STRATEGIC MANAGEMENT AND ORGANIZATIONAL

PERFORMANCE: FINDINGS FROM HEALTH

INSTITUTIONS IN NAIROBI COUNTY

BY

GEORGE KADONDI KASERA

UNITED STATES INTERNATIONAL UNIVERSITY –

AFRICA

FALL 2017

STRATEGIC MANAGEMENT AND ORGANIZATIONAL

PERFORMANCE: FINDINGS FROM HEALTH INSTITUTIONS

IN NAIROBI COUNTY

BY

GEORGE KADONDI KASERA

A Project Report Submitted to the Chandaria School of Business in

Partial Fulfilment of the Requirement for the Degree of Masters in

Business Administration (MBA)

UNITED STATES INTERNATIONAL UNIVERSITY – AFRICA

FALL 2017

iii

STUDENT’S DECLARATION

I, the undersigned, declare that this is my original work and has not been submitted to any

other college, institution or university other than United States International University –

Africa in Nairobi for academic credit.

Signed: _________________________________ Date: _______________________

George Kadondi Kasera (632250)

This project has been presented for examination with my approval as the appointed

supervisor.

Signed: _________________________________ Date: _______________________

Dr. Peter N. Kiriri

Signed: _________________________________ Date: _______________________

Dean, Chandaria School of Business

iv

COPYRIGHT

©GEORGE KADONDI KASERA, 2017

All Rights Reserved

v

ABSTRACT

The purpose of this study was to determine the effects of strategic management on

organizational performance in health institutions in Nairobi County. The study had three

research questions on what was the effect of strategic thinking, planning and strategy

implementation on organizational performance of health institutions in Nairobi County.

This study was descriptive and the study design was cross – sectional. The study was

designed to capture utilization of strategic management in health institutions in Nairobi,

representing a snapshot of one point in time. The study described and explained phenomena

that observations reflected measure social reality or describe what was in use in health

institutions in Nairobi. The independent variables were strategic thinking, strategic planning

and strategy implementation, while the dependent variable was organizational performance.

The study population was the management at health institutions that are Kenya Essential

Package for Health (KEPH) level four, five and six, and are in Nairobi County. For this

study, the sampling frame was the list of all health institutions that were KEPH level four or

five or six, and in Nairobi County based on the Kenya Master Health Facility List (Ministry

of Health, 2017). The health institution was the sampling unit. Census was used to enroll

every health institution into this study since they are few, and the unit of analysis was the

health institution. Primary data for this study was collected using a structured self-

administered questionnaire, that captured both qualitative and quantitative data,

administered to the study prospective participants after they had been recruited and enrolled.

Stata 12 ® was the statistical software used to analyze the data from the study. Data was

presented in charts and graphs.

Of the health institutions surveyed, 23 (96%) carried out strategic thinking while 7 (29%)

agreed that strategic thinking improves organizational performance. From the study,

organizational performance was positively correlated to strategic thinking, but the strength

of the relationship was weak since the value of the correlation coefficient was 0.0801.

With regard to strategic planning, 15 (63%) of the health institutions surveyed carried out

strategic planning, while only 6 (25%) agreed that it improved organizational performance.

On the other hand, organizational performance was negatively correlated to strategic

planning with the value of the correlation coefficient being – 0.4175.

vi

Of the health institutions surveyed, 10 (42%) carried out strategy implementation, while only

3 (12%) agreed that it improved organizational performance. Strategy implementation had a

negative correlation with organizational performance among health institutions in Nairobi

County with the value of the correlation coefficient being – 0.3164.

The study concludes that strategic thinking has a weak positive relationship on

organizational performance, while strategic planning and strategy implementation have a

negative relationship on organizational performance among health institutions in Nairobi

County. This study has raised the specter of there being other underlying factors that have a

bearing on organizational performance among health institutions in Nairobi County.

This study has provided evidence of the relationship between strategic management and

organizational performance in health institutions. Going forward, much as the study found

that the relationship between strategic thinking and organizational performance was positive,

this will be best measured through a key informant interview that is open since a lot of details

on strategic thinking are lost through closed ended questions in a questionnaire. In addition,

much as the correlation between strategic planning and organizational performance was

negative in this study, there is need to draw a distinction between public and private health

facilities since the drive between the two sets are different. Finally, it is important to design

a study that will make management of health institutions less sensitive about the information

they offer. This is so since many, especially the privately-owned health institutions guarded

the information they could share because it was competitive in nature.

vii

DEDICATION

To my late father, I dedicate this research paper to you posthumously in recognition of your

motivation and support throughout the study period.

viii

ACKNOWLEDGEMENT

I acknowledge the presence of God the Almighty in my life. For giving me the strength and

wisdom to have been able to prepare for the execution of this research project and finalizing

the research paper.

My sincere gratitude goes to my supervisor Dr. P. N. Kiriri for his guidance, advice and

effective timely response at each stage in the preparation and execution of this research paper

for examination. Thank you for your support and inspiration.

I would like to thank my dear family, friends and supervisors for their understanding,

resource input, endless love and encouragement throughout the research project execution

to the end.

Not to forget the top management of the health institutions and health facilities interviewed,

for without their corporation, the completion of this research paper would not have been

possible.

May God, bless you all.

ix

TABLE OF CONTENTS

STUDENT’S DECLARATION ......................................................................................... iii

COPYRIGHT ..................................................................................................................... iv

ABSTRACT ......................................................................................................................... v

DEDICATION ................................................................................................................... vii

ACKNOWLEDGEMENT ............................................................................................... viii

LIST OF TABLES ............................................................................................................. xii

LIST OF FIGURES .......................................................................................................... xiv

CHAPTER ONE .................................................................................................................. 1

1.0 INTRODUCTION ..................................................................................................... 1

1.1 Background of the Problem...................................................................................... 1

1.2 Statement of the Problem ......................................................................................... 6

1.3 Purpose of the Study ................................................................................................ 8

1.4 Research Questions .................................................................................................. 8

1.5 Rationale of the Study .............................................................................................. 9

1.6 Scope of the Study.................................................................................................. 10

1.7 Definition of Terms ................................................................................................ 11

1.8 Chapter Summary ................................................................................................... 12

CHAPTER TWO ............................................................................................................... 13

2.0 LITERATURE REVIEW ....................................................................................... 13

2.1 Introduction ............................................................................................................ 13

2.2 Strategic Thinking and Organizational Performance ............................................. 13

2.3 Strategic Planning and Organizational Performance ............................................. 22

2.4 Strategy Implementation and Organizational Performance ................................... 27

2.5 Chapter Summary ................................................................................................... 31

CHAPTER THREE ........................................................................................................... 32

x

3.0 RESEARCH METHODOLOGY ........................................................................... 32

3.1 Introduction ............................................................................................................ 32

3.2 Research Design ..................................................................................................... 32

3.3 Population and Sampling Design ........................................................................... 33

3.4 Data Collection Methods ........................................................................................ 34

3.5 Research Procedures .............................................................................................. 35

3.6 Data Analysis Methods .......................................................................................... 36

3.7 Chapter Summary ................................................................................................... 37

CHAPTER FOUR ............................................................................................................. 38

4.0 RESULTS AND FINDINGS ................................................................................... 38

4.1 Introduction ............................................................................................................ 38

4.2 General Information ............................................................................................... 38

4.3 Strategic Thinking and Organizational Performance ............................................. 42

4.4 Strategic Planning and Organizational Performance ............................................. 49

4.5 Strategy Implementation and Organizational Performance ................................... 58

4.6 Organizational Performance ................................................................................... 61

4.7 Bivariate Analysis .................................................................................................. 61

4.8 Chapter Summary ................................................................................................... 63

CHAPTER FIVE ............................................................................................................... 64

5.0 DISCUSSION, CONCLUSION AND RECOMMENDATIONS ........................ 64

5.1 Introduction ............................................................................................................ 64

5.2 Summary ................................................................................................................ 64

5.3 Discussion .............................................................................................................. 65

5.4 Conclusion .............................................................................................................. 69

5.5 Recommendations .................................................................................................. 70

REFERENCES .................................................................................................................. 72

xi

APPENDICES .................................................................................................................... 97

Appendix I: Cover Letter .............................................................................................. 97

Appendix II: Questionnaire .......................................................................................... 98

xii

LIST OF TABLES

Table 3.1: Population Distribution ...................................................................................... 33

Table 4.1: Gender of Study Respondents ............................................................................ 38

Table 4.2: Designation of Study Respondents .................................................................... 39

Table 4.3: Health Institutions’ KEPH Level ....................................................................... 41

Table 4.5: Health Institution Ownership ............................................................................. 42

Table 4.6: Health Institutions Carrying out Systems Perspective during Strategic Thinking

............................................................................................................................................. 43

Table 4.7: Perspective if System Perspective Improves Organizational Performance........ 43

Table 4.8: Actual Implementation of Intent Focused .......................................................... 44

Table 4.9: Perception if Intent Focused Improves Organizational Performance ................ 45

Table 4.10: Actual Implementation of Thinking in Time ................................................... 45

Table 4.11: Perception if Thinking in Time Improves Organizational Performance .......... 46

Table 4.12: Actual Implementation of Hypothesis Driven.................................................. 46

Table 4.13: Perception if Hypothesis Driven Improves Organizational Performance ........ 47

Table 4.14: Actual Implementation of Intelligent Opportunism ......................................... 47

Table 4.15: Perception if Intelligent Opportunism Improves Organizational Performance 47

Table 4.16: Actual Implementation of Strategic Thinking .................................................. 48

Table 4.17: Perception if Strategic Thinking Improves Organizational Performance ........ 48

Table 4.18: Comparison Between Actual Practice and Perception if Strategic Thinking

Improves Organizational Performance ................................................................................ 48

Table 4.19: Actual Implementation of System Perspective ................................................ 51

Table 4.20: Perception if System Perspective Improves Organizational Performance ....... 53

Table 4.21: Actual Formulation of Strategies based on Situational Analysis ..................... 54

Table 4.22: Perception if Strategy Formulation Improves Organizational Performance .... 54

Table 4.23: Strategic Management Techniques in Use Stratified by Health Institution

Ownership ............................................................................................................................ 55

xiii

Strategic Management Tool ................................................................................................ 55

Table 4.24: Actual Implementation of Strategic Planning .................................................. 57

Table 4.25: Perception if Strategic Planning Improves Organizational Performance ......... 57

Table 4.26: Comparison Between Actual Practice and Perception if Strategic Planning

Improves Organizational Performance ................................................................................ 57

Table 4.27: Actual Implementation of Strategy in Health Institutions................................ 58

Table 4.28: Perception if Strategy Implementation Improves Organizational Performance

............................................................................................................................................. 59

Table 4.29: Actual Implementation of Strategy .................................................................. 60

Table 4.30: Perception if Strategy Implementation Improves Organizational Performance

............................................................................................................................................. 60

Table 4.31: Comparison Between Actual Practice and Perception if Strategy Implementation

Improves Organizational Performance ................................................................................ 60

xiv

LIST OF FIGURES

Figure 2.1: Elements of Strategic Thinking......................................................................... 16

Figure 2.2: Analyzing and Understanding the Situation ..................................................... 26

Figure 2.3: Intended Versus Realized Strategy ................................................................... 29

Figure 4.1: Distribution of Respondents’ Age..................................................................... 40

Figure 4.2: Distribution of Respondents’ Duration in post ................................................. 40

Figure 4.3: Correlation between Strategic Thinking and Organizational Performance ...... 61

Figure 4.4: Correlation between Strategic Planning and Organizational Performance ....... 62

Figure 4.5: Correlation between Strategy Implementation and Organizational Performance

............................................................................................................................................. 62

CHAPTER ONE

1.0 INTRODUCTION

1.1 Background of the Problem

Strategy purpose is to determine the basic objectives of an organization and allocating

resources to their success. Strategy specifies the necessary direction that an organization

needs to move to meet its mission. Strategic management means that the management team

is going to direct employee activities towards the achievement of specific goals and

implementation plans (Bianca, 2017). A shared sense of strategy is of fundamental

importance to managers because it is essential for positioning an organization to face a

complex and uncertain future. Effective managers can use strategy to focus attention and

effort on real priorities, provide a consistent framework to guide decisions and actions, and

give an organization a new or renewed sense of purpose (Nutt & Backoff, 1992).

Strategic planning is concerned with formulating strategy, a “disciplined effort to produce

fundamental decisions and actions that shape and guide what an organization (or other entity)

is, what it does, and why it does it” (Bryson, 2004). It is a “big picture” approach that

addresses the most fundamental issues facing an organization in an attempt to promote the

best “fit” with the environment and ensure the organization’s long-term vitality and

effectiveness (Kemp, Funk, & Eadie, 1993) (Poister & Streib, 1999). Strategic management

is the broader process of managing an organization in a strategic manner on a continuing

basis. Strategic planning is a principal element of strategic management, which also involves

resource management, implementation, and control and evaluation (Steiss, 1985).

Numerous researchers and executives advocate strategic planning. Armstrong (1982), for

example, argued that an explicit planning process rather than haphazard guesswork results

in the collection and interpretation of data critical to creating and maintaining organization-

environment alignment. Similarly, Ansoff (1991) argued that planning generally produces

better alignment and financial results than does trial-and-error learning. Despite the intuitive

appeal of these arguments, several researchers have countered that explicit strategic planning

is dysfunctional, or at best irrelevant. Without using strategic management, decision-making

2

can be reactionary, which can lead to costly mistakes. These might include managers and

employees making decisions that aren't in line with the organization’s goals, money being

spent on unnecessary expenses and customers having different experiences each time they

interact with the organization (Bianca, 2017).

There are significant number of researches as well as more practical experiences in business

prove that an efficient and effective strategic planning can increase profitability. More recent

experimental proof indicates that corporates that adopt planning system perform well and

achieved their goals in terms of sales and profit growth more than the other corporates that

do not. Therefore, it’s obvious that practicing the strategic planning in any business will

show better performance compared with to non-planning system, also it helps the corporates

to get back on track and to enhance the business ability to predict changes in the

environment. The strategic planning should be a people process more than paper process (Al

isa, 2017).

Organizational performance on the other hand, is about creating values for the primary

beneficiaries of the organization (Al isa, 2017). A number of definitions of organizational

performance have been proposed by organizational and management scholars, all influenced

by the particular organizational perspectives held by the authors or proponents. Thorndike

(Thorndike, 1949) first noted the general trend among researchers to assess organizational

performance using a univariate model that focused on an ultimate criterion, such as profit or

productivity. This approach directed attention toward outcomes and viewed the organization

as a rational system that enables the attainment of certain objectives. Georgopolous and

Tannenbaum (1957) shifted the focus from univariate to multivariate by expanding the

criteria to include organizational flexibility and intraorganizational strain. Performance

under this conceptualization focused on how well an organization can achieve its objectives,

given certain resource constraints, without placing undue strain on its members. In the

following decades, organizational researchers conceptualized organizations in a variety of

ways, including rational entities in pursuit of goals (Latham & Locke, 1991), coalitions

reacting to strategic constituencies (Pfeffer & Salancik, 1978), garbage cans (Cohen, March,

& Olsen, 1972), open systems (Katz & Kahn, 1978), social contracts (Keeley, 1980),

political arenas (Gaertner & Ramnarayan, 1983), psychic prisons (Morgan, 1986), dynamic

networks (Miles & Snow, 1986), complex adaptive systems (Bennet & Bennet, 2004), and

complex responsive processes (Stacey, 2010). Each of these conceptualizations highlights

3

or reveals organizational phenomena that were overlooked by other definitions and serves

to frame the evaluation in a different perspective, particularly with respect to the values used

to assess an organization’s performance. Despite the numerous metaphors and perspectives

used to describe organizations, three conceptual frameworks continue to be used as primary

guides to empirical investigations of organizations: rational, natural, and open systems

(Scott, 2003). These conceptual frameworks evolved over the decades as new theories of

organization moved to a higher level of analysis, from social psychological to structural to

ecological. However, the underlying tenets of the models of organization have not changed,

and it is from these three conceptual frameworks that organizations can be further examined,

analyzed, and evaluated (Martz, 2013).

