Priorities in effective management of primary health care institutions in Lithuania: Perspectives of managers of public and private primary health care institutions

Background Primary health care institutions are looking for opportunities to create value for patients and to increase the competitiveness of the health care institution. Determination of competitive priorities for creation of value for patients in the management of primary health care institutions allows improving competitiveness and achieving a competitive advantage in the market. The aim of the study To determine the priorities in the management of public and private primary health care institutions by using the focus group discussion method with managers. Methods The study was exploratory with intention to find a ground for a management theory and to be the root for the development of health care reform in Lithuania. Focus group discussions were held in 10 Lithuanian counties; 10 focus group sessions were carried out. A total of 48 primary health care executives were interviewed. The participants of this qualitative study were given 8 questions related to value creation of the primary health care institution to patients and rise in competitiveness. The main question of the focus group discussion was “What are the main priorities of management of primary health care institution?” The criteria of data collection based on the deep understanding of the phenomenon and the richness of data expressed by participants of the research. Results Qualitative research showed that the priorities of management of primary health care institutions were work management of an organization; human resources management; patient management; and health policy decision making. The participants of focus groups pointed out that effective work of primary health care institutions is ensured by the model of management, doctor-patient communication, quality and timely delivery of health care services, and financial resources. The major decisions involving the management of patients were as follows: meeting patients’ expectations, quality and timely satisfaction of patients’ needs, effective solution of patients’ problems, patient-centered services, patient satisfaction, and communication with the patient. Accessibility to services, quality, geographical accessibility, disease prevention, strengthening of patients’ health and adequate funding were mentioned as the priorities of health policy.


The aim of the study
To determine the priorities in the management of public and private primary health care institutions by using the focus group discussion method with managers.

Methods
The study was exploratory with intention to find a ground for a management theory and to be the root for the development of health care reform in Lithuania. Focus group discussions were held in 10 Lithuanian counties; 10 focus group sessions were carried out. A total of 48 primary health care executives were interviewed. The participants of this qualitative study were given 8 questions related to value creation of the primary health care institution to patients and rise in competitiveness. The main question of the focus group discussion was "What are the main priorities of management of primary health care institution?" The criteria of data collection based on the deep understanding of the phenomenon and the richness of data expressed by participants of the research.

Results
Qualitative research showed that the priorities of management of primary health care institutions were work management of an organization; human resources management; patient management; and health policy decision making. The participants of focus groups pointed out that effective work of primary health care institutions is ensured by the model of PLOS  Introduction the primary health care and family health care institution. It is argued that the development of a primary medicine institution is a priority in management [7]. The main objectives of the first phase (2003)(2004)(2005) year) were to improve health care quality and accessibility to services, to optimize the scope and structure of health care needs. In order to improve the quality of health care services and accessibility, the strategy of health care restructuring was approved. Restructuring of health care is carried out in three priority areas: outpatient services, especially development of primary health care institutions; optimization of inpatient services and alternative forms of activity; and medical care and long-term nursing services [8]. The second phase (2006)(2007)(2008) year) of health care system restructuring involves the separation of primary and secondary level outpatient services with an emphasis on primary health care organization in rural areas and development of the network of private primary health care institutions [9]. The second phase of health care restructuring was designed to optimize the health care network and improve the service structure, based on health care needs in the population [10]. In the second phase, one of the key objectives was to develop a patient-centered primary health care institution and to achieve that by the end of 2008 at least 60% of primary health care services would be provided by privately employed family doctors [10]. The third stage (2009)(2010)(2011) year) of the restructuring of health care institutions and services aimed to provide safe, highquality, and accessible health care services to the population and efficient use of health care resources [11]. The aim was to ensure that primary health care would cover person-oriented, primary dental and primary mental health care, and the most rational use of human, material, financial resources. One of the main objectives was the development of private primary health care institution activities [11]. The fourth phase (2012-2016 year) of health care system development and hospital network consolidation regarded the development of the main direction outpatient services, particularly primary health care and disease prevention strengthening [12]. The importance of the primary health care system is defined by service provision to patients while focusing on meeting the patients' expectations and needs and improving patient satisfaction. Increasing competition among primary health care institutions gives patients the freedom to choose a health care institution and a doctor. Meeting the patients' expectations with health care services, primary health care human resources, and patients' partnership are the core priorities in the management of primary health care institutions. This qualitative study is important for the assessment of health care reform progress in Lithuania and to be the strategic direction for the health care reform development. The value of this study is defined by the chosen research method, executives of primary health care institutions were interviewed by using focus group discussions. The following objectives of the research were formulated: To determine the priorities of competitive advantage of the primary health care institution.
2 nd objective. To explore a key source of competitive advantage of the primary health care institution.
3 rd objective. To describe essential activities of patient management of the primary health care institution.
4 th objective. To reveal decisions that increase the competitiveness of the primary health care institution.

