the implementation, proposing strategies and their implementation, transferring responsibility, executive content, forging communications based on collaboration, implementation process, assigning the collaborating units, and holding meetings.”

Participant 8 stated that:

Project groups and target groups should be designed, and the opportunity for collaboration and contribution and consultation should be provided, communication should be facilitated, job security should be provided, and obligations and commitments of collaboration need to be provided. The requirements need to be documented, and the decision-making process should be designed to allow the contribution of all. Ideas and opinions should be accepted and assessed.

Participant 11 added, “We need to employ experts in implementing this plan; generally, contributions that exclude experts and elites will be of no use.”

Proper evaluation of the implementation and necessary amendments for completion of the process and its continuation is necessary, and the fourth recognized stage. “Evaluation, giving and receiving feedback, implementation of the amendments, and support for repeat and repeated actions” are subcategories related to this major category.

Participant 3 said, “After execution, we can seek the opinions of the executors and stakeholders and observe the deficiencies from their viewpoints; after that, we should make necessary amendments,” and participant 12 stated that “If we can have ongoing evaluation along with the amendments, we can achieve our goals sooner.”

Table 1. Free Codes, Subcategories, and Main Categories of the Present Study

Background Conditions

Special environmental conditions can influence strategies. Two major categories of “facilities and environmental conditions and environmental culture” were defined in this context. Three subcategories
of “current information situation, the condition of the current facilities, and the condition of the environment for the environmental conditions subcategories” were identified.

Participant 14 said, “The current economic and social conditions do not allow us to implement flexible projects, particularly because there are no proper laws and legislations in this regard.”

The identified subcategory related to the major category of environmental culture was “organizational culture, employee’s culture, and the current communication conditions.”

Participant 1 stated, “The organizational atmosphere that facilitates collaboration or has a successful experience in collaboration, the reward participants receive, and the motivation that is generated are among influential background factors.” Participant 19 said, “The style and manner of thinking of managers and health care personnel are very important. Considering experiences and evidence is very important; we should have a systemic view and be holistic.”

Mediating Conditions

These are general conditions that influence strategies. Two major categories of “documentation style (with subcategories of documentation gap and implementation and strategic planning) and implementation method (with subcategories of implementation type and speed)” were identified in this line.

Participant 9 said, “In implementing projects, meetings should be well-organized, meetings should be held promptly, and the teams should match one another, and managers should follow the implementation process.” Further, participant 4 believed that “If there are no discussions and interactions, there would not be any consensus. Every person performs individually; we need to work like clockwork, synchronized and timely.”

Outcomes

Outcomes, positive or negative, are apparent following implementing strategies. Subcategories of “organizational excellence, personal excellence, and problem finding and its solving” were recognized as the major category of the positive outcome, and the subcategory of “executive limitations” was recognized as the major category of the negative outcome.

Participant 22 stated, “We move from personal and individual decision-making toward group decision-making and, practically, a larger group endeavors to continue that path.”

Participant 5 said, “The most important outcomes are the breadth of experiences and increasing decision-making quality. Evaluation of the problems would be easier.”

Further, participant 32 believed, “One of the major drawbacks is being unfamiliar to the staff.

Figure 2. The paradigm template (model) of the collaborative management style

They lack the experience and skills, their compliance is poor, and they resist. Our organization has no ideal model, and the implementation is not coordinated.”

Generally, the conceptual model derived from the results of the interviews is demonstrated in Figure 2.

Discussion

This article identified distinct elements of collaborative management in line with implementing health care strategies based on the participants’ views. Regarding identified strategies for implementing collaborative management, “provision of implementation background, designing execution methods, proper implementation, evaluation, and amendment” were more prominent. The provision of environmental conditions and preparation of the environmental culture were effective and influential factors in implementing collaborative management, including some influential mediating factors, the implementation method, and documentation style. From the interviewees’ viewpoints, proper implementation of collaborative management can lead to individuals’ positive growth, organizational growth, and problem-finding and problem-solving. However, the resistance of managers and lack of monitoring were mentioned as negative outcomes in this research, which should be noted.

The findings of the current study in terms of causal conditions indicated that there was a subcategory called “executive barriers” under the main category of implementation barriers with the title of “executive barriers,” which is consistent with the results of Kostka et al (23). The results regarding the subcategory of “provision of basic requirements for implementation of strategies” included the provision of implementation, information, communication, and cultural backgrounds, which are consistent with the outcomes of Iyanda and Bello; they investigated the pathology of implementation of general strategies in Nigeria and discussed obscurity of the goals, ambiguity, and lack of suitable technology for implementation, lack of coordination, and corruption as the implementation obstacles (24). Wildavsky and Pressman believe that the successful implementation of strategies depends on the coordination between different organizations involved in implementation, and any lack of coordination can lead to implementation failure (25). The participants believed that subcategories of “evaluation, receiving, and providing feedback, implementation of amendments, support for reattempt and repeat” were related to the basic category of evaluation and amendment.