Strategic management concepts have been employed within health care organizations only

in the past 25 to 30 years. Indeed, many of the management methods adopted by healthcare

institutions, both public and private, were developed in the business sector. In many respects

health care has become a complex business using many of the same processes and much of

the same language as the most sophisticated business corporations (Swayne, Duncan, &

Ginter, 2006). Strategic management provides the momentum for change. Organizational

change is a fundamental part of survival. Because strategic managers understand the

relationship between change and survival, there have been many management approaches to

changing organizations. As health care leaders change and manage their organizations, they

chart new courses into the future.

In the field of healthcare: having the right strategic management tools and techniques that

can predict precise, timely and accessible information is essential to monitoring the services

offered to the population. Access to public health information is key to identifying

environmental exposure to diseases, as well as to tracking intervention development and

effectiveness. The efficiency of measures and techniques depends on the availability of

databases and analysis tools to generate helpful information to researchers, professionals,

decision-makers, politicians, and society in general. Generally speaking, public health

organizations collect considerable volumes of data; the challenge lies in identifying the

essential information within it and prioritizing problems, developing and evaluating policies

and measures, organizing their implementation, monitoring and controlling the delivery of

health services (Rogério, et al., 2016).

4

A shared sense of strategy is of fundamental importance to public managers because it is

essential for positioning an organization to face a complex and uncertain future. Effective

public managers can use strategy to focus attention and effort on real priorities, provide a

consistent framework to guide decisions and actions, and give an organization a new or

renewed sense of purpose (Nutt & Backoff, 1992). Strategic planning is concerned with

formulating strategy, a “disciplined effort to produce fundamental decisions and actions that

shape and guide what an organization (or other entity) is, what it does, and why it does it”

(Bryson, 2004). It is a “big picture” approach that addresses the most fundamental issues

facing an organization in an attempt to promote the best “fit” with the environment and

ensure the organization’s long-term vitality and effectiveness (Kemp, Funk, & Eadie, 1993)

(Poister & Streib, 1999). Strategic management is the broader process of managing an

organization in a strategic manner on a continuing basis. Strategic planning is a principal

element of strategic management, which also involves resource management,

implementation, and control and evaluation (Steiss, 1985) (Vinzant & Vinzant, 1996b).

The three activities of strategic management – strategic thinking, strategic planning, and

strategic momentum –provide many benefits to health care organizations. However, because

strategic management is a philosophy or way of managing an organization, its benefits are

not always quantifiable. Overall, strategic management: ties the organization together with

a common sense of purpose and shared values; improves financial performance in many

cases; provides the organization with a clear self-concept, specific goals, and guidance as

well as consistency in decision making; helps managers understand the present, think about

the future, and recognize the signals that suggest change; requires managers to communicate

both vertically and horizontally; improves overall coordination within the organization; and

encourages innovation and change within the organization to meet the needs of dynamic

situations (Swayne, Duncan, & Ginter, 2006).

In Kenya, dramatic changes in the healthcare industry that began in 2013, marked by the

implementation of new Constitution of Kenya that devolved healthcare service delivery from

national government to county governments. As a result, both public and private healthcare

institutions continue to face a turbulent, confusing, and often threatening environment.

Significant change comes from many sources including: national, county, and local health

care legislative and policy initiatives; international as well as domestic economic and market

5

forces; demographic shifts and lifestyle changes; technological advances; and healthcare

delivery changes within the industry.

In order to survive, healthcare institutions are taking steps to expand by accessing new

markets; making services and price more attractive; satisfying customers; developing new

strategies. Thus, managers and executives of the healthcare institutions looking for a suitable

tools and techniques in order to investigate the internal and external cost of the

products/service, get market information, product costs, analyze customer needs and wishes,

predict and assess organizational performance, as well to ensure competitive advantage in

production activities. Certainly, the healthcare systems in both public and private, as well as

other faith based institutions, have had to adapt to these changes and in the future, may have

to reinvent themselves once again. Healthcare institutions will have to effectively manage

change and become “masters of renewal” in this dynamic environment (Afonina, 2015).

Organizational performance is obviously a central issue in strategic management research.

Several authors have analyzed the organizational performance in terms of corporate strategy

(Chenhall & Langfield-Smith, 2007) (Carton & Hofer, 2006). Hamon (2003) defined

organizational performance as a variable used to measure the degree of organizational

performance in achieving organizations’ objectives, efficiency, and effectiveness in

achieving their goals (Robbins & Coulter, 2002). In addition, Ho (2008) defined

organizational performance as an indicator to measure the efficiency of an organization to

accomplish its objectives, in terms of achieving organization market orientation and

financial goals (Li, Ragu-Nathan, Ragu-Nathan, & Rao, 2006).

There are a number of indicators used to measure organizational performance since 1900;

however, among the popular indicators in the financial performance (FP) construct of

organizational performance were profit growth rate, return on sales (ROS), return on assets

(ROA), and overall performance (Hancott, 2005). Furthermore, Li et al. (Li, Ragu-Nathan,

Ragu-Nathan, & Rao, 2006) mentioned that organizational performance can be measured in

terms of market performance (MP) and FP, which consists of organization’s profits, return

on investments (ROI), market share, and also growth of sales (Chee-Hua, May-Chiun, &

Ramayah, 2013). Performance measurement refers to the choice of the appropriate measures

to evaluate performance. It is generally thought that it is difficult to choose the appropriate

measures for firm performance (Venkatraman & Grant, 1986). The issue related to the

6

pertinence of using exclusively financial rather than nonfinancial measurement is an

important one. For example, financial performance measurements may only reflect a part of

the firm’s profitability (Falshaw, Glaister, & Tatoglu, 2006).

In effect, they create new beginnings, new chances for success, new challenges for

employees, and new hopes for patients. Therefore, it is imperative that health care managers

understand the changes taking place in their environment; they should not simply be

responsive to them, but strive to create the future. Health care leaders must see into the

future, create new visions for success, and be prepared to make “quantum improvements”

(Efendioglu & Karabalut, 2010).

1.2 Statement of the Problem

Over the past three decades, strategic management has become a common part of executives’

lives. Whether trying to boost revenues, innovate, improve quality, increase efficiencies or

plan for the future, executives have looked for strategic management to help them. The

current environment of globalization and economic turbulence has increased the challenges

executives face and, therefore, the need to find the right strategies to meet these challenges.

To do this successfully, executives must be more knowledgeable than ever as they sort

through the options and select the right strategies for their companies. The selection process

itself can be as complicated as the business issues they need to solve (Casey & Goldman,

2010). They must choose strategies that will best help them make the business decisions that

lead to enhanced processes, products and services—and result in superior performance and

profits. Successful use of strategic management requires an understanding of the strengths

and weaknesses of each strategy as well as an ability to creatively integrate the right

strategies, in the right way, at the right time. In the absence of objective data, groundless

hype makes choosing and using strategic management a dangerous game of chance (Bain &

Company, 2017).

Long devised and implemented to deal with the ‘industrial dynamic’ marked by ‘competitive

behavior’ (Porter M. , 1982), strategy is now considered a field that makes it possible for the

leaders of public and private organizations to ‘take options on the future’ (Williamson,

1999). However, despite increasingly sophisticated training programs and highly advanced

academic research on strategic contents, processes, options and actions, the eff ectiveness of

7

public strategy is still a source of major controversies (Mazouz, Rousseau, & Hudon, 2016).

At best, the strategic thinking and tools do not seem to have been sufficiently adapted to the

context of public organizations (McHugh, 1997). At worst, the strategic exercise seems to

be incompatible with the non-competitive environment in which public administrations

traditionally operate. Despite the skepticism of researchers and practitioners, many public

administrations of Organization for Economic Co-operation and Development (OECD)

countries are now subject to legislation and regulations that have turned results based

management and strategic planning into tools that make it possible to intelligently combine

the purposes, objectives, means and resources required to steer states’ administrations

towards tangible results (Mazouz B. , 2014).

Undoubtedly, this renewed interest in strategic processes (Andrews R. , Boyne, Law, &

Walker, 2009) can be explained partly by the growing institutionalization of formal

approaches and frameworks of objective-based management (Charih, 2000) (Levine, 1985)

and, more recently, of results-based management (Emery, 2005) (Mazouz B. , 2014). This

is the case, for instance, of the GPRA in the US, of the LAP in Quebec and the Loi organique

sur les lois de finances (LOLF) in France.

Several recent works have highlighted the criticality of performance as a dependent variable,

with some persuasively arguing that the most obvious and useful set of research questions

should address the linkage between strategy and performance. Further, there is need to

identify enterprise level factors which influence organizational performance. A review of

organizational structure (Dalton, Todor, Spendolini, Fielding, & Porter, 1980) argued that

organizational performance is the single most important dependent variable in both the

public and private sector.

Strategic management can be applied in different areas, such as: general management,

marketing management, operations management, financial management, human resource

management, information technology, management science, planning and resource

allocation and, efficiency and effectiveness (Armstrong M. , 1993).

In the literature, there are findings focused on the relationship between strategic management

and organizational performance (Afonina, 2015). It should be noted that studies, which

examine the relationship between strategic management and organizational performance

remain uncertain. Some of the studies have argued that utilization of management influences

8

organizational performance (Indiatsu, Mwangi, & Mandere, 2014) (Iseri-Say, Toker, &

Kantur, 2008). While other studies concluded that there was no clear relationship between

strategic management and organizational performance (Rigby & Bilodeau, 2007)

(Efendioglu & Karabalut, 2010). Thus, in the literature there is very little empirical support

to justify this relationship. For example, Rigby (Rigby D. K., 1994) reflected the effect of

strategic management on organizational performance by considering five performance

categories (financial results, organizational integrity, performance capability, customer

equity and competitive advantage).

Given these mitigated results, studies examining the direct bivariate relationship between

rational strategic management and firm performance have been strongly criticized. Some

researchers have argued that context plays a considerable role in explaining the relationship

between firm processes and outcomes (Child, Elbanna, & Rodrigues, 2010). Therefore,

several contingency factors, such as the organizational structure, the nature of the

environment, and the size of the organization, have been introduced in the study of the

relationship between strategic planning and firm performance (Miller, Burke, & Glick,

1998). It has equally been suggested that some factors may have a mediating role in this

relationship (Rudd, Greenley, Beatson, & Lings, 2008). This study will test the role of

strategic management on organizational performance.

1.3 Purpose of the Study

The purpose of this study was to determine the effects of strategic management on

organizational performance in health institutions in Nairobi County.

1.4 Research Questions

1.4.1 What is the effect of strategic thinking on organizational performance of health

institutions in Nairobi County?

1.4.2 What is the effect of strategic planning on organizational performance of health

institutions in Nairobi County?

9

1.4.3 What is the effect of strategy implementation on organizational performance of

health institutions in Nairobi County?

1.5 Rationale of the Study

Benefits accrued from conducting the study and the relevance of the problem both to the

practice and theory is that its findings will assist healthcare leaders deal with important,

complex, and sometimes conflicting issues and trends. It shall help them in deciding on

which strategic management tools and techniques are most apt for the Kenyan setting.

It is likely that there will be new opportunities and threats to healthcare institutions that have

yet to be identified or fully assessed. Even more sobering, it seems certain that there will be

more change in the healthcare industry in the next ten years than there has been in the past

ten. Dealing with rapid, complex, and often discontinuous change requires leadership and

the right mix of strategic management. Successful healthcare institutions have leaders who

understand the nature and implications of external change, the ability to develop effective

strategies that account for change, and the will as well as the ability to actively manage the

momentum of the institution. Strategic management is fundamental in effective leading

institutions in dynamic environments.

1.5.1 Managers of Health Institutions

This study provided evidence of the relationship between strategic management and

organizational performance in healthcare since this had not sufficiently examined in previous

studies. The study explored if use of strategic management led to an integrated, systematic

approach to improving organizational performance to achieve strategic aims and promote a

health institution’s mission and values to attain what they needed to do.

1.5.2 Ministry of Health & County Governments

Devolution of healthcare has transformed the landscape of service delivery to create 47

County Governments and one National Government all involved in healthcare. Planning and

strategy have been approached from a formal perspective and this study found the impact of

strategic management on the performance of government health institutions.

10

1.5.3 Patients and Other Stakeholders

Patient satisfaction is a central concept and critical goal in the healthcare industry. This study

explored the impact of use of strategic management had towards improving patient

experience through improved service quality and strengthening re-purchase intention of

patients. This was measured by the number of patients who sought services in the health

institutions.

1.5.4 Academia and Research

This study provided empirical evidence about the use of the strategic management by health

institutions in an emerging market context. This has been a gray literature that has not been

published or shared more so in the Kenyan context. Since the advent of devolution of health

service delivery, the environment has undergone a lot of transformation and this study shed

light as to the new frontiers and how best to tackle the emerging challenges.

1.6 Scope of the Study

The study was conducted among health institutions that were KEPH Level 4, 5 and 6 within

Nairobi County. The population that was eligible for enrollment into the study was the

management for the aforementioned health institutions. The study was conducted between

August – October 2017. In view of these contributions, this study had limitations that need

to be accounted for in light of its research design. First, was existence of some degree of bias

in selection of sample of managers (convenient). Needless to say, as engaged scholars and

in the true spirit of Personal Construct Theory, all participants were asked to ‘tell it as it is’,

based on their lived experience, in terms of what they thought about their use of the tools

(Kelly, 1955). They were informed that the study was not looking for ‘right’ or ‘wrong’

answers, but are more interested in their experience per se, whether or not the tools in

question helped them perform better analysis for better decision-making. All participants

gained equal credit for sharing their experience, whether they describe good or bad

experiences with the tools. Hence, given the structured learning approach of the study

design, there was no indication of rater bias on the part of the participants.

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1.7 Definition of Terms

1.7.1 Strategy

Strategy is defined as large scale, future oriented plans interacting with the competitive

environment to achieve an organization’s objectives (Swayne, Duncan, & Ginter, 2006).

1.7.2 Organizational Performance

Performance is often presented as a multidimensional concept (Venkatraman & Grant,

1986). Two types of measures of firm performance can be distinguished: on the one hand,

financial (and relatively objective) measurements such as return on assets (ROA), return on

sales (ROS), and return on investment (ROE) and, on the other hand, nonfinancial (and

relatively subjective) measurements, for example, shareholder satisfaction, employee

satisfaction, and customer satisfaction (Ong & Teh, 2009) (Venkatraman & Grant, 1986).

1.7.3 Strategic Thinking

Strategic thinking is defined as an individual intellectual process, a mindset, or method of

intellectual analysis that asks people to position themselves as leaders and see the “big

picture” (Swayne, Duncan, & Ginter, 2006). Strategic thinking is a process of utilizing

previous experiences in a coherent framework and showing the best reaction in vital

situations (Noubar, Orangi, & Mejarshin, 2014).

1.7.4 Strategic Planning

Strategic planning is a rational and systematic process to evaluate an organization’s goals,

explore its competitive context, analyze its strategic alternatives, coordinate its activities,

and formulate the policies that will guide its decisions and actions (Andersen & Nielsen,

2009). Strategic planning is the periodic process of developing a set of steps for an

organization to accomplish its mission and vision using strategic thinking (Swayne, Duncan,

& Ginter, 2006). The result of the strategic planning process is a plan or strategy.

1.7.5 Strategy Implementation

Strategy implementation is the day-to-day activities of managing the strategy to achieve the

strategic goals of the organization (Swayne, Duncan, & Ginter, 2006). Strategy

implementation is defined as “the communication, interpretation, adoption, and enactment

of strategic plans” (Andrews R. , Boyne, Law, & Walker, 2011).