Ethical aspects
Scientists addressed the ethical aspects in qualitative research that combine relationships between researchers and participants, consent and anonymity, privacy and confidentiality [13]. In qualitative studies participant's world include participant recruitment, representations of participant's voices, involvement of vulnerable populations and ethical challenges related to the researcher's world include risk management, the process of emotional content [14]. The methodology of qualitative research is driven by theoretical assumptions and by choice of techniques [15]. The qualitative research conducted by awareness of the process and well-established ethical principles: autonomy (participants exercise their rights as autonomous persons), beneficence (research is doing good for others), justice (equal share and fairness) [16].

Material and methods
The qualitative research is an interactive, iterative process of participants and researchers jointly exploring the phenomenon to yield rich insights for theory building [17,18]. Data gathered through focus group sessions by sharing ideas, attitudes, insights, and experience on the chosen topic among the participants [17]. The deepest level of understanding provided by judgments, assumptions, behaviors, intentions [18]. In Lithuania primary health care institutions differ by ownership form, patients could choice the primary health care institution and there working the family doctor who could work in public or private primary health care institution. The methodology of the study is presented in the Fig 1. The mean size of the focus group was 5 participants. The mean duration of the focus group discussion was 1.21 h. The focus groups study was carried out in this sequence: • Participants for this focus group study were selected from the list composed by the Lithuanian Institute of Hygiene at the end of 2012. Selection was done following the principle of 50/50, with the intention to include the executives of both public and private primary health care institutions.
• The executive of the primary health care institution was contacted by phone and informed about the topic, purpose, time and place of group discussions.
• As soon as the leader of the primary health care institution agreed to participate in the focus group session, an invitation was sent by e-mail and/or presented to the participant or to hospital staff, which gave the invitation to the executive.
• After informing about focus group discussions and agreement to participate, informed consent to participate in focus group sessions was obtained.
• Focus group sessions were audiotaped and based on the records, analysis of focus group discussions was performed.
• In order to assess the quality of focus group discussions, the questionnaires were sent to participants of focus group discussions by e-mail after the study.
The focus group discussions involving the executives of primary health care institutions were conducted from May 2015 to March 2016 in 10 counties of Lithuania: Vilnius, Kaunas, Klaipėda, Šiauliai, Panevėžys, Utena, Alytus, Marijampolė, Tauragė, Telšiai. A total of 48 participants were enrolled into the qualitative study: 31 leaders of public primary health care  institutions and 17 leaders of private primary health care organizations. The profile of participants is described in the Table 1.
Qualitative study analysis revealed the opinion of the participants of focus group discussions toward management priorities of the primary health care institution. The study analysis was done based on participants' opinion, insights, and experience. The analytical approach of the qualitative study was based on the Grounded theory and the researchers following the principles of the rigor and quality of the analysis (Fig 2).
The data were analyzed as follows: 1. The data were categorized into priorities of "Management of organization," "Management of human resources," "Management of patients," "Management of health policy decisionmaking" from the participant perspective.
2. Each category was defined and differences and similarities were established. If the analysis categories related to the perspectives, it was predefined by the research team.
3. The data of the qualitative study were grouped by perspectives, categories and explained its content.

Results
The results of this qualitative study showed that priorities in the management of primary health care institutions were related to organization management, human resources management, patient management, and of health policy decision making.

