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Subject: Current Issues in

Health Services Management (MM566)

Group Report

Managing SARS Outbreaks

– the Stakeholders Model

Lecturer: Prof. Peter YUEN

Group Members:

CHOW Ching Man, Norita (Student no. : 01416967G)LAI Mei Ha, Melissa (Student no. : 03417124G,)

LAW Mei Sze, Regina (Student no: 02414020G)LEE Kwun Yin, ,Daniel (Student No. : 03409505G)LEUNG Shun Wah, Ava (Student no. : 03400105G)

Date of Submission: 3 May 2004

INTRODUCTION

This study uses the Stakeholders Model to evaluate the management of the SARS

outbreak in Hong Kong in 2003. Stakeholders are identified from the Hospital

Authority Head Office Senior Management’s perspective. Comparisons of the

performance of similar authority in Canada and Singapore in engaging their

stakeholders in the SARS outbreak management have been made where appropriate,

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with the objectives to learn from the common mistakes and good performance of others,

and make recommendations for management of future outbreaks of similar nature.

STAKEHOLDERS MODEL

Stakeholders Theory

Stakeholders are those individuals or groups who depend on the organization to

fulfill their own goals and on whom, in turn, the organization depends. In the other

words, any constituency in the environment that is affected by an organization’s

decisions and policies and that can influence the organization. Influence is likely to

occur only because individuals share expectations with others by being a part of a

stakeholder group. Individuals tend to identify themselves with the aims and ideals of

stakeholder groups, which may occur within departments, geographical locations,

different levels in the hierarchy, etc. Also important are external stakeholders of the

organization, typically financial institutions, customers, suppliers, shareholders and

unions. They may seek to influence company strategy through their links with internal

stakeholders. For example, customers may pressurize sales managers to represent their

interests within the company. Even if external stakeholders are passive, they may

represent real constraints on the development of new strategies.

Individuals may belong to more than one stakeholder group and stakeholder

groups will ‘line up’ differently depending on the issue or strategy in hand. For

example, marketing and production departments might be united in the face of

proposals to drop certain product lines, whilst being in fierce opposition regarding plans

to buy in new items to the product range. Often it is specific strategies that trigger off

the formation of stakeholder groups. For these reasons, the stakeholder concept is

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valuable when trying to understand the political context within which specific strategic

developments would take place (Johnson & Scholes, 2002).

Identifying the stakeholders

An organization’s mission and objectives need to be developed bearing in mind

two sets of interests:

1. the interests of those who have to carry them out e.g. the managers and employers -

Internal stakeholders;

2. the interests of those who have a stake in the outcome e.g. the shareholders,

government, customers, suppliers and other interested parties - External

stakeholders

Together these groups form the stakeholders – the individuals and groups who

have an interest in the organization and may therefore wish to influence its purpose,

mission and objectives.

The organization’s mission may take months of debate and consultation within the

organization. When its implications are clearly set out for the directors, managers and

employees, they may not necessarily accept the mission without question: there may be

objections as it is realized that individuals will have to work harder, undertake new

tasks, or face the prospect of leaving the company. The individuals and groups affected

may want to debate the matter further. Such individuals and groups have a stakeholding

in the organization and therefore wish to influence its mission.

This concept of stakeholding extends those working in the organization.

Shareholders in a public company, banks which have loaned the organization money,

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governments concerned about employment, investment and trade may also have

legitimate stakeholdings in the company. Customers and suppliers will also have an

interest in the organization. They may be informal, such as government involvement in

a private company, or formal, such as through a shareholding in the company. All can

be expected to be interested in and possibly wish to influence the future direction of the

organization (Lynch, 2003).

Inputs to the development of the company mission:

Internal Stakeholders

Executive officers

Board of directors

Stockholders

Employees

External Stakeholders

Customers

Suppliers

Creditors

Governments

Unions

Competitors

General public

Company

Mission

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Stakeholder analysis

Stakeholder analysis provides a link between internal analysis and external

analysis. Internal stakeholders are the management, the different departments within

the organization and its employees. The needs, wants and motivating factors for each

of these groups are different. What may please management could cause unease among

the workforce. On their own, no one group is able to completely influence the direction

and activities of the organization. There are groups, however, who posses greater

power than others. Stakeholder analysis seeks to identify these.

External stakeholders cannot simply be identified or listed; they differ between

organizations and industries. However, external stakeholders may be grouped into

segments which are frequently involved in the organization’s activities: owners

(shareholders), suppliers, customers and financiers. Other groups which could also

have stakeholder status for an organization are the government (central and local),

guilds and associations, and pressure groups who may or may not have an interest in the

success of an organization with its present or future activities (Cook & Farqularson,

1998).

There are various ways in which stakeholder analysis is performed to measurer the

relative power of different groups and individuals. These techniques typically utilize a

mapping or matrix approach.

1. Relative power matrix - The relative interests on the part of each group in the

organization’s proposed activity are given numerical values. The total for each

group is then analyzed to assess their power.

2. Power/interest matrix - The power/interest matrix seeks to describe the political

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context within which an individual strategy would be pursued by classifying

stakeholders in relation to the power they hold and the extent to which they are

likely to show interest in supporting or opposing a particular strategy.

The matrix indicates the type of relationship which organizations typically might

establish with stakeholder groups in the different quadrants.

Level of Interest

Power

Low High

Low A Minimal effort B Keep informed

High C Keep satisfied D Key players

Source: Adapted from A. Mendelow, Proceedings of the Second International

Conference on Information Systems, Cambridge, MA, 1991.