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1.7.6 Health Institution

A health institution is defined as any hospital, convalescent hospital, health maintenance

organization, health clinic, nursing home, extended care facility, or other institution devoted

to the care of sick, infirm, or aged person (Lectric Law Library, 2017).

1.7.7 Kenya Essential Package for Health (KEPH)

This is a basic and expandable package consisting of the following clusters: Health

promotion, environmental health, disease prevention and community health initiatives,

including epidemic and disaster preparedness and response; Maternal and Child Health;

Prevention, management and control of communicable diseases and non-communicable

diseases; that has been defined and consists of the most cost-effective priority healthcare

interventions and services, addressing the high disease burden, that are acceptable and

affordable within the resources available for the health sector (Ministry of Health, 2014).

1.8 Chapter Summary

Chapter one presents the background information to the research problem, identifies the

problem statement, states the purpose of the study and lists the research questions addressed

in the research project. In addition, it also presents the rationale, scope and definition of

terms used. Chapter two focuses on literature review. It lays out the strategic management

conceptual framework, then discusses the existing literature on effects of strategic thinking,

strategic planning and strategy implementation on organizational performance. Theories,

empirical data and other studies are discussed, supported and critiqued too, providing a firm

theoretical background for the study. Chapter three presents the research methodology used

this study. It details the research design, population and sampling, data collection methods,

research procedures and data analysis methods. Chapter four presents the results and findings

of the study. Chapter five presents the discussion, conclusion, and recommendations for

action and further research.

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CHAPTER TWO

2.0 LITERATURE REVIEW

2.1 Introduction

This chapter covers review of the existing literature on strategic management conceptual

framework and its effects on organizational performance. The chapter discusses in depth the

effect of strategic thinking, strategic planning and strategy implementation on the

organizational performance.

2.2 Strategic Thinking and Organizational Performance

The necessity of evolution in governmental and privately held organizations and companies

is the inevitable consequence of not only global changes but also of citizen and customers’

expectations of the organizations. Despite the existence of performance management in the

public sector for a quarter of century, there are still major problems and the expected

improvements in performance, accountability, transparency, and the quality of services have

not been made (Fryer, Antony, & Ogden, 2009). Today, setting and defining goals as well

as producing and assessing performance are the major challenges of top managers (Farhangi

& Dehghan, 2010). Attaining the best performance and achieving desired results is not

possible if there is not a formulated plan in an integrated system. This system should be able

to plan the performance, devise and implement its plans through an appropriate

administrative system, and assess the results using evaluation procedures in order to improve

the performance (Pirouz, Razavi, & Hashemi, 2009). There are different views on

performance. It can be only regarded as the obtained results. Individually, it refers to the

success and achievements of a person (Armstrong & Baron, 2005). Performance is “the

record a person has which is gained regardless of the goal, it is also defined as results of

work because they have the strongest connection with the strategic goals of organization,

customer satisfaction, and financial gains. One of the factors that affect an organization

reaching its goals is the employees’ thinking and commitment to the company.

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Strategic thinking is a representation of attitude and results from the person’ value system.

In recent decades, strategic thinking has received a lot of attention and it is claimed that it

distinguishes successful organizations from non-successful ones. In fact, the considerable

success of thriving companies stems from some powerful intangible factors in their

organizational culture and employees’ beliefs and values (Khalili, Armani, Rahimi,

Jamshidi, & Jamshidi, 2015).

Strategic thinking is considered as a very valuable and important component in the macro

management of organizations and businesses. Generally, strategic thinking is “an

understanding of and insight into the current situation and seizing opportunities”. This vision

helps with the proper and timely understanding of the market and its rules so that creative

and effective solutions would be suggested in response. In other words, opportunity involves

things that have not been attended to or there is a need for responding to them in the market,

and strategy is having suitable plans and vision to achieve the goals of the organization with

regard to meeting that need while considering interactions and chaos in the today’s relations

of business and companies. Strategic thinking enables managers to realize what factors are

effective in attaining desired goals. It involves real understanding of the market rules and

responding creatively to them; this is very important in the changeable environment of

business because without strategic thinking, companies cannot pursue the formulated

strategies effectively. The main characteristic of strategic thinking is having a wide

perspective on the organization’s future and environment. This requires understanding of the

relation between different issues and topics as well as of the way a solution to a problem in

a certain area influences another area or solution. Based on strategic thinking, a framework

would be suggested that enables the organization to reach its goals with a strategic vision

and to institutionalize it (Khalili, Armani, Rahimi, Jamshidi, & Jamshidi, 2015).

Strategic thinking is a process of utilizing previous experiences in a coherent framework and

showing the best reaction in vital situations (Noubar, Orangi, & Mejarshin, 2014). However,

what may look challenging regarding this issue is the degree of durability and stability of

planning and strategic management within the organization, and therefore a strategic

thinking of managers and employees is an assurance to the mentioned matter, and creation

of strategic thinking in managers of companies plays more important role than presenting

strategic plans since existence of such a thinking is a strong support for strategic plans within

any company. Strategic thinking is process which requires time and effort; it cannot be

15

bought and only can be earned through experience. In simple words, strategic thinking is a

logical development of thoughts (Fairholm & Card, 2009).

Strategic thinking helps the managers face changes, create plans for future developments

and absorb new opportunities. According to Mitzberg (2004) strategic thinking is an

integrated view from a business in manager’s mind. Seeing beyond is quite different from

seeing in front, because the first one lets you create the future. Strategic thinking in its lowest

level is a reaction to changes in environment and in its highest level is the reason to

emergence of new changes and values (Noubar, Orangi, & Mejarshin, 2014).

Having strategic thinking is advantageous for organizations since: it helps and directs

different levels of management in identifying goals, it makes designation of opportunities

and threats easier, it reinforces the management’s logics regarding the required assets and

workforce of company, it replaces the act with react within companies and help business to

be prepared for future changes. Like every process, strategic thinking has challenges and

obstacles such as: lack of systematic vision, lack of using collaborative management,

unavailability of exact information, lack of institutional trust, lack of organizational

encouraging culture (Noubar, Orangi, & Mejarshin, 2014).

Strategic thinking is consisted of several main elements: systems thinking, breaking down

organization to smaller systems collaborating with each other, creativity, developing new

solutions and business ideas to gain competitive edge, having vision, realizing the reasons

of company existence, its values and goals and having long term plans leading to those goals

(Pandelica, Pandelica, & Dumitru, 2009).

Several templates have been introduced by researchers to implement strategic thinking such

as: The Liedtka Model of the Elements of Strategic Thinking (Liedtka, 1998), Leading the

Revolution (Hamel G. , 2002), and The Fifth Discipline (Senge, 2006). The Fifth Discipline

template focuses on internal dimensions of organization and offers a framework that helps

institutions to solve problems using systems thinking method. These five disciplines are as

follows: Continue deepening and clarifying mangers vision, mental models refining to have

clear picture of our world in order to understand our environment and take proper actions,

building shared vision - a practice of unearthing shared pictures of the future that foster

genuine commitment and enrollment rather than compliance, team learning starts with

dialogue, the capacity of members of a team to suspend assumptions and enter into genuine

16

thinking together, and systems thinking - The Fifth Discipline that integrates the other four

(Senge, 2006).

Figure 2.1: Elements of Strategic Thinking

Source: Liedtka (1998)

There are weaknesses with regard to strategic thinking in both principle and practice. Top

managers’ lack of strategic thinking has been identified as the biggest obstacle to companies’

performance in the studies done about countries and industries (Khalili, Armani, Rahimi,

Jamshidi, & Jamshidi, 2015). There is a concern that this weakness will continue. Bonn

(Bonn, 2005) states that a group of experts have identified strategic thinking as one of the

ten important future areas of research. Moreover, leadership and strategy theoreticians have

shown that strategic thinking is required in multiple levels of an organization (Goldman &

Casey, 2010). The demand for information and thinking skills, which once were the subject

of debate among top managers, has deepened because all people need the ability to interpret

complex information and create their own realities (Khalili, Armani, Rahimi, Jamshidi, &

Jamshidi, 2015). In newer theories of strategic thinking, the focus is on organizational

procedures and routine tasks. This indicates that strategic thinking is useful for those who

work more closely with clients (Wooldridge, Schmid, & Floyd, 2008). According to

Wheatley (2006), the need for information and thinking skills that were once the purview of

17

top leaders is moving deeper into organizations, as everyone needs to be able to interpret

complex information and create their own realities.

The strategic thinking gap is due to a lack of understanding of the concept overall (Bonn,

2005) (Liedtka, 1998) (Mintzberg H. , The Rise and Fall of Strategic Planning: Reconceiving

Roles for Planning, Plans, Planners, 1994) and limited development of it among

organizational leaders (Bonn, 2005). Practitioners and theorists wrongly use the terms

strategic thinking, strategic planning, and strategic management interchangeably. This has

resulted in significant historical confusion in the literature, with the aforementioned terms

being used not only as substitutes but also as both nouns and verbs (Steiner, Miner, & Gray,

1982). Strategic thinking has been recognized as an individual activity influenced by the

context within which it takes place (Liedtka, 1998).

Research has found a statistically significant and positive relationship between strategic

thinking and organizational creativity (Khalili, Armani, Rahimi, Jamshidi, & Jamshidi,

2015). In addition, there is a significant relationship between organizational creativity and

the five components of strategic thinking including systems perspective, intent focused,

intelligent opportunism, hypothesis-driven, and thinking in time. Monovarian did a

descriptive survey titled ‘assessing strategic thinking among managers of the municipality

of Tehran’. Using Leidtka’s model which includes five elements of systems perspective,

intent focused, intelligent opportunism, hypothesis driven, and thinking in time, they

investigated strategic thinking among managers in the municipality of Tehran. Based on

experts’ views and available resources, the researchers created 29 sub-elements and

investigated the significance and current condition of all through a questionnaire distributed

among the managers in the municipality of Tehran. Analyzing the data through the Friedman

test and paired t-test revealed that despite some important measures like preparing strategic

documents in the municipality of Tehran, there is a significant gap between the significance

of the elements and their current condition in the organization that deserves attention

(Monavarian, Asgari, & Ashena, 2007).

A study conducted about the effects of top managers’ ability to think strategically on the

success of small and medium companies in Azarbaijan-e-shraghi. Five components of

strategic thinking were specified, and to assess the achievement of companies, the rise in

sales in three consecutive years was considered. The findings showed that the top managers’

18

ability to think strategically has a substantial effect on the success of small and medium

companies although in practice they do not use it enough (Sadegh, Yazdani, & Behrang,

2011). Research carried out on the crucial factors in strategic thinking. The results suggested

16 key variables in four main dimensions including systems perspective, individual factors,

organizational factors, and intuitive ones. All these dimensions are effective in the

realization of strategic thinking, so they can be considered for improving and promoting

strategic thinking in organizations (Khalili, Armani, Rahimi, Jamshidi, & Jamshidi, 2015).

2.2.1 Intent Focused

Hamel and Prahalad (Hamel & Prahalad, 1994) define strategic intent as a term (that) implies

a particular point of view about the long-term market or competitive position that a firm

hopes to build over the coming decade or so. Hence, it conveys a sense of direction. A

strategic intent is differentiated; it implies a competitively unique point of view about the

future. It holds out to employees the promise of exploring new competitive territory. Hence,

it conveys a sense of discovery. Strategic intent has an emotional edge to it; it is a goal that

employees perceive as inherently worthwhile. Hence, it implies a sense of destiny. Direction,

discovery, and destiny. These are the attributes of strategic intent.

Liedtka (1998) puts it this way: Strategic intent provides the focus that allows individuals

within an organization to marshal and leverage their energy, to focus attention, to resist

distraction, and to concentrate for as long as it takes to achieve a goal. In the disorienting

swirl of change, such psychic energy may well be the scarcest resource an organization has,

and only those who utilize it will succeed. Therefore, strategic thinking is fundamentally

concerned with, and driven by, the continuous shaping and re-shaping of intent (Lawrence,

1999).

2.2.2 A Systems Perspective

Strategic thinking is built on the foundation of a systems perspective. A strategic thinker has

a mental model of the complete end – to – end system of value creation, and understands the

interdependencies within it (Liedtka, 1998). Peter Senge also stresses the significance of

mental models in influencing our behavior. According to him: “New insights fail to get put

into practice because they conflict with deeply held internal images of how the world works,

images that limit us to familiar ways of thinking and acting. That is why the discipline of

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managing mental models - surfacing, testing, and improving our internal pictures of how the

world works - promises to be a major breakthrough” (Senge, 2006).

The mental model of how the world works must incorporate an understanding of both the

external and internal context of the organization. According to James Moore these mental

models must lead to the perception of a business in a context larger than that of the industry

in order to facilitate innovation. As he puts it: “I suggest that a company be viewed not as a

member of a single industry but as part of a business ecosystem that crosses a variety of

industries. In a business ecosystem, companies co-evolve capabilities around a new

innovation: they work co-operatively and competitively to support new products, satisfy

customer needs, and eventually incorporate the next round of innovations” (Moore, 1993).

Thus, the ability to manage in these converging arenas requires that managers think

strategically about the alliances they make within these competing networks and how they

position themselves within this ecosystem. In addition to understanding the external business

ecosystem in which a firm operates, strategic thinkers must also appreciate the inter-

relationships among the individual internal parts that, together, constitute the whole, as well

as the fact that the whole is greater than the sum of its parts (Lawrence, 1999).

Senge (2006) uses the term systems thinking to describe the same phenomenon, and suggests

that it is arguably the most critical of the five disciplines of the learning organization. He

advocates that systems thinking is what makes all other types of learning work in harmony

and points out that a fundamental problem for business organizations is the failure to see

problems as elements of systems failures because “most of an organization’s problems are

not unique errors but systems issues.”

The systems perspective enables individuals to clarify their role within the larger system and

the impact of their behavior on other parts of the system, as well as on the final outcome.

This approach addresses, therefore, not only the fit between the corporate, business, and

functional levels of strategy, but very importantly, the person level (Lawrence, 1999).

According to Liedtka (1998): “It is impossible to optimize the outcome of the system for the

end customer, without such understanding. The potential for damage wrought by well-

intentioned but parochial managers optimizing their part of the system at the expense of the

whole is substantial.”

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Thus, from a vertical perspective, strategic thinkers see the linkages in the system from

multiple perspectives and understand the relationship among the corporate, business, and

functional levels of strategies to the external context, as well as to the personal daily choices

they make. From a horizontal perspective, they also understand the connections across

departments and functions, and between suppliers and buyers (Lawrence, 1999).

2.2.3 Thinking in Time

The third element of strategic thinking is referred to as thinking in time. According to Hamel

and Prahalad (Hamel & Prahalad, 1994), strategy is not solely driven by the future, but by

the gap between the current reality and the intent for the future. According to them: Strategic

intent implies a sizeable stretch for an organization. Current capabilities and resources will

not suffice. This forces the organization to be more inventive, to make the most of limited

resources. Whereas the traditional view of strategy focuses on the degree of fit between

existing resources and current opportunities, strategic intent creates an extreme misfit

between resources and ambitions.

Thus, by connecting the past with the present and linking this to the future, strategic thinking

is always “thinking in time.” Neustadt (Neustadt & May, 1986) states that: Thinking in time

(has) three components. One is recognition that the future has no place to come from but the

past, hence the past has predictive value. Another is recognition that what matters for the

future in the present is departures from the past, alterations, changes, which prospectively or

actually divert familiar flows from accustomed channels. A third component is continuous

comparison, an almost constant oscillation from the present to future to past and back,

heedful of prospective change, concerned to expedite, limit, guide, counter, or accept it as

the fruits of such comparison suggest (Lawrence, 1999).

In a nutshell, strategic thinking connects the past, present, and future and in this way, uses

both an institution’s memory and its broad historical context as critical inputs into the

creation of its future. This oscillation between the past, present, and future is essential for

both strategy formulation and execution. Thinking in time needs both a sense of continuity

with the past and a sense of direction for the future to maintain a feeling of control in the

midst of change (Lawrence, 1999).