Management of organization
The study showed that "management of organization" perspective was divided into the following categories by the executives of public primary health care institutions: concept of family physician specialty, accessibility, examination, workload management, communication, quality, financial resources, patients, health promotion activities, image building, and decision management ( Table 2). The participants of private primary health care institutions divided "Management of Organization" category into workload management, accessibility, principles of marketing, services management, management of documents, communication, quality, financial resources, health promotion activities, and management of decisions. Each primary health care institution has its own management model, which includes the organizational structure, financial resources, human resources management, patient management, quality systems, and infrastructure: According to the opinion of executives from public primary health care institutions, the family doctor should not address patients' social problems, but should provide medical services. One of the most important priorities of management is family doctor-patient communication by ensuring adequate health care services to the patient. The executives of public primary health care institutions reported that the number of patients registered with an institution and their retention was important: . . .The patient is the main priority of primary health care. And the more the organization has registered patients, the better we will live, because the primary health care center absolutely holds out on itself, as nobody pays extra . . .
(woman, public primary health care, Kaunas county) In order to keep patients, the leaders of public primary health care institutions make decisions regarding staff workload management, number of services necessary to perform, patient queue management, provision of secondary-level services to patients, employee safety, procedure and document management, and institution accreditation. The opinion that the patient should visit his/her family doctor 1-2 times a year was expressed. Public primary health care institutions solve problems related to the registration of patients with family doctors, family doctor's visits to patient's home, and management of repeated visits. According to the opinion of focus groups participants, additional patients' examination at the primary level should be properly paid. The executives of public primary health care pointed out that one of the management priorities is dissemination of healthy lifestyle among patients as well as organization and implementation of health promotion programs. Because family doctors have a heavy workload, health care professionals could carry out health promotion activities for patients. The media plays an important role in shaping a positive image of primary health care organizations in the public and informing patients about health promotion programs and projects. The leaders of private primary health care institutions reported that the key priority of the primary health care organization is provision of assistance to people based on established medical norms while striving for effective functioning of the institution. The participants from the private primary health care sector stressed that 80% of the patient's problems were solved by the family doctor; therefore, health policy makers should pay greater attention to the primary health care institution. The executives of private primary health care organizations pointed out the place of the primary health care institution, services provided to patients (quality of services, speed and time of service provision, provision of services by phone), patients' queue management, family doctor-patient contact, and communication culture between staff and a patient as important factors. One of the management priorities is an increase in the number of registered patients in order to provide high quality health care services to patients. Attraction of additional financial resources, interinstitutional cooperation, and partnership with social partners were mentioned as management priorities by private primary health care leaders: The value of the primary health care institution could be created through workload management, accessibility, application of marketing principles, management of services, management of documents, communication, quality, financial resources, health promotion and management of decision making.

Management of human resources
Based on the opinion of the leaders of both public and private primary health care institutions, appropriate personnel are the institution's capital and the largest investment is human capital Table 3).
. . . The patient is our priority followed by our employees-the main capital of the institution. And it is needed to talk to them and to work with them, to solve problems, conflicts, etc . . .
(woman, public primary health care institution, Marijampolė county) The participants of focus groups pointed out that they solved issues related to the management of burnout syndrome among employees. A family doctor acts as "a keeper to direct patients to appropriate medical specialists." The main priorities of human resources management are family doctors' functions, employees' motivation, training and development of competencies, staff work management (workload, the length of visit, management of documents), the system of employees' penalties/praise, professionalism, and patients' confidence in staff. The executives of private primary health care institutions stressed that one of the key management priorities were staff attraction, its retention, and managers' personality. The main aim of the family doctor's work is to solve the patient's problem. The leaders of both private and public primary health care institutions agreed that work norms and responsibilities of family doctors are broad; therefore, it is important to evaluate the role of personnel of nursing and other specialties (gynecologist, surgeon, psychiatrist, and pediatrician) in family medicine. The executives from public primary health care reported that one of the most important tasks of human resources management was the replacement of an inefficient employee by more In opinion of the participants, it is necessary to determine not only staff responsibilities, but also patients should be responsible for their own health and its strengthening. The leaders from public primary health care institutions reported that it was important to ensure employees' preparedness to work with the patient, since family doctor's communication with the patient was indicated as the main priority of primary health care institution management.