Clearly, the acceptability of strategies to key players (segment D) is of major

importance. Often the most difficult issues relate to stakeholders in segment C

(institutional shareholders often fall into this category). Although these stakeholders

might, in general, be relatively passive, a disastrous situation can arise when their level

of interest is underrated and they suddenly reposition to Segment D and frustrate the

adoption of a new strategy. A view might be taken that it is a responsibility of

strategists or managers to raise the level of interest of powerful stakeholders (such as

institutional shareholders), so that they can better fulfill their expected role within the

corporate governance framework. Also, this could be concerned with how non-

executive directors could be assisted in fulfilling their role, say, through food

information and briefing.

Similarly, organizations might address the expectations of stakeholders in segment

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B through information – for example, to community groups. These stakeholders can be

crucially important “allies’ in influencing the attitudes of more powerful stakeholders:

for example, through lobbying.

Stakeholder mapping might help in understanding better some of the following

issues:

1. Whether the levels of interest and power of stakeholders properly reflect the

corporate governance framework within which the organization is operating, as in

the examples above (non-executive directors, community groups).

2. Who are likely to be the key blockers and facilitators of a strategy and how this

could be responded to – for example, in terms of education or persuasion?

3. Whether organizations should seek to reposition certain stakeholders. This could

be to lessen the influence of a key player or, in certain instances, to ensure that

there are more key players who will champion the strategy (this is often critical in

the public sector context).

4. The extent to which stakeholders may need to be assisted or encouraged to

maintain their level of interest or power. For example, public ‘endorsement’ by

powerful suppliers or customers may be critical to the success of a strategy.

Equally, it may necessary to discourage some stakeholders from repositioning

themselves. This is what is meant by keep satisfied in relation to stakeholders in

segment C, and to a lesser extent keep informed for those in segment B (Johnson

& Scholes, 2002).

Stakeholder Relationship Management

Stakeholder relationships management is important as it can lead to other

organizational outcomes such as improved predictability of environmental changes,

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more successful, innovations, greater degrees of trust among stakeholders, and greater

organizational flexibility to reduce the impact of change. In turn it affects the

organizational performance to a higher extent.

Stakeholder relationships can be managed in four steps. The first step is

identifying who the organization’s stakeholders. The second step is for managers to

determine what particular interests or concerns these stakeholders might have – product

quality, financial issues, safety of working conditions, environmental protection, and so

forth. Next managers must decide how critical each stakeholder is to the organization’s

decisions and actions. The final step is determining what specific approach they should

use to manage the external stakeholder relationships. This decision depends on how

critical the external stakeholder is to the organization and how uncertain the

environment is. The more critical the stakeholder and the more uncertain the

environment, the more that managers need to rely on establishing explicit stakeholder

partnerships.

The various approaches to managing stakeholder Relationships:

Stakeholder Importance

Environmental

Uncertainty

Critically

Importance

Important

but Not Critical

High

Uncertainty

Stakeholder

Partnerships

Boundary

Spanning

Low

Uncertainty

Stakeholder

Management

Scanning and

Monitoring the

Environment

When external stakeholders are important but not critical and environmental

uncertainty is low, managers usually rely on simply scanning and monitoring the

environment for trends and forces that may be changing. In this situation, it’s not

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necessary for managers to take specific actions to manage stakeholders. They just need

to stay informed about what’s happening with them, what concerns they might have,

and whether these concerns are changing.

When the stakeholder is important but not critical and environmental uncertainty is

high, managers need to be more proactive in their efforts to manage the stakeholder

relationships. They can do this by using boundary spanning, which involves

interacting in more specific ways with various external stakeholders to gather and

disseminate important information. In boundary spanning, organizational members

move freely between the organization and external stakeholders. The boundaries of the

organization become more flexile and permeable. Boundary spanners are often said to

have their feet in multiple settings – that is, they span the organizational boundaries.

For instance, individuals who interact day in and day out with external stakeholders as

they do their jobs – such as a salesperson for pharmaceutical company who interacts

with doctors and health care professionals, a public relations manager who talks with

newspaper and television reporters – would establish closer and more explicit

relationships with the various stakeholders. It’s a step beyond just simply scanning and

monitoring the environment because boundary spanners actively interact with

stakeholders as they gather and disseminate information.

When the stakeholder is critical and environmental uncertainty is low, managers

can use more direct stakeholder management efforts such as conducting customer

marketing research, encouraging competition among suppliers, establishing

governmental relations departments or lobbying efforts, initiating public relations

connections with public pressure groups, and so forth.

Finally, when the stakeholder is critical and environmental uncertainty is high,

managers should use stakeholder partnerships, which are proactive arrangements

between an organization and a stakeholder to pursue common goals. These types of

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partnering activities allow organizations to build bridges – organization-supplier,

organization-customer, organization-local communities, organization-competitor, and so

forth – to their stakeholders. Stakeholder partnerships involve significant levels of

commitment among the partners to be more interdependent rather than independent

(Robbins & Coulter, 2002).

Conflicts of Interests/ Expectations amongst stakeholders

The key issue with regard to stakeholders is that the organization needs to take

them into account in formulating its mission and objectives. If it does not, they may

object and cause real problems for the organization. Since the interests/ expectations of

stakeholder groups will differ, it is quite normal for conflict to exist regarding the

importance or desirability of many aspects of strategy.

The typical stakeholder expectations include the conflicts between growth and

profitability; growth and control/ independence; cost efficiency and jobs; volume/ mass

provision and quality/ specialization; and the problems of sub-optimization, where the

development of one part of an organization may be at the expense of another (Lynch,

2003).

Consequently, the organization will need to resolve which stakeholders have

priority: stakeholder power needs to be analyzed.