Executive necessities, inclination, and ability to use the collaboration approach were the subcategories of the major category of implementation facilitators. Factors that prevented the implementation of collaborative management were believed to belong to the subcategory of implementation inhibitors. These findings were consistent with the results of Jabbarzadeh Karbasi and Mazloomi (26) and Asadi et al (27).

The results of the current study in the category of background conditions and subcategories of facilities and environmental conditions are in line with the results of Bahadori et al (28) and Livani et al (9). Moreover, in the subcategory of culture, the results are in line with the studies by Masoumi et al (8) and Khodabakhshi et al (29). In the outputs of the analysis of the interviews, 2 categories in the interfering factors (mediating), including implementation style and documentation style, were identified. These results were similar to those of studies conducted by Xiu et al (30), Zabetpoor et al, and Khanifar et al (31, 32). The participants believed that the implementation of health care strategic plans could be categorized into 4 groups: “provision of the background for implementing health care strategies, designing the method of implementation of the strategic plan, proper implementation of the strategic plan, and amendment of strategic plans,” which are consistent with the results of Iyanda and Bello (24), Livani et al (9), and Khanifar et al (32).

Outcomes related to implementing the collaborative management plan were divided into positive and negative groups. Based on the participants’ opinions, significant parts of the outcomes of implementing collaborative management were positive outcomes in the subcategories of “organizational excellence, personal excellence, and problem finding and solving it.” Promotion of quality in the achievement of goals and improving productivity, facilitation of better coordination, increasing output in works, lowering the costs, productivity, and expanding the collaboration culture in the organization, employees harder work for achieving organization goals, perseverance of the staff, and continuation of the implementation agreed upon are only 1 section of the organizational outcomes of implementing the collaborative management plan that the interviewees expressed. Promoting employee respect and self-esteem were the most repeated codes in this subcategory.

One of the other personal benefit outcomes related to implementing collaborative management were increasing teamwork and contribution, commitment and job satisfaction, collaboration and development of a sense of cooperation and commitment to work, attention to the needs of the employees for respect, generation of the sense of ownership in the employees and foster their collaboration in this manner, using the maximum potentials and their commitment, and increasing the effect of effectiveness and the employee’s satisfaction.

Compared with dictatorial management, finding and solving problems through the collaborative management approach are very different. Therefore, their outcomes can be very different, too. From the interviewees’ viewpoints, an issue is dealt with from various perspectives in the collaborative management approach. Consequently, problems are dealt with more in-depth and can be precisely addressed and solved. Increased coordination in solving problems, capacity building for tolerating shortcomings, better recognition of the elements of the issue, dividing the risk and decision-making among all, considering different opinions in decision-making, and exploiting the benefits of collaborative decision-making were other outcomes related to finding and addressing problems. These results are consistent with those reported by Kohtamäki et al (33), Elbanna and Fadol (34), and Masoumi et al (8).

Negative outcomes related to implementing the collaborative management approach are outcomes that re-execution of them would cast doubt on them. These outcomes were categorized under the subcategory of “executive limitations” and “resistance of managers and lack of monitoring” were its subcategories. The novelty of this approach for the employees, lack of experience and skills of the employees and managers for implementation of this style, the meddling of the staff in all affairs, time-consuming meetings, and provocation of unrealistic expectations in the staff were among the outcomes that prevented the implementation of collaborative management. These subcategories are also mentioned in the research conducted by Masoumi et al (8) and Rajaee et al (35), demonstrating consistency in the results. Consequently, implementing collaborative management in line with health care strategies is reliant on the development of suitable systems for preparing executive necessities and enhancing the inclination and potential of implementation of a collaborative approach. Moreover, overcoming executive obstacles and conflicts of interest can be helpful in this regard.

Conclusion

For implementing collaborative management in health care and promoting the related cultures, effective collaboration with different stakeholders in health care organizations, which can provide a suitable foundation for benefiting from this management style and recruitment of all resources and forces, can lead to improved productivity. In the next steps, expanding knowledge and learning necessary skills for management are necessary. Ultimately, monitoring the performance of the health care system and comparing the outputs with other management styles and timely intervention can play an effective role in the implementation of collaborative management.