Management of patients
The main activities of patient management cover meeting the patient expectations, improvement in satisfaction, and effective solution of problems. The participants of focus groups reported the following key management priorities related to the patient: meeting patient expectations; quality and timely satisfaction of patient's needs; effective solution of patient's problems; services oriented to the patient; patient satisfaction; and communication with the patient ( Table 4).
The leaders of public primary health care institutions emphasized the assurance of healthcare services needed by patients as important, while based on the opinion of the executives of private primary health care institutions, it was important to attract and retain patients. The executives of private primary health care institutions are looking for ways how to increase the value for the patient created by the primary health care institution, and therefore, are implementing service standards in the activities: . . .To create value for patients, as competition grows in the quality of services. And everyone will automatically try to do the best that the patient would feel comfortable as much as possible . . .
(man, private health care institution, Vilnius county) The patient chooses a specialist, not a health care institution, and efficient human resources management is one of the most important sources of competitive advantage. The leaders of private primary health care institutions stressed the importance to evaluate the demographic structure of patients and a portfolio of primary health care services provided to them. The participants of focus group discussions expressed their view on patients' responsibility for their own health and its strengthening, with the priority given to lifestyle medicine. There is a prevailing opinion in the society that health care services and medicine are for free; therefore, it is necessary to raise public awareness of the health care system and health care services provided.

Management of health policy decision-making
During focus group discussions, there was an opinion that a monopoly exists in the Lithuanian primary health care market, and increasing competition would bring positive effects such as improvement in health care quality and an increase in patient satisfaction: . . . Sincere communication with the patient and constant his/her acceptance, not rejection, are very important in competition . . . (woman, public primary health care institution, Utenos county) Unequal conditions of competition reduces the ability to compete and to provide health care services more efficiently. The content of "Health Policy Decision-Making" category are presented in Table 5.
Competition is based on the management of financial flows, and the absence of competition does not guarantee competitive procurement and provision of services. The participants of focus group discussions reported the following major gaps in the health care market: health policy and strategy, structure and management of the health system (patient flows among primary, secondary, and tertiary levels; inequalities between rural and urban areas), concept of family physician specialty, assurance of teamwork at the primary health care level, reorganization of medical institutions, lack of substantiation of philosophy of a family medicine institution, cooperation with public health offices, allocation of funds, lack of treatment options, involvement of the public in the formation and dissemination of healthy lifestyle, legal regulation and compliance with real family medicine work, shortage of family doctors, and attraction of human resources to rural areas. The executives of both public and private primary health care institutions pointed out that the key management priorities were related to accessibility to services, geographical accessibility, quality, disease prevention, and patients' health strengthening: . . .I think that work management at first, then safety and its requirements followed by human resources and the quality of services . . .

(woman, public primary health care institution, Klaipėda county)
This study of focus groups showed that the management priorities of primary health care institutions include the management of an organization, human resources management, patient management, and health policy decision-making. Setting the priorities in the management of the institution is essential and depends on ownership of the institution and leadership of management.