Analyzing and Applying Stakeholder Power

Power is the ability of individuals or groups to persuade induce or coerce others

into following certain courses of action. Sources of power within organizations are

hierarchy (formal power) e.g. autocratic decision making, influence (informal power)

e.g. charismatic leadership, control of strategic resources e.g. strategic products,

possession of knowledge and skills e.g. computer specialists, control of the environment

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e.g. negotiating skills and involvement in strategy implementation e.g. by exercising

discretion. For external stakeholders, the sources of power are control of strategic

resources e.g. materials, involvement in strategy implementation e.g. distribution

outlets, possession of knowledge (skills) e.g. subcontractors and through internal links

e.g. informal influence.

As part of the analysis stakeholder power, some explicit investigation needs to be

undertaken of the sanctions available against specific stakeholder groups. These might

be used to ensure that, which conflict exists between stakeholder groups, some

resolution is achieved. Such analysis may be the beginning of a bargaining process

between the various groups. This is likely to involve compromise, depending on the

power of groups of stakeholders and their willingness to agree. It may also involve the

use of sanctions to bring pressure to bear on particularly difficult groups. The following

are the six major steps of stakeholders power study:

1. Identify the major stakeholders.

2. Establish their interests and claims on the organization, especially as new strategy

initiatives are developed.

3. Determine the degree of power that each group holds through its ability to force or

influence change as new strategies are developed.

4. Development of mission, objectives and strategy, possibly prioritized to minimize

power clashes.

5. Consider how to divert trouble before it starts, possibly by negotiating with key

groups.

6. Identify the sanctions available and, if necessary, apply them to ensure that the

purpose is formulated and any compromise reached (Lynch, 2003).

To summarize, stakeholding is an integral part of the different sectors of the

economy and a part of risk management. Stakeholding creates potential business links

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worth encouraging and taking up. If stakeholding is not handled suitably, it may have

the power to bring an organization to its knees and causes a lot of damages to the

organization.

In the following sections, the stakeholders of the Hospital Authority (HA) in

managing the SARS outbreak are identified from the perspectives of the Senior

Executives in the Head Office (HO). The performance of the HAHO in engaging the

various stakeholders in managing the SARS outbreak are evaluated. References to

overseas practice in Canada and Singapore are made where appropriate and how the

stakeholders can be better engaged in future outbreak of similar nature are

recommended.

STAKEHOLDERS OF THE HAHO SENIOR MANAGEMENT

The proper containment and control of the outbreak of the fatal infectious disease

SARS was the prime objective of the HAHO. It was also the objectives of all involved

in the public health management system including the Health, Welfare and Food

Bureau, the Department of Health, the HA Board, the Hospital Governing Committees

and the Cluster Management, the private health sector including the private hospitals,

and general practitioners. It is also of great concerns to the insurance companies; the

private and voluntary sectors including the suppliers, the nursing homes and the

academic and research professionals, the health care workers directly involved in the

frontline to combat the deadly disease and their professional associations and unions

and the patients whether or not contracted the SARS. Last but not least would be the

media and the public at large. All of them are stakeholders to HAHO in the SARS

outbreak management.

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Health, Welfare and Food Bureau (HWFB)

The HWFB is the policy bureau which has the overall policy responsibility for all

matters relating to health. It is supposed to match out the strategy for managing and

controlling the epidemic, co-ordinate the efforts in the health sector to combat the

disease. It also oversees Hong Kong’s emergency response. It monitors the performance

of HA and at the same time controls and approves funding for HA. With the above

mentioned high interests and high power over the public health policies and the

performance of HA, the HWFB is definitely one of the most important key players

amongst the various stakeholders of the HAHO Senior Management according to the

stakeholders interest / power mapping theory.

Department of Health (DH)

The DH is the Government’s Health Advisor and the executive arm of the

government in the health legislation and policy. It is also the health advocate of the

community. During the SARS epidemic, it liaised with HA on public health functions of

disease surveillance, contact tracing and collaborated with World Health Organization

(WHO) and international health agencies and authorities in giving information and

communicating warning of the highly communicable SARS disease. With the high

interests and high power in the public health system, the DH is another key player to the

HAHO Senior Management to be heavily and tactfully engaged in order to combat the

SARS and control the outbreak effectively.

However, before and during the SARS epidemic last year, there has been an

absence of a formal framework of responsibility reporting between the HA and the

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HWFB. Communication and decision making between HA, HWFB and DH was

basically relied on the historical informal system. There were no specific rules for

engagement of the stakeholders. The chain of command was not clear which had

resulted in poor decisions and confusions at all levels.

Similar problems were experienced in Ontario, Canada. There were three levels of

government, namely the federal level, the provincial level and the local / territorial level

who all have legislative authority over health issues. They all have jurisdictions

governing emergencies which cover infectious diseases, epidemics and public health

threats. During the SARS period, the jurisdiction between the federal, provincial and

territorial governments were mixed. There was uncertainty about federal powers in

public health. The mechanism for collaborative decision making was weak and there

was no or limited data sharing across government to enable efficient and effective

contact tracing and disease surveillance. The Provincial Operations Centre (POC) for

Emergency Response was co-chaired by the Ontario’s Commissioner of Public Safety

and Security and the Ontario’s Chief Medical Officer and Commissioner of Public

Health. Tensions existed between the two co-chairs of the POC with differing

management styles. Matters were further complicated as other branches of the Health

Canada helped to manage the interactions with hospitals, long-term care facilities,

physicians, and elements of the health services system. Control, command and

leadership at the municipal, provincial and ultimately national levels were unclear.