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2.2.4 Intelligent Opportunism

The essence of this notion is the idea of openness to new experience which allows one to

take advantage of alternative strategies that may emerge as more relevant to a rapidly

changing business environment. Mintzberg (1999) sees this approach as underscoring the

difference between emergent strategy and deliberate strategy. In practicing intelligent

opportunism, it is important that organizations seriously consider the input from lower level

employees or more innovative employees who may be instrumental in embracing or

identifying alternative strategies that may be more appropriate for the environment. For

example, Intel’s predominant role in the microprocessor industry was largely the result of a

renegade band of scientists acting in defiance of senior management’s stated strategic

objectives. Given this, one can well imagine the loss to industry if the focus is only on rigidly

defined and mandated top-down strategies to the exclusion of other emerging strategies and

voices of dissent (Lawrence, 1999).

2.2.5 Hypothesis-driven

Like the “scientific method”, strategic thinking embraces hypothesis generation and testing

as core activities. According to Liedtka (1998), this approach is somewhat foreign to most

managers: Yet in an environment of ever-increasing information availability and decreasing

time to think, the ability to develop good hypotheses and test them efficiently is critical, the

ability to work well with hypotheses is the core competence of the best strategy consulting

firms.

Because strategic thinking is hypothesis-driven, it circumvents the analytical-intuitive

dichotomy that has dominated much of the debate on the value of formal planning. Strategic

thinking is both creative and critical, although accomplishing both types of thinking

simultaneously is difficult, because of the requirement to suspend critical judgement in order

to think more creatively (Lawrence, 1999).

Nonetheless, the scientific method is able to accommodates both creative and analytical

thinking sequentially through its use of iterative cycles of hypothesis generating and testing.

Hypothesis generation poses the creative question, “What if?” Hypothesis testing follows

up with the critical question, “If then.” And evaluates the data relevant to the analysis. Taken

together and repeated longitudinally this process allows an organization to pose a variety of

hypotheses, without sacrificing the ability to explore novel ideas and approaches. The effect

22

is an organization that can transcend simplistic notions of cause and effect and pursue life-

long learning (Lawrence, 1999).

Liedtka (1998) states that, “Taken together, these five elements describe a strategic thinker

with a broad field view that sees the whole and the connections between its pieces, both

across the four vertical levels of strategy and the horizontal elements of the end-to-end value

system.”

2.3 Strategic Planning and Organizational Performance

The process of strategic planning defines where the organization is going and sometimes

where it is not going. It defines the organization and provides focus. At the same time, the

plan sets direction for the organization and – through a common understanding of the vision

and broad goals – provides a template for everyone in the organization to make consistent

decisions that move the organization toward its envisioned future. Strategic planning, in

large part, is a decision-making activity. Although these decisions are often supported by a

great deal of quantifiable data, strategic decisions are fundamentally judgmental. Because

strategic decisions cannot always be quantified, managers must rely on “informed judgment”

in making this type of decision (Swayne, Duncan, & Ginter, 2006). Rather, it must consider

the nature of the future environment in which planning decisions and actions are intended to

operate.

Planning is a process that does not end when a plan is agreed upon rather, it must be

implemented. Also at any time during the implantation and control process, plans may

require modification to avoid becoming useless or even damaging, implying that decisions

must be made at many points in the planning process. For instance, managers must decide

which predictions in such areas as the economy, and the actions of competitions are likely

to be most accurate. They must also analyze organizational resources and decide how to

allocate them to achieve their goals most effectively (Olusanya, Olumuyiwa, Adelaja, &

Chukwuemeka, 2012). Again, Koontz et al (Koontz, O'Donnell, & Weibrich, 1980)

introduces an issue known as the nature of planning which can be highlighted by for aspects

of planning. These aspects are contributions to purpose and objectives‟ primacy of planning,

pervasiveness of planning and efficiency of plans.

23

Two distinct approaches to strategy making have attracted the attention of practitioners and

researchers: the rational approach and the adaptive approach (Grant R. , 2003). The adaptive

approach, which is a process of making strategy based on intuition, creativity, and learning

(Mintzberg H. , 1994), is gaining more interest in today’s dynamic environment. In contrast,

rational strategic planning has been known since the 1950s through the work of Selznick

(Selznick, 1957). It is “a systematic process through which an organization agrees on

priorities that are essential to its mission and are responsive to the environment” (Allison &

Kaye, 2005). Indeed, rational strategic planning is based on the idea that organizations adapt

to changes in their environment by making rational decisions (Chaffee, 1985). Rational

strategic planning is a formal, logical, systematic, and continuous process (Hough & White,

2003) with the following steps: definition of the mission and long-term objectives of the

organization, analysis of its environment, generation and evaluation of strategic alternatives,

implementation of the chosen strategy, and finally, monitoring of the results (Crittenden &

Crittenden, 2000). It is a normative and rational approach to strategy making (Hough &

White, 2003), even though it has been strongly criticized for its uncertain effects on firm

performance (Robinson & Pearce, 1983). Indeed, the proponents of the adaptive approach

to strategy making criticize rational strategic planning, arguing that it bridles creativity and

spontaneity, creates rigidity, and encourages excessive bureaucracy (Mintzberg H., 1994)

therefore reducing the organization’s ability to quickly adapt to change. Nonetheless,

rational strategic planning has many proponents (Ansoff, 1991) (Robinson & Pearce, 1988).

According to them, rational strategic planning is much more effective than an informal

process because it involves the collection and analysis of pertinent information allowing an

organization to make more informed and fact-based strategic decisions and therefore to be

more aligned with its environment.

Also, rational strategic planning enables an organization to determine its strategic direction

(Porter M. , 1996), identify relevant opportunities and effectively seize them (Hough &

White, 2003), and anticipate change and create strategic options to deal with change (Rudd,

Greenley, Beatson, & Lings, 2008). More recently, Casey and Goldman (2010) found that

participation in organized strategic planning processes and involvement in developing

strategic plans enhances strategic thinking. Also, Elbanna (2012) showed that a

comprehensive strategic planning process is a vital tool for improving performance.

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The most important organizational decisions, such as entering a market, introducing a new

service, or acquiring a competitor, although based on information and analysis, are

essentially judgments. Decision consistency is central to strategy; when an organization

exhibits a consistent behavior, it has a strategy (Al isa, 2017). The requirements of decision

consistency suggest that a strategy is the means an organization chooses to move from where

it is today to a desired state sometime in the future. Thus, strategy also may be viewed as a

set of guidelines or a plan that will help assure consistency in decision making and serve as

a map to the future. Strategic plans indicate what types of decisions are appropriate or

inappropriate for an organization. Developing the road map (strategic plan) requires

situational analysis, strategy formulation, and planning the implementation of the strategy

(Swayne, Duncan, & Ginter, 2006).

Strategic planning has received special attention in strategic management research,

particularly in terms of its relationship with financial performance and its role in strategic

decision-making (Grant R. , 2003). In fact, researchers have made considerable efforts to

study the relationship between strategic planning and firm performance because

understanding the nature of this relationship is crucial to organizations. However, the results

of these studies are considered uncertain and contradictory with no clear conclusions

(Falshaw, Glaister, & Tatoglu, 2006) (Grant R. , 2003) (Mintzberg H., 1994). For instance,

Sarason and Tegarden (2003) found a positive relationship between rational strategic

planning and firm performance, Fredrickson and Mitchell (1984) a negative relationship, and

Robinson and Pearce (Robinson & Pearce, 1983) no significant relationship at all.

Given these mitigated results, studies examining the direct bivariate relationship between

rational strategic planning and firm performance have been strongly criticized. Some

researchers have argued that context plays a considerable role in explaining the relationship

between firm processes and outcomes (Child, Elbanna, & Rodrigues, 2010). Therefore,

several contingency factors, such as the organizational structure, the nature of the

environment, and the size of the organization, have been introduced in the study of the

relationship between strategic planning and firm performance (Miller, Burke, & Glick,

1998). It has equally been suggested that some factors may have a mediating role in this

relationship (Rudd, Greenley, Beatson, & Lings, 2008) (Ouakouak & Ouedraogo, 2013). In

this research, we are testing the role of strategic planning on organizational performance.

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2.3.1 Situational Analysis

Analyzing and understanding the situation is accomplished by three separate strategic

thinking activities: external environmental analysis; internal environmental analysis; and the

development or refinement of the organization’s directional strategies. The interaction and

results of these activities form the basis for the development of strategy. These three

interrelated activities drive the strategy (Swayne, Duncan, & Ginter, 2006).

A closer look at these three-interrelated strategic thinking and planning activities is presented

in Figure 2.2 below. These influences must be understood before a strategy can be

formulated, as they represent the organization’s situation. Forces in the external environment

suggest “what the organization should do.” That is, success is a matter of being effective in

the environment – doing the “right” thing. Strategy is additionally influenced by the internal

resources, competencies, and capabilities of the organization and represents “what the

organization can do.” Finally, strategy is driven by a common mission, common vision, and

common set of organizational values and goals – the directional strategies. The directional

strategies are the result of considerable thought and analysis by top management and indicate

“what the organization wants to do.” Together, these forces are the essential input to strategy

formulation. They are not completely distinct and separate; they overlap, interact with, and

influence one another (Swayne, Duncan, & Ginter, 2006).

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Figure 2.2: Analyzing and Understanding the Situation

Source: Luthans, Hodgetts, & Thompson, 1990

2.3.2 Strategy Formulation

Strategy formulation refers to the process through which a firm defines its overall long-term

direction and scope. It involves establishing the way a company creates value through the

configuration of its activities and resources in the markets in which it operates. Strategy

formulation is a purposeful, deliberate exercise to develop a company’s competitive

advantage and thus enhance its performance (Gimbert, Bisbe, & Mendoza, 2010) (Collis &

Montgomery, 2005) (Porter M. , 1996).

The way organizations formulate strategy has become one of the most contested areas of

debate in the strategic management field. In the conventional approach (the so-called

‘prescriptive’ or ‘design’ school of thought), strategy development is mainly the result of a

systematic, rational process of deliberate planning by a top management team, which is then

communicated to the organization for implementation. In large companies, this process

typically occurs through formal strategic planning systems. An alternative approach, based

27

on descriptive studies of strategy formation, sees strategy as the result that emerges from a

complex, multi-level process of organizational decision-making. The realized strategy is

thus the outcome of two simultaneous processes: on the one hand, the execution of the

strategy as conceived by the top management team (deliberate strategy) and, on the other,

the cumulative effect of day-to-day decision-making in a changing environment which

eventually results in the formation of emergent strategies (Mintzberg & Waters, 1985).

Central to the continued survival of any organization is the ability to formulate and execute

an effective strategy despite the limitations of organizational resources and the constraints

of the external environment. Private-sector firms must plan to face challenges from

competitors, rulings of regulatory bodies, shifts in the commercial context including changes

in interest rates and economic activity, and shortages of personnel and supplies. Public-

sector organizations also face many of these challenges but in different forms, as well as the

additional considerations of an election cycle that may cause changes in leadership, a wide

variety of stakeholders with competing agendas, and the subjective nature of success given

these diverse perspectives (Rose & Cray, 2010).

2.4 Strategy Implementation and Organizational Performance

The third element of strategic management shown in Figure 2.2, strategic momentum

(strategic implementation), concerns the day-to-day activities of managing the strategy to

achieve the strategic goals of the organization. Thus, once plans are developed, they must be

actively managed and implemented to maintain the momentum of the strategy. Strategic

thinking and periodic planning should never stop; they become ingrained in the culture and

philosophy of a strategically managed organization. As part of managing the strategy,

strategic momentum: is the actual work to accomplish specific objectives, concerns decision-

making processes and their consequences, provides the style and culture, fosters anticipation,

innovation, and excellence, evaluates strategy performance through control, is a learning

process, and relies on and reinforces strategic thinking and periodic strategic planning

(Swayne, Duncan, & Ginter, 2006).

Strategic planning activities are common in all types of organizations. Top managers come

together to develop a strategic plan, often using strategic thinking, and many important issues

28

are discussed and documented. However, sometimes a strategic plan is created and everyone

enthusiastically returns to the organization only to find “business as usual” – nothing really

changes, the strategic momentum is lost, and plans are never implemented. This is a critical

issue for all organizations, as many have noted before, implementing strategy is often more

difficult than formulating it, and it is widely accepted to be an aspect of management where

many organizations fail (Hrebiniak, 2006) (Nutt P. , 1999). As next year rolls around, it is

once again time for the annual strategic planning retreat and the cycle repeats itself. This is

an example of strategic planning without strategic momentum. Alan Weiss, in his irreverent

book, Our Emperors Have No Clothes, explains that in these situations the problem is that,

“Strategy is usually viewed as an annual exercise at best, an event that creates a ‘product,’

and not a process to be used to actually run the business” (Weiss, 1995). Moreover, much of

the process literature focuses on the effects of strategy formulation, and there is very little

evidence on the processes that organizations use when implementing their strategies and the

consequences for performance (Bantel & Osborn, 2001) (Dobni & Luffnan, 2003).

Strategic implementation ensures an ongoing philosophy for developing and managing the

plans, actions, and control of the organization. It attempts to continually orchestrate a fit

between the organization’s external environment (political, regulatory, economic,

technological, social, and competitive forces) and its internal situation (culture, organization

structure, resources, products and services, and so on). In some cases, orchestrating the fit

may mean responding to external forces; in other cases, the organization may attempt to

actually shape its environment (change the rules for success). External change is inevitable;

often the shifts may be subtle, other times they can be discontinuous and extremely

disruptive. When such dramatic changes occur, new opportunities emerge and new

competencies are born, while others die or are rendered inconsequential. Inevitably, the basic

rules of competing and survival will change (Mische, 2001).

For many organizations, strategic planning is the easiest part of strategic management and

the planning process receives the greatest attention. However, plans must be implemented

to create momentum and to realize strategic intent. Poor implementation or lack of

implementation has rendered many strategic plans as worthless. Whereas the strategic plan

and its underlying strategic thinking must be viewed as important, they fall apart without

implementation and the decision-making guidelines provided for managers at all levels in

the organization (Swayne, Duncan, & Ginter, 2006).

29

If the strategy is not actively managed, it will not happen. Sometimes it is difficult for

managers to plan or envision the long-term future of an organization in a dynamic

environment. Managers often need to react to unanticipated developments and new

competitive pressures. Different environmental characteristics and different organizational

forms require new and different ways of defining strategy (Camillus, 1996).

Strategy becomes an intuitive, entrepreneurial, political, culture-based, or learning process.

In these cases, maps are of limited value. Managers must create and discover an unfolding

future, using their ability to learn together in groups and interact politically in a spontaneous,

self-organizing manner. However, learning is difficult in organizations. Learning requires

engagement, mastering unfamiliar ideas, and adopting new behaviors. Engaged learning

demands that executives share leadership, face harsh truths, and take learning personally. It

requires them to fundamentally change the way they manage (Linder, 2000).

As a result, strategy emerges spontaneously from the chaos of challenge and contradiction,

through a process of real-time learning and politics. For these uncharted, complex situations,

a compass indicating a general direction, steadied by leadership, may be more appropriate

than a map of known events, territories, and ideas. Clearly, rational strategies do not always

work out as planned (an unrealized strategy). In other cases, an organization may end up

with a strategy that was quite unexpected as a result of having been “swept away by events”

(an emergent strategy) (Swayne, Duncan, & Ginter, 2006).

Figure 2.3: Intended Versus Realized Strategy

Source: Mintzberg H. , Patterns in Strategy Formation, 1978

30

Mintzberg added several possible outcomes to those presented in Figure 2.5. For example,

he discussed strategies that, as they were realized, changed form and became, in part at least,

emergent; emergent strategies that were formalized as deliberate ones; and intended

strategies that were over-realized. It is quite possible that a strategy may be developed and

subsequently realized. However, we must be realistic enough to understand that when we

engage in strategic management the theoretical ideal (strategy developed, then realized) may

not, and in all probability, will not, be the case. A great deal may go wrong (Mintzberg H. ,

Patterns in Strategy Formation, 1978).

