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,

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

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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 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

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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,

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

Stakeholder analysis

External Stakeholders

Customers

Suppliers

Creditors

Governments

Unions

Competitors

General public

Company

Mission

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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

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

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

stakeholders can be crucially important “allies’ in influencing the attitudes of more

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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,

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.

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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

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

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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

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

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

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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 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.

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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

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.

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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.

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

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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

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.

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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

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

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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

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

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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 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

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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 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.

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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 highly infectious disease, during the SARS period, there was

no 100% accurate and instant clinical testing method for verifying the SARS cases.

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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 HA and DH.

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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

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

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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

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

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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

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eliminate fears of HCW and get their engagements.

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

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Territorial government had established National Crisis Communication strategy prior

to 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

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control SARS. The ministry would carry out audits on health care institutions to

ensure 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

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internal 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

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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

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early part of 2003, 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

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program by senior HAHO staff commenced on 11 March and continued to 25 April,

2003, after which it 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.

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

high influencing power.

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

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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 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

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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 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.

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Universities and Scholars

Universities and Scholars bear the responsibility of providing education and

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

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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 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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