Recommendations on engaging the HWFB and DH

To address the issues, it is recommended that the HA, HWFB and DH should

reach prior agreement on the clear delineation of roles, responsibilities, accountability

and authority respectively. The authority and responsibilities of each party should be

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clearly understood and adhered to by all parties.

The benefits of a single authority engaged all the relevant parties of the public

health management structure with clear delineation of role in one single command was

evidenced by effectiveness of the Singapore experience of the Task Force set up and

chaired by the Director of Medical Services including experts from the Ministry of

Health and hospital responsible for the overall management of the epidemic during the

SARS period.

The National Advisory Committee (NAC) on SARS and Public Health, established

by the Canadian Government in May 2003 to provide a “third party assessment of

current public health efforts and lessons learned for ongoing and future infectious

disease control” also recommended that “the Government of Canada should move

promptly to establish a Canadian Agency for Public Health, a legislated service agency,

and give it the appropriate and consolidated authorities necessary to provide leadership

and action on public health matters, such as national disease outbreaks and

emergencies, with or without additional authorities regarding national disease

surveillance capacity.”

The HA Board

Amongst the various stakeholders that faced by the HAHO Senior Management,

the HA Board is another key play who have high interests and high authority on HAHO.

The HA Board have statutory governance authority and responsibilities on HA. The

Board should provide oversight and strategic direction to HA at all times. The role

should be even more prominent in crisis situation and it should also functions faster

with greater intensity.

However, a streamlined structure to enable the HA Board to perform the

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governance function and to provide strategic directions during crisis situation is absent.

The six functional committees on planning, medical services development, human

resources, support services development, finance and audit together with the standing

committee on public complaints could not provide timely and advice in the crisis

situation. The Board nor the Committees were well informed of the HA situation though

the Chairman of the Board was heavily involved in the HA Operation.

Recommendations to engage the HA Board

The role of the HA Board in governance in respect of its position and dealing with

the HAHO Senior Management should be clearly defined. The respective roles of the

HA Board, the HA Chairman and the HA Chief Executive should be clearly delineated

with respect to responsibility, authority and accountability. While it is unrealistic and

inefficient to involve the whole HA Board on every urgent decision in combating the

SARS, a set of principles to guide the HA Board and HAHO Senior Management to

determine when to involve the Board Chairman and members in the process should be

developed. A “Task Force” with clear mandate from the Board should be established to

take up full responsibility for the board during the crisis while a reporting mechanism

should be established to kept other Board Members well informed of the progress in the

war against the epidemics.

The Hospital Governing Committees

With the set up of the Hospital Authority, Hospital Governing Committees (HGC)

for 35 public hospitals were also set up. The HGCs have statutory governing authority

on the running and operations of the hospitals. However, in practice, the HGCs are

largely advisory as members are all volunteers. The members would not have much

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interest and time in the hospital management or SARS management in the crisis

situation. The ambiguity in roles and purposes of the HGCs were further intensified

with the development of the Cluster Management Structure with hospital management

authority rest with the Cluster Chief Executive.

Recommendations on engaging the HGCs

According to the power interest mapping principle under the stakeholders model,

the HGCs with high power but low interests should still be kept informed of the

situation, in particular, any important decision of closure of the A&E service or even the

closure of the whole hospital. It would be good to have a clear agreement on the role of

the HGC in HA’s new Cluster Management Structure in particular during a crisis

situation. Communication and reporting mechanism should be established to maintain a

smooth information flow to engage their full support on every important decision made

on the operations of any particular hospital.

Cluster Management (Cluster Chief Executives)

The Cluster Chief Executives (CCEs) are one of the most important key players

amongst the various stakeholders faced by the HAHO Senior Management. They are

part of the HAHO Senior Management Team on one hand but on the other hand, they

are the direct management of the staff, facilities, and resources in hospital in providing

the hospital services to patients and combating the epidemic. There may be conflict of

interests between the Cluster objectives to contain the epidemic in the Cluster level by

refusing to accept patients transferred from other clusters or reluctant to render support

or deploying staff to other clusters to help out. Confused / contradictory messages may

be coming HAHO and clusters and caused confusions to the frontline. The conflicts of

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interests might also lead to inefficient decision making in the central and ineffective

implementation in the cluster level. Views from the frontline were not feedback to the

senior management at HAHO.

Recommendations on engaging the CCEs and Cluster Management

To address the issues, a clear command and control structure i.e. the “war cabinet”

to manage the outbreak or epidemic should be set up at the HAHO level being oversight

by the HA Board or its Task Force. Contingency plans should be formulated and well

trialed out during peacetime. Centralized functions during crisis situation should be

clearly identified with dedicated manpower, properly trained, to be mobilized in a short

notice. During the crisis situation, the “War Cabinet” would take up overall control and

responsibilities on all actions in combating the SARS or epidemic.

Private Hospitals

In the stakeholders’ mapping, the interests of the private hospitals to SARS are

high but their powers to SARS are low, so keeping informing the private hospitals is the

good way for the Hospital Authority and the government to do during the SARS period.

The interest of private hospital is quite clear. The main concern in any time is to

make the profit and generate enough cash flow for the continuing operation. By gaining

the sufficient cash net inflow to the private hospitals, they can achieve their general

missions, visions and objectives of providing better quality of medical services and

maintain the high standard of medical care, hygiene, medical environment safety and

other statutory requirements. During SARS period, the focus of their interest was

concentrated on whether the SARS incident could affect their transactions. SARS is a

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highly infectious disease, during the SARS period, there was no 100% accurate and

instant clinical testing method for verifying the SARS cases. So, the administration

teams of private hospital concerned greatly on the liability of compensation on their

employee and patients being infected by SARS in their hospitals. In the same time, as

the personal protection supplies, e.g. masks and gowns, consumed quickly, there was a

risk of using up all protection supplies. The private hospitals may need to make the

decision of the temporary closure of operation due to lack of protection supplies to the

employee working in the high-risk area, e.g. Intensive Care Unit. Unfortunately, there

were no governmental departments or Hospital Authority to coordinate the procurement

of the medical protection supplies for the private hospitals. The private hospitals did not

jointly acquire the medical protection supplies, they also competed one another to grab

the limited medical protection supplies from the vendors. It showed the lack of

cooperation among the private hospitals, the Private Hospital Association was too loose

to encourage the cooperation of its members.