One factor that may mediate the impact of implementation style on performance is the

strategy of the organization. The argument that organizations should adapt their internal

characteristics to reflect their strategies has a venerable status in the management literature,

and research on private organizations broadly supports the view that a fit between strategies

and processes is associated with better performance (Donaldson, 1996) (Govindarajan,

1988). Miles and Snow’s (1978) seminal model of strategic management suggested that

strategies fall into a small number of ideal types and that to achieve success, they should be

consistently related to the organization’s internal processes. Our conceptualization of

strategy is based on Miles and Snow’s typology of four ideal types of organizational

strategies. Prospectors are organizations that “almost continually search for market

opportunities, and regularly experiment with potential responses to emerging environmental

trends” (Miles & Snow, 1978). In the public sector, prospectors often seek to expand budgets

and pioneer the development of new products and services. Defenders are organizations that

take a conservative view of new product development. They typically compete on price and

quality rather than on new products or markets and “devote primary attention to improving

the efficiency of their existing operations” (Miles & Snow, 1978); in short, they seek better

performance on a limited number of core products and services.

Public sector defenders are likely to focus on low-risk strategies designed to enhance the

efficiency of their existing services. Analyzers represent an intermediate category, sharing

elements of both prospector and defender. Reactors are organizations in which top managers

frequently perceive change and uncertainty in their organizational environments but lack a

consistent and stable strategy. A reactor “seldom makes adjustment of any sort until forced

to do so by environmental pressures” (Miles & Snow, 1978). Reactors in the public sector

lack a strategy of their own but wait to be cajoled or coerced by external forces, such as the

31

interventions of regulators. Boyne and Walker (Boyne & Walker, 2004) evaluated the

relevance of the Miles and Snow (1978) framework to public organizations. They criticize

most prior research on strategy content for placing organizations in mutually exclusive boxes

and assuming that each organization has only a single strategic orientation and is, for

example, just a prospector or a defender. Boyne and Walker argued that organizations’

strategies are messy and complex rather than neat and simple. A mix of strategies is likely

to be pursued at the same time, so it is inappropriate to categorize organizations as belonging

solely to a single type (e.g., reactor or prospector).

2.5 Chapter Summary

Chapter Two presents the literature review. It discusses the existing literature on strategic

management tools and techniques, their use and effect on organizational performance. The

discussion tackles all the research questions posed and provides a firm theoretical

background for the study. The next chapter, Chapter Three covers the methodology used in

the study.

32

CHAPTER THREE

3.0 RESEARCH METHODOLOGY

3.1 Introduction

This chapter presents the research methodology. The chapter covers research design,

population and sampling design, data collection methods, research procedures, data analysis

methods and chapter summary.

3.2 Research Design

Research design constitutes the blueprint for the collection, measurement, and analysis of

data. It aids the researcher in the allocation of limited resources by posing crucial choices in

methodology (Cooper & Schindler, 2011). The function of a research design is to ensure that

the evidence obtained enables us to answer the initial question as unambiguously as possible

(Vaus, 2005). It is a plan and structure of investigation so conceived as to obtain answers to

research questions. The plan is the overall scheme or program of the research. It includes an

outline of what the investigator will do from writing hypotheses and their operational

implications to the final analysis of data. Research design expresses both the structure of the

research problem – the framework, organization or configuration of the relationships among

variables of a study - and the plan of investigation used to obtain empirical evidence on

those relationships (Cooper & Schindler, 2011).

This study was descriptive and the study design was cross – sectional. The study was

designed to capture utilization of strategic management in health institutions in Nairobi,

representing a snapshot of one point in time. Being descriptive in nature, it will help find out

who, what, where, and by whom. The study looked at strategic thinking, strategic planning

and strategy implementation in health institutions, and how the health institution

management committees or boards are involved in strategy. The study described and

explained phenomena that observations reflected measure social reality or describe what was

in use in health institutions in Nairobi. The independent variables were strategic thinking,

33

strategic planning and strategy implementation, while the dependent variable was

organizational performance.

3.3 Population and Sampling Design

3.3.1 Population

Population is a collection of persons, objects, or items of interest (Black, 2012), while

Saunders and Lewis define population as the complete set of cases or group members

(Saunders, Lewis, & Thornhill, 2012). The definition of the word population according to

Cooper and Schindler is the most comprehensive one; a population is the total collection of

elements about which we wish to make inferences (Cooper & Schindler, 2001). The study

population was the management at health institutions that are Kenya Essential Package for

Health (KEPH) Level Four, Five and Six, and are in Nairobi County. The population was

composed of hospitals, major laboratories and a national blood transfusion center. The

ownership of these health institutions varied from Government (Ministry of Health, Armed

Forces), Private Enterprise and Faith – Based (Kenya Episcopal Conference-Catholic

Secretariat and Christian Health Association of Kenya).

Table 3.1: Population Distribution

Health Institution KEPH Level Number Percentage

Level 4 30 82%

Level 5 4 11%

Level 6 3 8%

Total 37 100%

Source: Ministry of Health Master Health Facility List (2017)

34

3.3.2 Sampling Design

3.3.2.1 Sampling Frame

Sampling frame is a list of elements in the population from which the sample is actually

drawn from (Cooper & Schindler, 2001), while Saunders and Lewis state define a sampling

frame as, the complete list of all the cases in the population, from which a probability sample

is drawn (Saunders, Lewis, & Thornhill, 2012). For this study, the sampling frame was the

list of all health institutions that were KEPH level four or five or six, and in Nairobi County

based on the Kenya Master Health Facility List (Ministry of Health, 2017). The health

institution was the sampling unit.

3.3.2.2 Sampling Technique

Sampling technique is the scientific procedure of selecting those sample units which would

provide the required estimates with associated margins of uncertainty, arising from

examining a part not the whole (George Mason University, 2017). A census was used to

enroll every health institution into this study since they are few, and the unit of analysis was

the health institution. Census is an attempt to collect data from every member of the

population being studied rather than choosing a sample (SAGE, 2017). This was settled on

since the number of the population is small.

3.3.2.3 Sample Size

Having the total number of health institutions that are KEPH level four or five or six in

Nairobi County being 37 (population size, N) according to the Kenya Master Health Facility

List, the entire population was enrolled into the study since it was a census.

3.4 Data Collection Methods

Primary data for this study was collected using a structured self-administered questionnaire

administered to the study prospective participants after they had been recruited and enrolled.

The questionnaire had closed ended questions. In addition, Likert scales were used to capture

ordinal level of data. Further, nominal, interval and ratio levels of data were captured too.

The questionnaire was structured into five sections covering the demographic information

of the interviewee and health institution, strategic thinking, strategic planning, strategy

35

implementation and organizational performance. The questionnaire used in the study

captured both qualitative and quantitative data.

Data was collected using a structured self – administered questionnaire for the following

reasons: allows contact with otherwise inaccessible respondents (e.g. CEO), often the lowest

– cost option, expanded geographic coverage without increase in costs, required minimal

staff, perceived as more anonymous, allowed respondents time to think about questions,

more complex instruments can be used, fast access to the computer literate, rapid data

collection, visuals may be used (Cooper & Schindler, 2001). Additional benefits were:

cheaper and quicker to administer (to widely dispersed populations), absence of interviewer

effects and variation and convenient for respondents (University of Zagreb, 2017).

3.5 Research Procedures

Pilot test refers to mini-versions of a full-scale study (also called ‘feasibility’ studies), as

well as the specific pre-testing of a particular research instrument such as a questionnaire or

interview schedule (van Teijlingen & Hundley, 2002). The questionnaire was pilot tested

among 10 participants to detect weakness in design and instrumentation. The tool was

reviewed after the pilot and refined further with feedback from the pilot.

The traditional criteria for validity find their roots in a positivist tradition, and to an extent,

positivism has been defined by a systematic theory of validity. Within the positivist

terminology, validity resided amongst, and was the result and culmination of other empirical

conceptions: universal laws, evidence, objectivity, truth, actuality, deduction, reason, fact

and mathematical data to name just a few (Winter, 2000). Validity in quantitative research

is defined as “construct validity”. The construct is the initial concept, notion, question or

hypothesis that determines which data is to be gathered and how it is to be gathered. They

also assert that quantitative researchers actively cause or affect the interplay between

construct and data in order to validate their investigation, usually by the application of a test

or other process. In this sense, the involvement of the researchers in the research process

would greatly reduce the validity of a test (Golafshani, 2003).

To establish how representative the study was and suitability of the questions, the feedback

from the supervisor was sought that improved the content and structure of the questionnaire.

36

Reliability is defined as the extent to which results are consistent over time and an accurate

representation of the total population under study is referred to as reliability and if the results

of a study can be reproduced under a similar methodology, then the research instrument is

considered to be reliable (Golafshani, 2003). Embodied in this citation is the idea of

replicability or repeatability of results or observations. There are three types of reliability

referred to in quantitative research, which relate to: the degree to which a measurement,

given repeatedly, remains the same; the stability of a measurement over time; and the

similarity of measurements within a given time period (Kirk & Miller, 1986). The researcher

selected a pilot group of ten managers at three health institutions who did not participate in

the main study to test the stability of the questionnaire. In order to test the reliability of the

questionnaire, internal consistency techniques will be applied using Cronbach’s alpha. The

pilot data was not included in the actual study.

The questionnaire was converted to an online platform. Data was collected from 28th July

2017 to 15th September 2017. Further, to improve response rates, the study participants were

assured of anonymity and feedback from the results of the study.

3.6 Data Analysis Methods

The data from the study was stored on a private web – based platform (https://ona.io) from

where it was downloaded in excel spreadsheet format. Once downloaded, the data was coded

and cleaned. The cleaned data was then analyzed using descriptive statistics, i.e. measures

of central tendency and of variability, and inferential statistics using regression. After

analysis, the data was then presented in tables and figures. Stata 12 ® is the statistical

software that was used to analyze the data.

Output from the Likert Scales were converted to a binary format by aggregating agree and

strongly agree as “agree” and the rest as “disagree”. In addition, various variables under

each of the broad sections of strategic thinking, planning and implementation were then

aggregated and cut off points established at the mid – points so as to determine if the health

institution carried out strategic thinking, planning and strategy implementation or no, and

what their attitudes were. Further, comparisons were made between actual practice of

strategic thinking, planning and implementation and attitudes if they improved

organizational performance.

37

The study measured organizational performance as numbers of outpatients, inpatients seen

or samples processed. To standardize them, the change between the years 2016 and 2014 as

the base year (reference point), was measured and converted to percentage.

Pearson correlation was used as a bivariate analysis method to measure the strengths of

association between two variables and the direction of the relationships. The dependent

variable of the study was organizational performance, while the independent variables were

strategic thinking, planning and strategy implementation. This was used to measure the

strength and direction of relationships.

3.7 Chapter Summary

Chapter Three presents the research methodology used in this study. It details the research

design, population and sampling, data collection methods, research procedures and how data

collected is to be analyzed. The next chapter, Chapter Four presents the study findings.

38

CHAPTER FOUR

4.0 RESULTS AND FINDINGS

4.1 Introduction

This chapter presents the key results and findings of the research study. The questionnaires

administered aimed to answer the three research questions on the effect of strategic thinking,

planning and strategy implementation on organizational performance of health institutions

in Nairobi County. The results and findings as derived from the responses are discussed here.

In addition, the chapter closes with a summary.

4.2 General Information

A total of 24 questionnaires were administered to the sample elements of 37 health

institutions across Nairobi County, giving a response rate of 65%. The completed

questionnaires were cleaned, coded, then analyzed using Stata 12 ®.

4.2.1 Gender of Study Respondents

The descriptive statistics show that the gender split is 14 (58%) for male respondents and 10

(42%) for female respondents as captured in Table 4.1 below.

Table 4.1: Gender of Study Respondents

Variable Number (%)

Gender Male 14 (58%)

Female 10 (42%)

Total 24 (100%)

39

4.2.2 Designation of Study Respondents

Of the study respondents who participated in the survey, 22 (92%) were top-tier management

(CEO, CFO, COO, Chief Matron, Medical Superintendent, Hospital Administrator) and 2

(8%) Mid-level Management. This is captured in Table 4.2 below.

Table 4.2: Designation of Study Respondents

Variable Number (%)

Designation of

Respondents

Top-tier management

(CEO, CFO, COO, Chief Matron, Medical

Superintendent)

22 (92%)

Mid-level Management 2 (8%)

Other 0 (0%)

Total 24 (100%)

4.2.3 Age of Study Respondents

The study was interested in knowing the age of respondents. The distribution of the

respondent age was normal as shown in Figure 4.1 below, with the mean age of the 24

respondents as 39.83 years, with a standard deviation of 7.57 years.

40

Figure 4.1: Distribution of Respondents’ Age

4.2.4 Respondents’ Duration in Post

The study was interested in knowing the duration the respondents had lasted in post. The

distribution the 24 respondents had taken in – post was skewed to the right as shown in

Figure 4.2 below, with a median duration of 3 years and an IQR of 2.0 – 5.5 years.

Figure 4.2: Distribution of Respondents’ Duration in post

01

23

45

Fre

que

ncy

20 30 40 50 60Repondent Age (Years)

Distribution of Respondent Age

05

10

15

20

Fre

que

ncy

0 5 10 15 20Duration in-post (Years)

Distribution of Duration in-post

41

4.2.5 Health Institutions’ KEPH Level

Of the health institutions that participated in the survey, 3 (13%) were Level 6, 1 (4%) Level

5 and 20 (83%) Level 4. This is captured in Table 4.3 below.

Table 4.3: Health Institutions’ KEPH Level

Variable Number (%)

KEPH Level Level 6 3 (13%)

Level 5 1 (4%)

Level 4 20 (83%)

Total 24 (100%)

4.2.6 Health Institutions Type

Of the health institutions that participated in the survey, 4 (17%) were laboratories, 15 (63%)

primary care hospitals, 2 (8%) secondary care hospitals, 2 (8%) comprehensive and referral

hospitals, and 1 (4%) dispensaries and outpatient only. This is captured in Table 4.4 below.

Table 4.4: Health Institutions Type

Variable Number (%)

Health Institution

Type

Laboratory 4 (17%)

Primary Care Hospital 15 (63%)

Dispensaries and clinic-out patient only 1 (4%)

Secondary Care Hospital 2 (8%)

Comprehensive Teaching & Referral 2 (8%)

Total 24 (100%)

42

4.2.7 Health Institution Ownership

As regards ownership, of the health institutions that participated in the survey, 9 (38%) are

owned by Government (National and County), 12 (50%) private, and 3 (12%) faith based.

This is captured in Table 4.5 below.

Table 4.5: Health Institution Ownership

Variable Number (%)

Health Institution

Type

Government 9 (38%)

Private 12 (50%)

Faith Based 3 (12%)

Total 24 (100%)

4.3 Strategic Thinking and Organizational Performance

4.3.1 Systems Perspective

To test if the health institutions had mental models of the complete system of value creation

from beginning to end, and that understood the interdependencies within the chain, the study

checked if top executives were assigned formal responsibility for strategic thinking, strategic

planning was a top priority and if the institution followed a designed set of standard operating

procedures in the strategic thinking. Further, it was explored on the perceptions of the

institutions if the above-mentioned parameters improved organizational performance.

In the health facilities that participated in the survey, all i.e. 24 (100%) had strategic planning

as a top priority, while 22 (92%) top executives are assigned formal responsibility for

strategic planning and 17 (71%) followed a defined set of procedures during strategic

planning process. This is captured in table 4.6 below.