Discussion
Competitiveness among primary health care institutions develops an exclusive position in the market, and value creation for patients provides a competitive advantage and helps the health care institution to achieve exceptional positions in the health care sector [19]. Improvement in the management of primary health care institutions increases competitiveness; therefore, setting the priorities of value creation and selection of competitive abilities are essential both for the patient and the health care system. The main priorities of service management are human resources management, value creation, management of changes [20], as well as orientation to a customer and expertise [21]. Other studies pointed out that the strategic priority of an organization was to achieve long-term satisfaction of customers [22]. In the UK, patient-centered care and patient involvement are the central priorities of health policy [23]. In Thailand, competitive priorities for services providers were examined, and quality (34.5%), service provision (20.4%), orientation to customer (12.9%), and know-how (12.5%) were found to be the most important priorities [24]. The qualitative study carried out by Pinho et al. in Portugal explored the factors of value co-creation and showed that a holistic view to a patient, available information, communication, and information availability to a patient were the main elements of value co-creation [25]. In the US, the essential priorities of the health care system are quality of well-being and cost effectiveness [26]. In Norway, the following priorities of the health care system were acknowledged: severity of condition, effect, and cost-effectiveness [27]. With the help of a Grounded theory approach, communication, strategy of management, and partnership were founded to be priorities in public health [28]. In the US, the priorities of competitiveness in public hospitals are quality, price, production, flexibility, and performance [29]. Hospitals create trust with patients and the community and evaluate the performance by Priorities in effective management of primary health care institutions in Lithuania: Perspectives of managers clinical outcomes, patient satisfaction, and financial results [30]. In the ageing society, the priority of primary health care institutions is chronic disease management in line with policy initiatives such as changing care processes, developing relationships with society, maintaining patient management, using clinical information systems, and teamwork building with community nurses [31]. While managing chronic diseases in the primary health care institution, the staff recognizes the fundamentals values of practice: quality, ethics, and orientation to patients [32]. Scientific literature discusses about the determination of health care priorities based on social values such as transparency, accountability, participation, clinical effectiveness, cost-effectiveness, equity/justice, solidarity, and autonomy [33]. Previous studies conducted in Lithuania investigated the priorities of value creation for patients and competitive abilities of health care services: patient satisfaction [34]; patient expectations [35]; patients' role in the decision-making process [36,37]; accessibility to health care services [38,39]; quality of health care services [40][41][42]; patients' confidence in health care services [43]; importance of modern health care management [44]; stress management in family doctors' work [45]; nurses' satisfaction with job [46][47][48]; and application of marketing elements in health care institutions [49].
The significance of the qualitative study is based on theoretical and practical importance. The theoretical significance is evident because the scientific issue on priorities in the management of primary health care has received little attention by carrying out qualitative studies. The study results can be root for arising of scientific management theories. The practical importance of the study is related to the results of focus group research and its can be a strategic directions for developing the health care reform in Lithuania. Focus groups discussions revealed that the priorities in the management of primary health care institutions included work organization, human resources management, management of patients, and health policy decision making. In our study, the executives of public health care institutions stressed expectations and needs, orientation to patients, satisfaction, and management of services to be the main priorities of patient' management; while the leaders of private health care institutions reported that the priorities of patient management were expectations, value proposition, alternatives of choice, management of services, satisfaction, responsibilities, and communication.
Scientific literature discusses about human resources as a key source of competitive advantage of the institution. The findings of focus group study showed that priorities in the management of human resources included responsibilities, qualification, motivation, selection, time management and management of burnout syndrome, communication and emotional intelligence. The participants of focus group sessions paid attention to employee's responsibilities and motivation. The executives from private primary health care institutions paid attention to marketing principles in work management of the institution, while the leaders from public primary health care institutions considered image-building of the institution as important. Value creation for patients is based on the mechanism of values and results for patients including effective meeting the patients' expectations and needs, health improvement, accessibility, satisfaction, and quality.

Conclusions
1. Effective work organization of primary health care services helps to achieve a competitive advantage in the market.
2. Motivated and qualified staff of the primary health care institution is the main capital and element of competitive advantage.
3. Meeting the patient expectations, patient satisfaction, and effective problem solving are essential solutions of patient management.
4. Sources of competitiveness in primary health care institutions include a unified e-system throughout the country, improvement in the quality of services, improvement in tariff management of services provided by the family doctor, provision of social services, and search for funding resources with an emphasis on innovations.

Study limitations and directions for future research
In any scientific research, there are a number of study limitations and future directions. The strengths of this focus group study carried out in Lithuania could be mentioned: the executives of both public and private primary health care institutions were invited to participate in this study and the study involved the participants from all counties of the country. One of the limitations of this study is that focus group discussions involved the executives from only primary health care level institutions, and future research should enroll participants from secondary and tertiary levels. The researchers expressed that the study involved the managers from primary health care institutions and it would be interesting to research the opinion of patients about priorities of primary care. The researchers point out that this study can be the direction for future research in order to compare the results with the findings in other countries. In management science this qualitative study and the results can be a basis for the health care reform development and the foundation for new theories.