As the SARS frightened the general public, the patients were very worried to be

infected when they visited the hospitals. The lack of confidence leaded to great drops in

all kinds of non-emergency inpatient, outpatient cases and minor surgeries, but there is

a significant increase in obstetric cases as the mothers thought delivering their babies in

the private hospitals was safer than in the public hospitals. In order to protect their

vulnerable business, the private hospitals avoid admitting any SARS suspected cases

through screening the visiting patients in the very beginning. Also, they request the

Hospital Authority to accept all transfer of SARS suspected cases. The private hospitals

thought that the guidelines provided by the Department of Health and Hospital

Authority are very vague and there were very few communication, so the private

hospitals regularly ask for the latest guidelines and the information of SARS from the

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HA and DH.

The private hospitals are recommended to enhance their coordination among

themselves through the Private Hospital Association on jointly acquiring the medical

supplies and medicine, and set up a Crisis Coordination Team under the Private

Hospital Association to set up a surge capacity for medical supplies and workforce for

their members to satisfy the instant need during the crisis period. Canada has similar

established platform for coordinating the surge capacity: Health Emergency Response

Team (HERT) to mobilize select groups of skilled personnel, such as quarantine officers

and nurses. Also, it addresses the specific requirement of a health emergency for an

epidemic or outbreak of infectious diseases. Although the private hospitals are

competitors one another, the cooperation of procurement can increase their bargaining

power for lower cost of medical supplies and medicine, and maximize their capacity

and efficiency to solve the instant outbreak.

Private Practitioners

In the stakeholders’ mapping, the interests of the private practitioners, or called

GPs, to SARS are high but their powers to SARS are low, so the Hospital Authority and

Department of Health should keep informing the private practitioners on the SARS

matters in order to deal with that kind of stakeholders well.

The private practitioners are vulnerable business in the SARS period. When a

private practitioner in a clinic was infected with SARS during the early days in SARS

period and spread to his patient, the transaction of the GPs dropped significantly. They

were in dilemma on treating the visiting patients. As the symptoms of SARS are quite

similar to other common low-risk infectious diseases in the community, they really

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wanted more patients to visit their clinics but they did not know how to verify the

SARS cases and whether their protective gowns and masks could protect them from

being infected by their visiting patients. During SARS, the guideline provided by

Department of Health was not clear enough. They seemed to be neglected and so they

demanded Department of Health could provide the latest information of SARS and the

suspected cases and clear referral guideline and infection control guideline as well.

Also, they are quite trivial to compete with other hospitals and group medical practices

to acquire the medical protective supplies, so they demand Department of Health, HA

or other government departments to coordinate the supplies of PPE for all private

practices

In order to better serve that kind of stakeholders, the Department of Health should

set up a information platform (IS system) for the private practices to communicate and

share the information for patient history, latest referral and infection control guidelines

for SARS and other highly infectious diseases. Also, an electronic infectious disease

reporting platform, similar to the information system set up in Canada, should be

established and widely used among all private practices for better alerting in crisis

management when one of the GPs recognises the suspected case of an infectious

disease in the community. For the GPs, they should contribute their patients’ histories to

the database and let those information easily acquired by public and private practices

under the agreement of the patients each time, in order to balance the transparency of

medical information for medical purpose and the individual privacy enjoyed under the

current common law in Hong Kong.

Insurance Companies

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In the stakeholders’ mapping, the powers of insurance companies to SARS

incident are low, but interests of the insurance companies to SARS incident varied in

two different period, during SARS and after SARS, which is low and high respectively.

So, minimal effort should be put on the insurance companies during the SARS period.

After SARS period, the Hospital Authority and Department of Health should keep

informing the insurance companies in order to deal with that kind of stakeholders well.

The insurance companies concern all matters affecting their profitability,

especially the risk emergent during the crisis. In order to secure their profit, they use

certain kinds of estimation by actuarial science to balance the risk control and rewards

from competitive insurance premium. After SARS period, there was a trend in

increasing claim for the compensation for the damages relating to infectious diseases

from the employees and the patients under the insurance plan of the employers,

especially hospitals. So, they decided to avoid facing unpredictable risk for the claim of

employee and third party compensation due to infectious diseases by restricting the

coverage of their medical insurance provided to the employers. Upon renewal of

insurance plan for the medical practices, they removed the terms for covering the

employees and third-party medical compensation relating to infectious diseases.

Moreover, they raised the insurance premium to Hospital Authority and private

hospitals by fewer extent and 4 to 6 times respectively.

So, in order to show the social responsibility of the whole insurance field to the

society of Hong Kong, they should lower the premium as the coverage of infectious

diseases is excluded. Higher premiums charged by the insurance companies in the

renewed contracts for less coverage are not sensible. Also, the government should set

up an independent corporation like Hong Kong Mortgage Corporation Limited to

coordinate all kinds of medical employee compensation insurance to develop a large

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pool and reduce the concentration risk faced by the individual insurance companies,

especially for those providing insurance plan only to private hospitals. After collecting

the large pool of medical insurance plans, the independent corporation can resell those

employee insurance plans to the insurance companies and receive small percentage of

charges from the insurance companies for maintaining the operation of that corporation.