43

Table 4.6: Health Institutions Carrying out Systems Perspective during Strategic

Thinking

Health Institutions carrying out Systems Perspective

Yes No

Top executives assigned formal responsibility 22 (92%) 2 (8%)

Strategic planning a top priority 24 (100%) 0 (0%)

Follow a designed set of procedures 17 (71%) 7 (29%)

In the health facilities that participated in the survey, all i.e. 24 (100%) agreed that assigning

top executives formal responsibility for strategic planning improves organizational

performance, while 23 (96%) agreed that having strategic planning as a top priority improves

organizational performance and 21 (88%) agreed that following a defined set of procedures

during strategic planning process improves organizational performance. This is captured in

table 4.7 below.

Table 4.7: Perspective if System Perspective Improves Organizational Performance

Perception if Systems Perspective improves Organization Performance

Agree Disagree

Top executives assigned formal responsibility 24 (100%) 0 (0%)

Strategic planning a top priority 23 (96%) 1 (4%)

Follow a designed set of procedures 21 (88%) 3 (12%)

44

4.3.2 Intent focused

In this study, strategic intent implied a particular point of view about the long-term market

or competitive position that a health institution hoped to build over the coming decade or so.

Hence, it conveyed a sense of direction. Strategic intent was differentiated; it implied a

competitively unique point of view about the future. In the study, it was measured by

provision of resources for strategic planning, awareness of strategy among management and

higher-level staff, and if the institution had written goals that allowed individuals within an

institution to marshal and leverage their energy, to focus attention, to resist distraction, and

to concentrate for as long as it takes to achieve them.

Of the health institutions that participated in the survey, 21 (88%) provided resources (time,

money, staff support) specifically earmarked for strategic planning, while 22 (92%) had their

management and higher-level staff aware of their institution's mission and understood it. In

addition, 20 (83%) had written goals (short or long term). Further, 19 (79%) had written

goals quantified with measurable targets (e.g. volume, market share, growth rate,

profitability). This is elaborated in table 4.8 below.

Table 4.8: Actual Implementation of Intent Focused

Health Institutions carrying out Intent Focused

Yes No

Provision of resources for strategic planning 21 (88%) 3 (12%)

Management & higher – level staff aware of mission 22 (92%) 2 (8%)

Written Goals 20 (83%) 4 (17%)

Written goals quantified with measurable targets 19 (79%) 5 (21%)

In the health institutions that participated in the survey, 23 (96%) agreed that provision of

resources (time, money, staff support) specifically earmarked for strategic planning

improves organizational performance, while 23 (96%) agreed that awareness among

management and higher-level staff of the institution's mission improves organizational

45

performance. In addition, 22 (92%) agreed that having written goals (short or long term)

improves organizational performance. Further, 23 (96%) agreed that having written goals

quantified with measurable targets (e.g. volume, market share, growth rate, profitability)

improves organizational performance. This is outlined in table 4.9 below.

Table 4.9: Perception if Intent Focused Improves Organizational Performance

Perception if Intent Focused improves Organization Performance

Agree Disagree

Provision of resources for strategic planning 23 (96%) 1 (4%)

Management & higher – level staff aware of mission 23 (96%) 1 (4%)

Written Goals 22 (92%) 2 (8%)

Written goals quantified with measurable targets 23 (93%) 1 (4%)

4.3.3 Thinking in time

Thinking in time connects the past, present, and future and in this way, uses both an

institution’s memory and its broad historical context as critical inputs into the creation of its

future. This oscillation between the past, present, and future is essential for both strategy

formulation and execution. This was measured by the level of participation of management

and higher – level staff in goal setting in view of the institution’s broad historical context.

Of the health institutions that participated in the survey, none (0%) had their management

and higher-level staff participating in goal setting. This is aptly captured in table 4.10 below.

Table 4.10: Actual Implementation of Thinking in Time

Health Institutions carrying out Intent Focused

Yes No

Management & higher – level staff participate in goal setting 0 (0%) 24 (100%)

46

All of the health institutions that participated in the survey, 24 (100%), agreed that

management and higher-level staff participation in goal setting improves organizational

performance. This is captured in table 4.11 below.

Table 4.11: Perception if Thinking in Time Improves Organizational Performance

Perception if Thinking in Time improves Organization Performance

Agree Disagree

Management & higher – level staff participation in goal setting 24 (100%) 0 (100%)

4.3.4 Hypothesis driven

In an environment of ever-increasing information availability and decreasing time to think,

the ability to develop good hypotheses and test them efficiently is critical, the ability to work

well with hypotheses is the core competence of the best institutions. The study measured if

the institutions’ strategic thinking were hypothesis driven by measuring if they compared

actual performance versus actual goals set. Of the health institutions that participated in the

study, 21 (88%) measured actual performance versus goals set. This is in table 4.12 below.

Table 4.12: Actual Implementation of Hypothesis Driven

Health Institutions carrying out Hypothesis Driven

Yes No

Measuring actual performance vs goals 21 (88%) 3 (12%)

Further, 21 (88%) of the health institutions that participated in the study agreed that

measuring actual performance versus goals set improves organizational performance. This

is in table 4.13 below.

47

Table 4.13: Perception if Hypothesis Driven Improves Organizational Performance

Perception if Hypothesis Driven improves Organization Performance

Agree Disagree

Measuring actual performance vs goals 21 (88%) 3 (12%)

4.3.5 Intelligent Opportunism

The study measured intelligent opportunism by checking how many had a written mission

statement and if it captured openness to new experience which allows the institution take

advantage of alternative strategies that may emerge as more relevant to a rapidly changing

business environment. In the health institutions that participated in the survey, 21 (88%) had

a written mission statement as indicated in table 4.14 below.

Table 4.14: Actual Implementation of Intelligent Opportunism

Health Institutions carrying out Intelligent Opportunism

Yes No

Written Mission Statement 21 (88%) 3 (12%)

Further, 23 (96%) of the health institutions that participated in the survey agreed that having

a written mission statement improves organizational performance as indicated in table 4.15

below.

Table 4.15: Perception if Intelligent Opportunism Improves Organizational

Performance

Perception if Intelligent Opportunism improves Organization Performance

Agree Disagree

Written Mission Statement 23 (96%) 1 (4%)

48

4.3.5 Summary of Strategic Thinking and Organizational Performance

In aggregate, 23 (96%) of the health institutions surveyed carry out strategic thinking while

7 (29%) agreed that strategic thinking improves organizational performance as captured in

tables 4.16 and 4.17 respectively.

Table 4.16: Actual Implementation of Strategic Thinking

Health Institutions carrying out Strategic Thinking

Yes No

Strategic Thinking 23 (96%) 1 (4%)

Table 4.17: Perception if Strategic Thinking Improves Organizational Performance

Perception if Strategic Thinking improves Organization Performance

Agree Disagree

Strategic Thinking 7 (29%) 17 (71%)

Of the 23 health institutions that were implementing strategic thinking, only 7 agreed that it

improves organizational performance, while the rest disagreed. This is captured in table 4.18

below.

Table 4.18: Comparison Between Actual Practice and Perception if Strategic

Thinking Improves Organizational Performance

Perception if Strategic Thinking

Improves Organizational

Performance

Agree Disagree Total

Actual Implementation

of Strategic Thinking

Yes 7 16 23

No 0 1 1

Total 7 17 24

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4.4 Strategic Planning and Organizational Performance

Strategic planning is a decision-making and documentation process that creates the strategic

plan. In the study, this was further broken down to two broad areas namely: situational

analysis and strategy formulation.

4.4.1 Situational Analysis

Situation analysis refers to a collection of methods that managers use to analyze a health

institution's internal and external environment to understand its institution's capabilities,

customers, and business environment.

One of the greatest challenges for health care institutions is identifying the changes that are

most likely to occur and then planning for that future. This study grouped the health sector

environment into the following broad categories: legislative/political, economic,

social/demographic and competitive.

In the legislative/ political category, 20 (83%) of the health institutions that participated in

the survey assessed factors such as cost and availability of capital, government regulations

and state of the economy.

In the analysis of economic factors, 21 (88%) of health institutions had knowledge of and

access to sources of information about the health sector, markets, and other external factors.

In addition, 18 (75%) of health institutions analyzed profitability indicator trends (after-tax

earnings, return on assets, etc.).

In the social/ demographic category, 17 (71%) health institutions analyzed demographic,

behavioral and other consumer trends. In addition, 21 (88%) analyzed their pricing strategy

and its effects on customer behavior. Further, 22 (92%) analyzed quality of customer service,

satisfaction, loyalty and defection data.

In the situational analysis of competition, 20 (83%) health institutions periodically gathered

and analyzed data about the health market and other external factors which affect the

business. Of the health institutions surveyed, 22 (92%) identified key threats and

opportunities during market analysis, while 18 (75%) compared their performance and

operational characteristics with those of competitors. In addition, 20 (83%) assessed the

health sector as whole in terms of new competitors and concepts, new technologies,

50

procurement practices, price trends, labor practices. Further, 22 (92%) of health institutions

analyzed their key strengths and weaknesses, while 21 (88%) assessed its human resource

management and development programs.

After conducting the situational analysis, management of 23 (96%) health institutions had

access to the internal data discussed above. Key strategic issues (e.g. outlet expansion,

profitability improvement, positioning change) were identified in 17 (71%) health

institutions after conducting a situational analysis review. These are captured in table 4.19

below.

51

Table 4.19: Actual Implementation of System Perspective

Health Institutions carrying out Situational Analysis

Yes No

Assessment of factors such as cost and availability of capital,

government regulations and state of the economy

20 (83%) 4 (17%)

Knowledge of and access to sources of information about the

sector, markets, and other external factors

21 (88%) 3 (12%)

Profit trends analysis 18 (75%) 6 (25%)

Analysis of demographic, behavioral & other consumer trends 17 (71%) 7 (29%)

Analysis of pricing strategy and its effects on customer behavior 21 (88%) 3 (12%)

Analysis of quality of customer service, satisfaction, loyalty &

defection data

22 (92%) 2 (8%)

Market analysis 20 (83%) 4 (17%)

Threats & Opportunities 22 (92%) 2 (8%)

Comparison with competitors 18 (75%) 6 (25%)

Assessment of the sector as whole in terms of new competitors

and concepts, new technologies, procurement practices, price

trends, labor practices

20 (83%) 4 (17%)

Strengths and weaknesses 22 (92%) 2 (8%)

Assessment of human resource management and development

programs

21 (88%) 3 (12%)

Management access to internal information 23 (96%) 1 (4%)

Identification of key strategic issues after conducting a

situational analysis review

17 (71%) 7 (29%)

52

The study measured the perception if situational analysis improves organizational

performance. In the legislative/ political category, 22 (92%) of the health institutions that

participated in the survey agreed that assessment of factors such as cost and availability of

capital, government regulations and state of the economy improves organizational

performance.

As regards analysis of economic factors, 21 (88%) of health institutions surveyed agreed

having knowledge of and access to sources of information about the health sector, markets,

and other external factors improves organizational performance. In addition, 23 (96%) of

health institutions agreed that analysis of profitability indicator trends (after-tax earnings,

return on assets, etc.) improves organizational performance.

In the social/ demographic category, 19 (79%) health institutions agreed that analysis of

demographic, behavioral and other consumer trends improves organizational performance.

In addition, 22 (92%) agreed that analysis of pricing strategy and its effects on customer

behavior improves organizational performance. Further, 23 (96%) agreed that analysis of

quality of customer service, satisfaction, loyalty and defection data improves organizational

performance.

As regards analysis of competition, 22 (92%) health institutions agreed that periodically

gathering and analyzing data about the health market and other external factors which affect

the business improves organizational performance. Of the health institutions surveyed, all

24 (100%) agreed that identification of key threats and opportunities during market analysis

improves organizational performance, while 21 (88%) agreed that comparing their

performance and operational characteristics with those of competitors improves

organizational performance. In addition, 22 (92%) agreed that assessment of the health

sector as whole in terms of new competitors and concepts, new technologies, procurement

practices, price trends, labor practices improves organizational performance. Further, all 24

(100%) of health institutions surveyed agreed that analysis of their key strengths and

weaknesses improves organizational performance. Finally, 22 (92%) health institutions

agreed that assessment of their human resource management and development programs

improves organizational performance.

As regards management access to the internal data, all 24 (100%) health institutions

surveyed agreed that it improves organizational performance. In addition, 23 (96%) of health

53

institutions agreed that identification of key strategic issues (e.g. outlet expansion,

profitability improvement, positioning change) after conducting a situational analysis review

improves organizational performance. These are captured in table 4.20 below.

Table 4.20: Perception if System Perspective Improves Organizational Performance

Perception if Systems Perspective improves Organization Performance

Agree Disagree

Assessment of factors such as cost and availability of capital,

government regulations and state of the economy

22 (92%) 2 (8%)

Knowledge of and access to sources of information about the

sector, markets, and other external factors

21 (88%) 3 (12%)

Profit trends analysis 23 (96%) 1 (4%)

Analysis of demographic, behavioral & other consumer trends 19 (79%) 5 (21%)

Analysis of pricing strategy and its effects on customer

behavior

22 (92%) 2 (8%)

Analysis of quality of customer service, satisfaction, loyalty &

defection data

23 (96%) 1 (4%)

Market analysis 22 (92%) 2 (8%)

Threats & Opportunities 24 (100%) 0 (0%)

Comparison with competitors 21 (88%) 3 (12%)

Assessment of the sector as whole in terms of new competitors

and concepts, new technologies, procurement practices, price

trends, labor practices

22 (92%) 2 (8%)

Strengths and weaknesses 24 (100%) 0 (0%)

Assessment of human resource management and development

programs

22 (92%) 2 (8%)

Management access to internal information 24 (100%) 0 (0%)

Identification of key strategic issues after conducting a

situational analysis review

23 (96%) 1 (4%)

4.4.2 Strategy Formulation

Strategy formulation is the process by which a health institution chooses the most

appropriate courses of action to achieve its defined goals, based on the situational analysis.

The study evaluated if health institutions formulate strategies based on situational analysis

and what strategic management techniques and tools are in use. In addition, the study

evaluated the perceptions of the managers if strategy formulation based on situational

54

analysis and use of strategic management tools and techniques improve organizational

performance.

Of the health institutions surveyed, 19 (79%) formulated strategies based on situational

analysis as captured by table 4.21 below.

Table 4.21: Actual Formulation of Strategies based on Situational Analysis

Health Institutions Formulating Strategies based on Situational Analysis

Yes No

Use of situational analysis to formulate strategic plans 19 (79%) 5 (21%)

Among the 24 health institutions surveyed, 22 (92%) agreed that use of situational analysis

to formulate strategies improves organizational performance. In addition, all 24 (100%) of

them agree that use of strategic management techniques and tools improves organizational

performance. This is captured in table 4.22 below.

Table 4.22: Perception if Strategy Formulation Improves Organizational

Performance

Perception if Strategy Formulation improves Organization Performance

Agree Disagree

Use of situational analysis to formulate strategic plans 22 (92%) 2 (8%)

Strategic Management Techniques and Tools 24 (100%) 0 (0%)

Among the strategic management tools and techniques that the survey covered, mission and

vision statements (71%), benchmarking (67%) and customer relationship management

(63%) were the most popular in use across all health institutions irrespective of the

ownership.

55

Benchmarking (78%) and mission and vision statements (67%) were the two most popular

strategic management techniques and tools in use among health institutions owned by the

Government. In privately owned health institutions, customer relationship management was

the most utilized strategic management technique and tool at 83%, followed by social media

programs (67%), and mission and vision statements (67%). In the faith – based organization

owned health institutions, mission and vision statements was utilized in all of them (100%),

and there was a tie in the utilization of benchmarking, business process reengineering,

customer relationship management and outsourcing at 67%. These are captured in table 4.23

below.