Health Care Workers (HCW)

HCW are with high level of interest and high power. They are the key players

in managing the SARS outbreaks. It is because SARS threatens their lives as well as

the lives of their families. The fighting against the disease is mainly relied on them.

If they joint together to refuse to work or ‘work-to-regulation’, the whole health

care system will be paralyzed. In confronting SARS such a new, unknown origin and

cause, and behaved differently from anything seen before, and with no effective

treatment to cure, HCW fear of being infected of SARS or infecting their families.

They are also afraid of being discriminated. Some are afraid of to go to work in

hospitals and to care for SARS patients. Some also afraid to associate with other

HCW, or even spouses of health care workers, particularly those from SARS units.

They also linger resentment of colleagues who might not have contributed what was

expected. Some feel helpless, angry and guilty. This fear was further engendered

both by the sensationalism of the media coverage and inconsistent information coming

from the government and hospitals.Despite these, most HCW still support each other

and to ensure that all patients receive the best care possible. Hence, the engagement of

HCW for fighting against SARS is very important. Effective communication and

effective precautions against SARS can help to eliminate fears of HCW and get their

engagements.

23



Evaluations in communication and precaution measures among three areas,

namely, Hong Kong, Singapore and Canada can help us to get some insight into the

incident and the most effective methods can be borrowed for fighting against future

similar disease.

Communication

Singapore set up two websites for communication. Between 1 to 3 March 2003,

two Singaporean admitted to hospitals. On 17 March 2003, the Ministry of Health

(MOH) issues daily press statements to update the public on the situation in Singapore.

A list of FAQs has also been released to the media and have been put on the MOH

website. MOH also set up a hotline to handle all general public enquires. HCW and

Singaporeans can go to the websites to get what information they want. Thus, little

rumor will be created.

In the experience of Canada, communication is not so effective. Although local

public health units have responsibility to collect infectious disease information for

reportable disease at the individual case level, and provider are required to report such

information to the public health units. Public health does not have clear enough

responsibility to report this information back to providers. Public Health did not interact

closely with hospitals to identify the process and practices to the infections.

Communication related to SARS came from various components of the health care

system, with no clearly identified source and often with conflicting and or out-of-date

advice. There is no updated information on SARS as quoted by a staff that the

continuous requests for information on a minute-by-minute basis, day and night will

hampered the efforts of a limited number of overworked staff. Federal/Provincial

Territorial government had established National Crisis Communication strategy prior to

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SARS to facilitate the planning and response to the communication inherent in a wide

rang of emergencies. But it was not yet performed during SARS period.

In Hong Kong, rumor also arose during SARS period. In 22 February 2003,

Professor Liu from Gangzhou attended KWH and infected his family member and

HCW. HAHO level did not alert other hospitals of the potential risk. During early

March, staff generally were not taking any extra precautions.

The outbreaks at PWH and PYNEH should trigger HA to issue a loud and clear

warning to all HA staff. However, communication is not sufficiently clear or effective.

Finally, HCW found the outbreaks from the newspaper. There was no explicit warning

about the possibility of patients who were ‘unsuspected’ but could spread the disease.

As late as 31 March 2003, a daily update newsletter was printed and hand delivered to

staff at the frontline. A lack of internal feedback made HWC to air their grievances

through daily radio phone-in program. Hence, at the end of April the Board Task Force

set up three executive groups. The board members made regular visits to hospital

helping to improve communications and to ensure that important messages on infection

control and PPE supplies were reaching the frontline.

Precaution Measures

The government Singapore also performed better. On 6 March 2003, MOH

advised hospitals to isolate patients and take necessary infection control measure. In

‘the statement from the Minister for Health coping with SARS’ of 4 April 2003 detailed

the precaution measures against SARS and how to deal with patients with SARS. All

health care institutions needed to set up special teams to prevent and control SARS.

The ministry would carry out audits on health care institutions to ensure

25



compliance with the infection control practices.

However in Canada, there are very different policies and procedures for dealing

with outbreaks of infectious disease among hospitals. The protocols did not appear to

provide sufficient information or instruction to define how to manage severe outbreaks.

HWC emphasized the need for standard protocols and practice in outbreak

management.

In Hong Kong, as late as 27 March 2003, a policy to suspend visiting to suspected

and confirmed SARS patients was implemented. On 3 April 203, ‘no visiting’ policy

was introduced as well as guidelines on mandatory wearing of masks for all patients

and staff.

Therefore, the performance of Singapore in SARS case seems the best among the

other two. Singapore government reacts more quickly and have contingency plan on

emergency events.

Recommendations

The government should establish a surveillance role to accumulate and analyze the

locally collected information and establish a communication process that alerts hospital

about unusual patterns. The government should also set up a single communication

source for communication and a process to minimize frequent changes to information

and conflicting information in an emergency.

In cases of an emerging unknown infectious disease any indications that it is

infective to HCW should be communicated to frontline staff immediately, together with

guidelines in infection control measures. The HA must review its strategy for internal

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communications and level of resources and expertise it allocates to this vital area.

Mechanism must be established to facilitate obtaining frank and timely feedback from

HWC in times of crisis. The HA should provide continuous training for HWC over

infection control and precaution measures. The HA should set up formal psychological

counseling unit to help staff and their families in every hospital. HA can set up an

insurance fund to cover HCW who become sick or die through work during emergency

period such as SARS. The HA should make use of two kind of communication

channels, i.e. cascade message and target message to ensure message can be read by

HCW.

Unions and Professional Associations

Their main concerns are the interest of members. They aim at fostering friendly

relations and co-operation amongst members and at enhancing professional

development of members. Therefore, they are with high level of interest and high

power. They are the passive key players in managing the SARS outbreaks.

In Singapore, a Courage Fund has been set up by the two health care clusters, the

Singapore Medical Association, Singapore Nurses Association to help families of needy

SARS patients in honor of all HCW in Singapore. Thus, the influences of unions and

professional associations are not very great in Singapore. The government can engage

them in SARS event.

In Canada, unions and professional associations are more influential. Owing to

the mounting association pressure form nursing associations, unions, opposition

politicians and media, the Province of Ontario announced investigation into the SARS

crisis. Ontario Hospital Association and the Ontario Medical Association made efforts

27



to communicate with their members about SARS and to support the outbreak response.

In Hong Kong, unions and professional associations are also more influential.

They joint effort to combat SARS, updated information on SARS, organized SARS

seminars, source protective gears for members, educate the public on how to protect

themselves, set up community network among private medical practitioners for

screening SARS, and set up SARS sub-page in their homepage at internet. The

examples are Hong Kong Medical Association (HKMA), Hong Kong Public Doctors’

Association and Association of Hong Kong Nursing Staffs. The HKMA also participate

in and support research on SARS, mobilizing members to act as voluntary medical

advisers to school (One School One Doctor Scheme). In addition, it mobilizes its

members to volunteer their services to HA patients with chronic illnesses, who are

afraid of going to public hospitals for follow-up.

In spite of the information of Singapore and Canada is not enough, it involves

difficulty in comparison. Anyway, they can engage unions and professional

associations to give a hand to fight against SARS.

Recommendations

The HA should communicate more with them and exercise more influence on the

as they can be treated as a reserve of professional manpower in future similar disease.

Moreover, they also provide ethical standard input to their members.

Media

During SARS, Media had played an important role in responding to the incident

and it was because of their reporting which in turn activate the concerned organizations

to take actions that made the whole situation changed. Firstly in the early part of 2003,

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the Hong Kong media started reporting on pneumonia-like ‘mystery illness’ affecting

people in Guangdong. In the vacuum of definitive information the media reports

focused on panic buying of white vinegar, which was rumored to provide protection.

Following with hindsight the first official announcement at a Guangzhou City

Government News Conference on the ominous warning of the looming threat of over

100 cases of atypical pneumonia including healthcare workers who worked in a few

local hospitals where there was neither enough awareness of the disease nor adequate

supply of protective gear. Then came up with the case of Professor Liu, the hospital

outbreak amongst healthcare workers, the Metropole Hotel connection, the Amoy

Gardens involvement and so on, all these were reported by the media to the public. The

media had raised the attention of the Hospital Authority, the related government

departments and the general public. Their interests are to report the first-hand material:

exposing the new unknown infectious disease, the action of the Hospital Authority and

the weaknesses of the management structure, reflecting the situation of the frontlines,

seeking information, expert opinion with the related matters to increase the knowledge

level, kept the pubic being informed of the situation and help to disseminate the correct

information and preventive measures.

In engaging with the media and to alleviate the public panic, Hospital Authority

had enhanced the communication with the public and the media which was coordinated

by the HA Public Affairs Department. During the outbreak a range of methods were

used to communicate with the media and public including: press releases (35 by

HAHO, 7 by clusters and 30 by hospitals); press briefings; editors briefings; radio

programs; 16 TV programs; 24 educational talks; 6 community forums; 7 contributed

articles; and an exhibition. Daily attendance at a radio phone-in program by senior

HAHO staff commenced on 11 March and continued to 25 April, 2003, after which it

29



was arranged as necessary. For the initial period, the communication and information

was still confusing and public had the impression that HA was hiding something. The

situation was improved until 19 March, 2003 when HAHO and DH conducted a joint

daily press briefing. Through April HAHA continued to arrange communications with a

view to inform and educate the public on prevention of SARS. This included

announcements on treatment, interviews with recovered staff and patients and meetings

with columnist, editors and academics (Report of the HA Review Panel on the SARS

Outbreak, 2003).

Although HA was noticed in improving their performance progressively during the

course of SARS with the media but still that it lost the external communications battle.

This was initially rooted in a failure to provide effective means for internal staff

feedback, which resulted in staff raising their concerns in the public arena. This was

reflected through the daily radio phone-in program which HA staff publicly aired phone

calls to their own Directors voicing out various complaints.

Herewith recommend the HAHO should appoint an experienced public affairs staff

or agreed spokesman to handle the media so as to maintain a consistent and unity of

message to avoid confusion. Also the Director attending the media program should

make positive use of the airtime to disseminate policy, information, contingency

measures and reassurance to public and staff rather than answering public questions and

being used as a punch bag or defending itself against mounting criticism. Also it would

be better to appear on different media channel with fair occurrence to avoid dominate

by any one of the media so as to get an equilibrium of power of different media.

The key player function was being performed distinctly by the media with their

high influencing power.

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Patients

The interests of patients are high as they were keen to know the whole situation of

SARS. Such as the disease, treatment, preventive measures and so forth. As the non

SARS patients were trying their best to protect oneself and family to avoid infected. On

the other hand, the SARS patients would want to know how the HA was going to treat

them, what were the progress of the disease and the same that they were afraid of

infecting the others. So the policy and quality of care of the hospital were most concern

of them but they got no power to interfere with HA.

According to the mapping, HA would well engage with this segment of

stakeholder if HA could keep inform of the situation to them. But HA was not

performing well as it itself was so confused in various aspects which in turn caused the

consequent effect of the patients. The patients were worry, anxious, confuse about the

policy of hospital and felt being isolated, and discriminated. They might even have no

confidence and trust of HA which they might deny of information.