Table 4.23: Strategic Management Techniques in Use Stratified by Health Institution

Ownership

Strategic Management Tool Government

n

Faith

Based

N

Private

n

Total

n

Balanced Scorecard 3 0 4 7

Benchmarking 7 2 7 16

Big Data Analytics 2 0 3 5

Business Process Reengineering 1 2 5 8

Change Management Programs 2 0 7 9

Complexity Reduction 0 1 0 1

Core Competencies 4 1 6 11

Customer Relationship

Management

3 2 10 15

Customer Segmentation 1 0 6 7

56

Decision Rights Tools 1 0 0 1

Downsizing 0 1 1 2

Employee Engagement Surveys 3 1 6 10

Mergers and Acquisitions 0 0 1 1

Mission and Vision Statements 6 3 8 17

Open Innovation 2 1 3 6

Outsourcing 2 2 6 10

Price Optimization Models 2 1 3 6

Satisfaction and Loyalty

Management

2 1 4 7

Scenario and Contingency

Planning

1 0 3 4

Social Media Programs 1 1 8 10

Strategic Alliances 0 1 3 4

Supply Chain Management 4 0 3 7

Total Quality Management 3 1 3 7

Zero based Budgeting 2 0 0 2

4.4.3 Summary of Strategic Planning and Organizational Performance

In aggregate, 15 (63%) of the health institutions surveyed carried out strategic planning,

while only 6 (25%) agreed that it improved organizational performance as indicated in tables

4.24 and 4.25 below.

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Table 4.24: Actual Implementation of Strategic Planning

Health Institutions carrying out Strategic Planning

Yes No

Strategic Planning 15 (63%) 9 (37%)

Table 4.25: Perception if Strategic Planning Improves Organizational Performance

Perception if Strategic Planning improves Organization Performance

Agree Disagree

Strategic Planning 6 (25%) 18 (75%)

Of the 15 health institutions that were carrying out strategic planning, only 5 agreed that it

improves organizational performance, while the rest disagreed. This is captured in table 4.26

below.

Table 4.26: Comparison Between Actual Practice and Perception if Strategic

Planning Improves Organizational Performance

Perception if Strategic Planning

Improves Organizational

Performance

Agree Disagree Total

Actual Implementation

of Strategic Planning

Yes 5 10 15

No 1 8 9

Total 6 18 24

58

4.5 Strategy Implementation and Organizational Performance

Of the health institutions surveyed, 23 (96%) made strategic decisions and implementation

action plans based upon their strategic plans. In addition, 21 (88%) health institutions clearly

assigned lead responsibility for action plan implementation to a person or team. Twenty

(83%) of the health institutions allocated resources for strategy implementation, with 19

(79%) setting clearly defined key performance indicators for each action plan element.

Further, 18 (75%) had monitoring and evaluation system to track performance and 19 (79%)

rewarded individuals responsible for successful performance. These are captured in table

4.27 below.

Table 4.27: Actual Implementation of Strategy in Health Institutions

Health Institutions implementing strategy

Yes No

Strategic decisions (implementation action plans) based on

strategic plan

23 (96%) 1 (4%)

Clearly assigned lead responsibility for action plan

implementation to a person/ team

21 (88%) 3 (12%)

Allocation of resource for strategy implementation 20 (83%) 4 (17%)

Clearly defined key performance indicators 19 (79%) 5 (21%)

Monitoring and evaluation system in place to track

performance

18 (75%) 6 (25%)

Rewarding individuals responsible for successful

performance

19 (79%) 5 (21%)

Of the health institutions surveyed, 23 (96%) agreed that making strategic decisions and

implementation action plans based upon strategic plans improves organizational

performance. In addition, 21 (88%) health institutions agreed that clearly assigning lead

responsibility for action plan implementation to a person or team improves organizational

performance. All 24 (100%) of the health institutions surveyed agreed that allocating

59

resources for strategy implementation improves organizational performance, with all in

concurrence that setting clearly defined key performance indicators for each action plan

element improves organizational performance. Further, 23 (96%) agreed that having a

monitoring and evaluation system to track performance improves organizational

performance and 23 (96%) agreed that rewarding individuals responsible for successful

performance improves organizational performance. These are captured in table 4.28 below.

Table 4.28: Perception if Strategy Implementation Improves Organizational

Performance

Perception if Strategy Implementation improves Organization Performance

Agree Disagree

Strategic decisions (implementation action plans) based on

strategic plan

23 (96%) 1 (4%)

Clearly assigned lead responsibility for action plan

implementation to a person/ team

21 (88%) 3 (12%)

Allocation of resource for strategy implementation 24 (100%) 0 (0%)

Clearly defined key performance indicators 24 (100%) 0 (0%)

Monitoring and evaluation system in place to track

performance

23 (96%) 1 (4%)

Rewarding individuals responsible for successful

performance

23 (96%) 1 (4%)

4.5.1 Summary of Strategy Implementation and Organizational Performance

In aggregate, 10 (42%) of the health institutions surveyed carried out strategy

implementation, while only 3 (12%) agreed that it improved organizational performance as

indicated in tables 4.29 and 4.30 respectively.

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Table 4.29: Actual Implementation of Strategy

Health Institutions carrying out Strategy Implementation

Yes No

Strategy Implementation 10 (42%) 14 (58%)

Table 4.30: Perception if Strategy Implementation Improves Organizational

Performance

Perception if Strategy Implementation improves Organization Performance

Agree Disagree

Strategy Implementation 3 (12%) 21 (88%)

Of the 10 health institutions that were implementing strategy, only 1 agreed that it improves

organizational performance, while the rest disagreed. This is captured in table 4.31 below.

Table 4.31: Comparison Between Actual Practice and Perception if Strategy

Implementation Improves Organizational Performance

Perception if Strategy Implementation

Improves Organizational

Performance

Agree Disagree Total

Actual Implementation

of Strategy

Yes 1 9 10

No 2 12 14

Total 3 21 24

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4.6 Organizational Performance

The distribution of percentage change in organizational performance among the respondents

was skewed to the right, with a median duration of 17.3% and an IQR of 2 – 47%.

4.7 Bivariate Analysis

Pearson Correlation was used to measure the strengths of association between two variables

and the direction of the relationship. In this study, the dependent variable was the percentage

change in organizational performance, while the independent variables were strategic

thinking, planning and strategy implementation.

From the study, percentage change in organizational performance was positively correlated

to strategic thinking, but the strength of the relationship was weak since the value of the

correlation coefficient was 0.0801 as indicated in Graph 4.3 below.

Figure 4.3: Correlation between Strategic Thinking and Organizational Performance

On the other hand, organizational performance was negatively correlated with strategic

planning with the value of the correlation coefficient being – 0.4175 as indicated in Graph

4.4 below.

62

Figure 4.4: Correlation between Strategic Planning and Organizational Performance

From the study, strategy implementation was negatively correlated with organizational

performance with the value of the correlation coefficient being – 0.3164 as indicated in

Graph 4.5 below.

Figure 4.5: Correlation between Strategy Implementation and Organizational

Performance

63

The strength of the relationship between organizational performance and both strategic

planning and strategy implementation was stronger than with strategic thinking.

4.8 Chapter Summary

This chapter presents the results and findings of the study. Findings are presented in

frequency tables and graphs/ figures. The presentation is aligned to the research questions

and covers strategic thinking, planning, strategy implementation and organizational

performance in the 24 health institutions that participated in the survey.

64

CHAPTER FIVE

5.0 DISCUSSION, CONCLUSION AND RECOMMENDATIONS

5.1 Introduction

This chapter presents the discussion of research findings, conclusion and recommendations

of the study. The chapter sections are aligned with the research questions.

5.2 Summary

The purpose of this study was to determine the effects of strategic management on

organizational performance in health institutions in Nairobi County. The study had three

research questions on what was the effect of strategic thinking, planning and strategy

implementation on organizational performance of health institutions in Nairobi County.

This study was descriptive and the study design was cross – sectional. The study was

designed to capture utilization of strategic management in health institutions in Nairobi,

representing a snapshot of one point in time. The study described and explained phenomena

that observations reflected measure social reality or describe what was in use in health

institutions in Nairobi. The independent variables were strategic thinking, strategic planning

and strategy implementation, while the dependent variable was organizational performance.

The study population was the management at health institutions that are Kenya Essential

Package for Health (KEPH) level four, five and six, and are in Nairobi County. For this

study, the sampling frame was the list of all health institutions that were KEPH level four or

five or six, and in Nairobi County based on the Kenya Master Health Facility List (Ministry

of Health, 2017). The health institution was the sampling unit. Census was used to enroll

every health institution into this study since they are few, and the unit of analysis was the

health institution. Primary data for this study was collected using a structured self-

administered questionnaire, that captured both qualitative and quantitative data,

administered to the study prospective participants after they had been recruited and enrolled.

Stata 12 ® was the statistical software used to analyze the data from the study. Data was

presented in charts and graphs.

65

Of the health institutions surveyed, 23 (96%) carried out strategic thinking while 7 (29%)

agreed that strategic thinking improves organizational performance. From the study,

organizational performance was positively correlated to strategic thinking, but the strength

of the relationship was weak since the value of the correlation coefficient was 0.0801.

With regard to strategic planning, 15 (63%) of the health institutions surveyed carried out

strategic planning, while only 6 (25%) agreed that it improved organizational performance.

On the other hand, organizational performance was negatively correlated to strategic

planning with the value of the correlation coefficient being – 0.4175.

Of the health institutions surveyed, 10 (42%) carried out strategy implementation, while only

3 (12%) agreed that it improved organizational performance. Strategy implementation had a

negative correlation with organizational performance among health institutions in Nairobi

County with the value of the correlation coefficient being – 0.3164.

5.3 Discussion

5.3.1 Relationship between Strategic Thinking and Organizational Performance

The effect of managers' strategic thinking on organizational performance was explored in

this study. The findings indicated a positive correlation of managers' strategic thinking on

organizational performance. Having elucidated this relationship, though weak, it was shown

that all components of managers' strategic thinking have a positive effect on organizational

performance in health institutions in Nairobi County. In other words, it can be stated that

existence of strategic thinking and strategic vision among the managers is led to more

concentration and attention to the effective strategic factors on survival and growth of the

institution and therefore, gaining competitive advantage, increased innovation and creativity,

corporate entrepreneurship and patient numbers.

This finding is consistent with the results of Vafaei's study (Vafaei, Shad, & Rostami, 2016)

regarding the positive effect of strategic thinking on productivity, innovation, and

organizational performance. From a study on antecedents and outcomes of strategic thinking,

the results of empirical analysis provided evidence that there was a positive relationship

between strategic thinking and marketing performance with the standardized path

coefficients between strategic thinking, and profit, sales and market share being 0.233, 0.198

66

and 0.209 respectively (Moon, 2013). In addition, in a study evaluating the effect of strategic

thinking on corporate entrepreneurship (Vafaei, Shad, & Rostami, 2016), the findings

indicated the positive effect of managers' strategic thinking on corporate entrepreneurship.

Results of testing the main hypothesis illustrate the positive effect of managers' strategic

thinking on corporate entrepreneurship at confidence level 99%. Having confirmed the

research hypotheses, it was shown that all components of managers' strategic thinking have

a positive effect on corporate entrepreneurship. In other words, it can be stated that existence

of strategic thinking and strategic vision among the managers is led to more concentration

and attention to the effective strategic factors on survival and growth of the organization and

therefore, gaining competitive advantage, increased innovation and creativity, and corporate

entrepreneurship. This finding is consistent with the results of Marashi's study (2015)

regarding the positive effect of strategic thinking on productivity, innovation, and

organizational creativity. Also, it can be stated that managers who have strategic thinking

pave the way for the establishment of the culture of innovation and entrepreneurship. This

is also consistent with Chakraborty et al' study (Chakraborty, Thompson, & Yehoue, 2016).

In this regard, one of the tasks of experts and researchers in the field of human resources is

to expand the strategies of strategic thinking via training the concepts and principles of

employing strategic thinking among the managers and leaders and focusing on its positive

role in increasing of entrepreneurial atmosphere in the organization.

Dominance over strategic thinking is very important for health institutions which intend to

change their future as well as their environment. The topic of strategic thinking has highly

been considered in the field of strategic management in the last decade and the importance

of strategic thinking capability for managers has been mentioned in many studies. Improving

the capability of strategic thinking in managers as one of the key factors in the effectiveness

of strategic management process requires more attention. Strategic thinking is the process of

proposing and exploring hypotheses about the future which creates the foundation for

mission, purposes and strategies of the organization and contains an extensive range of

subjects. Strategic thinking is a vital management skill in the modern millennium; a skill

which requires empowerment of the organization for survival and growth in the current

competitive environment (Khalili, Armani, Rahimi, Jamshidi, & Jamshidi, 2015).

67

5.3.2 Relationship between Strategic Planning and Organizational Performance

The effect of managers' strategic planning on organizational performance was explored in

this study. The findings indicated a negative correlation of managers' strategic planning on

organizational performance. Having elucidated this relationship, though of moderate

strength, it was shown that all components of managers' strategic planning have a negative

effect on organizational performance in health institutions in Nairobi County. This finding

mirrors results of a study that evaluated if strategic planning enhanced or impeded innovation

and firm performance (Song, Im, van der Bij, & Song, 2011) that challenged the traditional

views of strategic planning. The evidence suggested that strategic planning impeded, not

enhanced, the number of new product development projects. The study found a negative and

significant relationship between strategic planning and the number of new product

development projects, in support of Moorman and Miner’s (1998a, 1998b) claim that

improvisation represents an experiential, emergent learning process rather than an

institutional process and therefore provides a viable path to generating new product

development projects. In addition, it indicated that larger firms benefited less, not more, from

strategic planning for improving firm performance.

On the contrary, there have been numerous studies that have shown a positive relationship

between strategic planning and organizational performance. Findings of a study that

evaluated the role of strategic alignment as a missing link between strategic consensus and

organizational performance (Walter, Kellermanns, Floyd, Veiga, & Matherne, 2013)

indicated a positive correlation between strategic alignment (strategic planning) and

organizational performance of 0.16. In addition, in a study that evaluated formal strategic

analyses and organizational performance by decomposing the rational model (Mueller,

Mone, & Barker III, 2007), the results indicated an interaction term consisting of formal

analysis for informational purposes and environmental dynamism approached statistical

significance (p = .12) and a positive relationship between the informational use of formal

analysis and performance in both low and high dynamism environments. Further, in a study

that evaluated different roles of middle level managers on organizational performance

(Dasgupta, 2015), found that the regression model shows a moderate association between

the combined eff ect of all roles in strategic planning and organizational performance (r =

0.508).

68

The basis of making a plan, is the integration of what the institution should do, wants to do,

and can do to provide a picture of the situation. It is a key activity to induce change, more

so in organizational performance. Being able to see, interpret, and handle the plan making

and other change-provoking phenomena in the broader context requires an analytic tool(s)

to make the work of managers more realistic and effective. In other words, this broader

context should not be looked upon as an environment of fuzzy conditions and unpredictable

dynamics, with which managers have to cope for better or worse. Instead, this environment

must be a part of their professional field, with which they have to deal, but they also have to

be equipped ‘to accommodate uncertainty as a core ontological state of the world’ (Gunder,

2008). This is needed in order to break with the inclination to self referentiality, resulting in

denying the environment, as far as it does not support the reproduction of the current

routines.

The study found out that strategic planning activities are common across all the health

institutions. Top managers came together to develop a strategic plan, often used strategic

thinking, and many important issues are discussed and documented. However, sometimes

the strategic plan created and everyone enthusiastically returned to the organization only to

find “business as usual” – nothing really changes, the strategic momentum was lost, and

plans are never implemented (Rigby D. K., 2015).

Strategic planning is that process. Strategic planning provides the structure to consider issues

and reach consensus on how the organization should proceed. Having a periodic structured

process initiates a reconsideration, discussion, and documentation of all the assumptions.

Without planned process managers never quite get to it. Without a process, ideas are not

discussed, conclusions are not reached, decisions are not made, strategies are not adopted,

and strategic thinking is not documented.