In order to handle the segment of stakeholder better, we would recommend HA

providing simple, clear, open, honest and transparent communication to secure the trust

and confidence of patients. For patient care, HA should train staff about effective

communication, provide communication channels e.g. designed phone for patients to

communicate with relatives, provide delivery service for patients’ necessities. Also HA

could make use of different patient group to disseminate information to avoid

confusion. For the environment and facilities: development of operational protocol in

general ward for an out break of infectious disease, early introduction and

implementation of cohort or step down wards to reduce the risk of cross infection. For

infection control measures: strict implementation was important so orientation and

31



briefing of measures on admissions to patients was necessary. Improvement of the

toilet and shower facilities, adequate bed spacing and arrangement of negative pressure

or isolation room for high risk procedures should be followed.

For post-discharge service, enhancement of follow-up care, advice and

psychological support were important. HA should organize programs for high quality

aftercare and counseling to all surviving SARS patients and families.

Suppliers

Suppliers are those organizations supplying material resources that needed for the

provision of health care services, which included pharmaceuticals, medical equipment

companies, personal protective equipment manufacturers, etc.,. As the activities and

decisions of the suppliers can influence or impede the operation of the health care

service provider, they bear high power and are important external stakeholders to the

Hospital Authority. There existed lots of uncertainty during the SARS epidemic and this

episode had brought lots of commercial chances to them as the demand of medical

related necessities increase drastically. According to the stakeholders’ theory, the

Hospital Authority should build up stakeholder partnership with the suppliers to

maintain good communication and commercial relationship between the two parties.

Apart from profit making commercial activities, the suppliers bear the social

responsibility of serving the public by providing good quality medical products and

promoting the health care service standard of the public. During SARS period, the price

of protective clothing increase sharply as the demand increases. Moreover, there existed

the crisis of medical equipment shortage. To prevent the same problem, we suggest

developing a contingency mechanism to ensure there will be adequate supply of

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medical necessities with reasonable price.

Residential care homes

Residential care homes may either be profit making or non-profit making. They

may have to receive step down cases from acute hospital and bear the responsibility of

protecting their resident from getting infected. To achieve this goal, they have to follow

the instructions from the government in maintaining the hygiene standard of the hostel,

make notification and report in case of the outbreak of disease. However, during the

SARS period they were neither able to participate in the decision making process of the

Hospital Authority nor affect its operation.

Being an external stakeholder bearing high interest but low power, the Hospital

Authority should keep the residential care homes informed. According to the

stakeholder theory, when the stakeholder is not critical but the environmental

uncertainty is high, managers can use boundary spanning in order to manage the

stakeholder relationship more proactively. The Hospital Authority should set up

committee with the keepers of residential care home to ensure patent communication,

gathering and disseminate important information, and sharing patient care experience.

Besides, more resources should be put on developing the Community Geriatric

Assessment Team or Visiting Medical Officer Schemes to provide support in

surveillance, disease prevention and containment to prevent future outbreak of

infectious disease.

Universities and Scholars

Universities and Scholars bear the responsibility of providing education and

33



promote academic development. Moreover, they have the social responsibility to

maintain the health and stability of the Hong Kong population in times of crises.

During the SARS period, they took the role of investigating the social and clinical

management method in containing the disease, which was very important in affecting

the policies and actions of the Hospital Authority.

Being a critical stakeholder, to ensure proactive arrangement between the Hospital

Authority and the scholars, a joint academic and clinical panel in investigating the

episode should be set up to maintain their stakeholder partnership in pursuing the

common goal of disease containment. Moreover, the Hospital Authority should work

with the universities and research funding providers to set up a research team placing

due emphasis on projects investigating public health and communicable disease

containment which prevent future outbreaks of other infectious disease. Besides, joint

effort should be make between the Hospital Authority and the universities in educating

the population by promoting the public hygiene and health.

CONCLUSION

The success of combating SARS can be affected by how the key players and other

stakeholders are dealt with. As the main organization that combat the disease, the HA

should work in one accord with the HWFB and DH, the key players in the public health

management structure to set up a united information platform in communication to

avoid confusion in command and information among all the stakeholders. Moreover,

the HAHO should work jointly with the HA Board to clearly delineate the roles and

responsibilities of the Board, the Chairman and the Chief Executive during crises

situation and set up permanent policies in addressing the roles, responsibilities and

authorities of all stakeholders involved. There should be clear plans on when and how

34



the various stakeholders should be engaged in outbreak of similar nature in the future.

Control and command should then be centralized to one office to declare all the

procedures, protocols and actions, and the allocation of medical supplies and workforce

in times of outbreaks.

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References

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Limited.

4. Report of the Hospital Authority Review Panel on the SARS Outbreak. (2003)

Hospital Authority.

5. Robbins S. & Coulter M. (2002). Management. 7th ED. Prentice Hall, New Jersey.

6. Learning from SARS – renewal of Public Health in Canada

7. A report of the National Advisory Committee on SARS and Public Health, Oct,

2003

8. Report of the Hospital Authority Review Panel on the SARS Outbreak, Sept, 2003

9. Ministry of Health of Singapore-Newsroom http://app.moh.gov.sg/new/new01.asp

access on 1 May 2004

10. SARS of Singapore http://www.moh.gov.sg/sars/index.htmlaccess on 1 May 2004

http://app.moh.gov.sg/new/new01.asp

http://www.moh.gov.sg/sars/index.html


http://app.moh.gov.sg/new/new01.asp


stakeholders model - combined]

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