5.3.3 Relationship between Strategy Implementation and Organizational Performance

The effect of managers' strategy implementation on organizational performance was

explored in this study. The findings indicated a negative correlation of managers' strategy

implementation on organizational performance. Having elucidated this relationship, though

moderate, it was shown that all components of managers' strategy implementation have a

negative effect on organizational performance in health institutions in Nairobi County.

69

These findings of a negative relationship are contrary to a case study conducted in the United

Arab Emirates to analyze comprehensive implementation of strategic plans in emerging

economies (Elbanna & Fadol, 2016) indicated that the comprehensiveness of the strategic

plan implementation was significantly influenced by three factors related to strategy

formulation, namely, the formulation mode, participation, and political behavior and that the

comprehensiveness of the strategic plan implementation was related positively to the

effectiveness of the strategic planning and organizational performance. In addition, a study

conducted to evaluate the effects of strategic planning on corporate performance in Babcock

University indicated that once organizations comply with strategic plans, there was

corresponding better corporate performance (Owolabi & Makinde, 2012).

Strategy implementation ensure an ongoing philosophy for developing and managing the

plans, actions, and control of the institution. It attempted to continually orchestrate a fit

between the institution’s external environment (political, regulatory, economic,

technological, social, and competitive forces) and its internal situation (culture, organization

structure, resources, products and services, and so on) (Bain & Company, 2017). In some

cases, orchestrating the fit may have meant responding to external forces; in other cases, the

institution may have attempted to actually shape its environment (change the rules for

success) (Mische, 2001). External change was inevitable; often the shifts were subtle, other

times they could have been discontinuous and extremely disruptive. When such dramatic

changes occurred, new opportunities emerged and new competencies were born, while

others died or were rendered inconsequential. Inevitably, the basic rules of competing and

survival changed. Therefore, strategic thinking and periodic planning did not cease. Strategic

implementation was how an institution constructively managed change, evaluated strategy,

and reinvented or renewed itself (Friedl & Biloslavo, 2009).

5.4 Conclusion

This study represents, in our opinion, an essential contribution to the literature on the effect

of strategic management on organizational performance. The study has used a model

developed to assess and diagnose the effects of various dimensions of strategic management,

i.e. strategic thinking, planning and strategy implementation on organizational performance

among health institutions in Nairobi County. It has contributed to a better understanding of

70

the relationship between variables presumed to influence the results of an organization and

its performance.

5.4.1 Strategic Thinking and Organizational Performance

From the findings and discussion, the study concludes that strategic thinking has a weak

positive relationship on organizational performance. This is consistent with a number of

studies that have been conducted.

5.4.2 Strategic Planning and Organizational Performance

From the findings and discussion, the study concludes that strategic planning has a negative

relationship on organizational performance among health institutions in Nairobi County.

5.4.3 Strategy Implementation and Organizational Performance

From the findings and discussion, the study concludes that strategy implementation has a

negative relationship on organizational performance among health institutions in Nairobi

County. This study has raised the specter of there being other underlying factors that have a

bearing on organizational performance among health institutions in Nairobi County.

5.5 Recommendations

5.5.1 Recommendations for Improvement

5.5.1.1 Strategic Thinking and Organizational Performance

This study has provided evidence of the relationship between strategic management and

organizational performance in health institutions. Going forward, much as the study found

that the relationship between strategic thinking and organizational performance was positive,

this will be best measured through a key informant interview that is open since a lot of details

on strategic thinking are lost through closed ended questions in a questionnaire.

5.5.1.2 Strategic Planning and Organizational Performance

Much as the correlation between strategic planning and organizational performance was

negative in this study, there is need to draw a distinction between public and private health

facilities since the drive between the two sets are different.

71

5.5.1.3 Strategy Implementation and Organizational Performance

Going forward, it is important to design a study that will make management of health

institutions less sensitive about the information they offer. This is so since many, especially

the privately-owned health institutions guarded the information they could share because it

was competitive in nature.

5.5.2 Recommendations for Further Studies

This study can be extended in several ways. We can repeat the study in one or two years

which will offer the possibility to do a comparative analysis and see how the analyzed firms

evolved over time and improved their performance. In order to increase the validity of our

results we can try combine the data collected through questionnaires with secondary data

(absolute values for different key performance indicators). Future research can examine the

effect of strategic management after standardizing organizational performance into key

performance indicators for key business processes within hospitals. The key performance

business processes that can be evaluated can be broken down to departments within the

hospital to include outpatient flow, emergency flow, inpatient flow, surgical services,

medication management, revenue cycle and access management.

72

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APPENDICES

Appendix I: Cover Letter

Dear Respondent

I am a post – graduate student studying towards my Masters in Business Administration

(Strategic Management) at the United States International University – Nairobi. The purpose

of this study is to determine the effects of strategic management on organizational

performance in health institutions in Nairobi County.

You are part our selected sample of respondents whose views we seek on the above-

mentioned matter. We would therefore appreciate it if you could answer a few questions. It

will take approximately thirty minutes of your time to fill in the questionnaire.

We guarantee you complete anonymity and there are no correct or incorrect responses.

Please answer the questions as accurately as possible. For each statement, circle the response

which best describes your experience or perception. Mark one answer for each statement and

attempt to answer all questions.

I guarantee that all information will be handled with STRICT CONFIDENTIALITY.

Thank you very much.

Dr. George Kadondi Kasera

USIU - AFRICA

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Appendix II: Questionnaire

This questionnaire is designed to help you critique your strategic planning and management

process. It is structured to allow review of the process to determine which strategic planning

steps the organization now performs well, not so well, or not at all. Even if your organization

does no strategic planning at present, a review of this questionnaire should be instructive as

the individual questions identify those considerations that are primary in designing and

implementing an effective process.

99

SECTION A: GENERAL INFORMATION

Form Number

Date

Name of Respondent

Designation of Respondent

Respondent Gender

Respondent’s Age

Name of Health Institution

Health Institution KEPH Level

Health Institution Type

Health Institution Ownership

For each question below, circle the appropriate number to indicate the degree of agreement

or disagreement if the variable asked has improved organizational performance of your

organization.

SECTION B: STRATEGIC THINKING & ORGANIZATIONAL

PERFORMANCE

1a. Are top executives assigned formal responsibility for

your organization's strategic planning?

Yes O

No O

100

1b. Formal responsibility by top executives for the

organization’s strategic planning improves

organizational performance.

Strongly Agree O

Agree O

Neutral O

Disagree O

Strongly

Disagree

O

2a. Is strategic planning a top priority activity for your

organization?

Yes O

No O

2b. Strategic planning being a top priority activity,

performed on a regular basis, e.g., each year improves

organizational performance.

Strongly Agree O

Agree O

Neutral O

Disagree O

Strongly

Disagree

O

3a. Does your organization provide resources (time, money,

staff support) specifically earmarked for strategic

planning?

Yes O

No O

3b. Strongly Agree O

101

Providing resources (managers’ time, money, staff

support, etc.) earmarked specifically for strategic

planning improves organizational performance.

Agree O

Neutral O

Disagree O

Strongly

Disagree

O

4a. Does your institution follow a defined set of procedures

during strategic planning process?

Yes O

No O

4b. Following a defined set of procedures during strategic

planning process improves organizational performance.

Strongly Agree O

Agree O

Neutral O

Disagree O

Strongly

Disagree

O

5a. Does your organization have a written mission

statement?

Yes O

No O

5b. Having a written mission statement improves

organizational performance.

Strongly Agree O

Agree O

102

Neutral O

Disagree O

Strongly

Disagree

O

6a. Is the management and higher-level staff aware of your

organization's mission and understand it?

Yes O

No O

6b. Management and higher-level staff being aware of the

mission and understanding it improves organizational

performance.

Strongly Agree O

Agree O

Neutral O

Disagree O

Strongly

Disagree

O

7a. Does your organization have written goals (short or long

term)?

Yes O

No O

7b. Having written goals (short or long term) improves

organizational performance.

Strongly Agree O

Agree O

Neutral O

103

Disagree O

Strongly

Disagree

O

7c. Are the written goals quantified with measurable targets

(e.g. volume, market share, growth rate, profitability)?

Yes O

No O

7d. Having goals list quantified with measurable targets

(e.g., volume, market share, growth rate, profitability)

improves organizational performance.

Strongly Agree O

Agree O

Neutral O

Disagree O

Strongly

Disagree

O

8a. Does your organization systematically measure actual

performance vs goals set?

Yes O

No O

8b. Systematically measuring actual performance vs. goals

set improves organizational performance.

Strongly Agree O

Agree O

Neutral O

Disagree O

104

Strongly

Disagree

O

9a. Does your management and higher-level staff participate

in setting goals?

Yes O

No O

9b. Participation by management and higher-level staff in

setting goals improves organizational performance.

Strongly Agree O

Agree O

Neutral O

Disagree O

Strongly

Disagree

O

SECTION C: STRATEGIC PLANNING & ORGANIZATIONAL

PERFORMANCE

10a. Does your organization periodically gather and analyze

data about the market and other external factors which

affect the business?

Yes O

No O

10b. Periodically gathering and analyzing data about market

and other external factors which affect the business

improves organizational performance.

Strongly Agree O

Agree O

Neutral O

Disagree O

105

Strongly

Disagree

O

11a. Does your organization identify key threats &

opportunities during market analysis?

Yes O

No O

11b. Identification of key threats & opportunities during

market analysis improves organizational performance.

Strongly Agree O

Agree O

Neutral O

Disagree O

Strongly

Disagree

O

12a. Does your organization compare its performance and

operational characteristics with those of competitors?

Yes O

No O

12b. Comparison of the organization’s performance and

operational characteristics with those of competitors

improves organizational performance.

Strongly Agree O

Agree O

Neutral O

Disagree O

Strongly

Disagree

O

106

13a. Does your organization analyze demographic, behavioral

and other consumer trends?

Yes O

No O

13b. Analysis of demographic, behavioral, and other

consumer trends improves organizational performance.

Strongly Agree O

Agree O

Neutral O

Disagree O

Strongly

Disagree

O

14a. Does your organization assess the sector as whole in

terms of new competitors and concepts, new

technologies, procurement practices, price trends, labor

practices?

Yes O

No O

14b. Assessment of the sector as a whole in terms of new

competitors and concepts, new technologies,

procurement practices, price trends, labor practices

improves organizational performance.

Strongly Agree O

Agree O

Neutral O

Disagree O

Strongly

Disagree

O

15a. Yes O

107

Does your organization assess factors such as cost and

availability of capital, government regulations and state

of the economy?

No O

15b. Assessment of factors such as cost and availability of

capital, government regulations and state of the economy

improves organizational performance.

Strongly Agree O

Agree O

Neutral O

Disagree O

Strongly

Disagree

O

16a. Does your organization have knowledge of and access to

sources of information about the sector, markets, and

other external factors?

Yes O

No O

16b. Having knowledge of and access to sources of

information about the sector, markets, and other external

factors improves organizational performance.

Strongly Agree O

Agree O

Neutral O

Disagree O

Strongly

Disagree

O

17a. Yes O

108

Does your organization analyze its key strengths and

weaknesses?

No O

17b. Internal analysis to identify key strengths and

weaknesses improves organizational performance.

Strongly Agree O

Agree O

Neutral O

Disagree O

Strongly

Disagree

O

18a. Does your organization analyze profitability indicator

trends (after-tax earnings, return on assets, etc.)?

Yes O

No O

18b. Analysis of profitability trends improves organizational

performance.

Strongly Agree O

Agree O

Neutral O

Disagree O

Strongly

Disagree

O

19a. Does your organization analyze its pricing strategy and

its effects on customer behavior?

Yes O

No O

109

19b. Analysis of pricing strategy and its effects on customer

behavior improves organizational performance.

Strongly Agree O

Agree O

Neutral O

Disagree O

Strongly

Disagree

O

20a. Does your organization analyze quality of customer

service, satisfaction, loyalty & defection data?

Yes O

No O

20b. Analysis of quality of customer service, customer

satisfaction, loyalty & defection data improves

organizational performance.

Strongly Agree O

Agree O

Neutral O

Disagree O

Strongly

Disagree

O

21a. Does your organization assess its human resource

management and development programs?

Yes O

No O

21b. Strongly Agree O

110

Assessment of human resource management and

development programs improves organizational

performance.

Agree O

Neutral O

Disagree O

Strongly

Disagree

O

22a. Is the internal data discussed above easily accessible to

the management?

Yes O

No O

22b. Accessible internal data by the management improves

organizational performance.

Strongly Agree O

Agree O

Neutral O

Disagree O

Strongly

Disagree

O

23a. Does your organization identify key strategic issues (e.g.

outlet expansion, profitability improvement, positioning

change) after conducting a situational analysis review?

Yes O

No O

23b. Strongly Agree O

Agree O

111

Identification of key strategic issues after conducting a

situational analysis review improves organizational

performance.

Neutral O

Disagree O

Strongly

Disagree

O

24a. Does your organization use situational diagnosis to

formulate strategic plan options?

Yes O

No O

24b. Use of situational diagnosis to formulate strategic plan

options improves organizational performance.

Strongly Agree O

Agree O

Neutral O

Disagree O

Strongly

Disagree

O

25a. Which strategic management techniques has your organization used? (Select

Multiple)

a) Balanced Scorecard O

b) Benchmarking O

c) Big Data Analytics O

d) Business Process Reengineering O

112

e) Change Management Programs O

f) Complexity Reduction O

g) Core Competencies O

h) Customer Relationship Management O

i) Customer Segmentation O

j) Decision Rights Tools O

k) Downsizing O

l) Employee Engagement Surveys O

m) Mergers and Acquisitions O

n) Mission and Vision Statements O

o) Open Innovation O

p) Outsourcing O

q) Price Optimization Models O

r) Satisfaction and Loyalty Management O

s) Scenario and Contingency Planning O

t) Social Media Programs O

113

u) Strategic Alliances O

v) Supply Chain Management O

w) Total Quality Management O

x) Zero based Budgeting O

y) Don't Know O

25b. Use of strategic management techniques improve

organizational performance.

Strongly Agree O

Agree O

Neutral O

Disagree O

Strongly

Disagree

O

SECTION D: STRATEGY IMPLEMENTATION & ORGANIZATIONAL

PERFORMANCE

26a. Does your organization make strategic decisions

(implementation action plans) based upon the strategic

plan?

Yes O

No O

26b. Strongly Agree O

Agree O

114

Making strategic decisions (implementation action

plans) based upon the strategic plan improves

organizational performance.

Neutral O

Disagree O

Strongly

Disagree

O

27a. Has your organization clearly assigned lead

responsibility for action plan implementation to a person/

team?

Yes O

No O

27b. Clearly assigning lead responsibility for action plan

implementation to a person / team improves

organizational performance.

Strongly Agree O

Agree O

Neutral O

Disagree O

Strongly

Disagree

O

28a. Has your organization allocated resources for strategy

implementation?

Yes O

No O

28b. Allocation of resources for strategy implementation

improves organizational performance.

Strongly Agree O

Agree O

Neutral O

115

Disagree O

Strongly

Disagree

O

29a. Has your organization set clearly defined key

performance indicators for each plan element?

Yes O

No O

29b. Setting clearly defined key performance indicators for

each plan element improves organizational performance.

Strongly Agree O

Agree O

Neutral O

Disagree O

Strongly

Disagree

O

30a. Does your organization have a monitoring and evaluation

system to track performance?

Yes O

No O

30b. Having a monitoring and evaluation system for tracking

performance improves organizational performance.

Strongly Agree O

Agree O

Neutral O

Disagree O

116

Strongly

Disagree

O

31a. Does your organization reward individuals responsible

for successful performance?

Yes O

No O

31b. Rewarding individuals responsible for successful

performance improves organizational performance.

Strongly Agree O

Agree O

Neutral O

Disagree O

Strongly

Disagree

O

32a. Do you know the number of patients (samples) your

organization has seen over the past three years?

Yes O

No O

32b. Number of patients (samples*) seen in 2016

32c. Number of patients (samples*) seen in 2015

32d. Number of patients (samples*) seen in 2014