Critical Success Factors (CSF) analysis is one of the more difficult strategic management tools to understand, and is even harder to use effectively in real-world management. If properly applied, however, CSF analysis does provide a robust and very practical assessment for strategic planners and can be very effective. As with most management tools, CSF analysis is probably more effective when used together with another, complementary tool such as SWOT or PEST analysis, because the best use of the CSF analysis is as a tool for planning and exercising control techniques over processes, rather than as an environmental assessment tool.
What Are Critical Success Factors
If business and management researchers had an easy answer to that question, perhaps CSF analysis would not be such a challenge to learn to use well. In the most general sense, CSFs are the small number of activities that absolutely must be undertaken effectively for the company to have success. What those specific activities are is a source of confusion, because they are entirely dependent on the unique circumstances of the firm. That has not, however, stopped researchers from trying to develop a definitive, universal list of CSFs that can apply to any company. In a study done about five years ago (K.J. Fryer, J. Antony & A. Douglas, “Critical success factors for continuous improvement in the public sector”, The TQM Magazine, vol. 19, no. 5, 2007), researchers reviewed 29 separate studies on CSFs and interviewed a number of organizations, and came up with a chart that tells us exactly nothing about which success factors are indeed “critical” (see Table 1):
|Success Factor||Percentage of studies and businesses surveyed which defined the factor as “Critical,” by business sector:|
|Mixed Sectors||Manufacturing||Service||Public Sector|
|Training & learning||67%||57%||100%||75%|
|Quality data measurement & reporting||47%||14%||33%||50%|
|Corporate quality culture||47%||57%||67%||50%|
|Ongoing monitoring & assessment||20%||14%||0%||50%|
The problem of choosing appropriate CSFs is immediately apparent; management commitment is an obvious choice, but it seems rather at odds with what we learn in management studies that a factor such as “Employee empowerment” would be fairly important to many different business sectors, while factors that should complement that – Communication and Teamwork – are not considered very important at all, and somewhat incredibly are apparently completely ignored by service-sector businesses.
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But of course, this single example should be taken with a grain of salt; as they say, your results may vary, and if there is one valuable takeaway from it, it is the suggestion of success factors that may be considered as a starting point, regardless if they are eventually found to be actually “critical” or not to a specific organization. It is also important to remember that CSFs are not fixed; they can and probably should change as the circumstances of the business change. For example, other studies have found that it is both common and relatively beneficial for firms facing financial or other crises to shift their CSFs to ones with more short-term effects and change the focus back to a more long-term perspective once the immediate difficulties are resolved.
Developing & Using the CSF Analysis
The interesting thing about using the CSF analysis is that the process of determining what your organization’s critical success factors really are is essentially the whole point. Once the CSFs are identified, steps to see that they are managed properly can be developed using different tools or good old experience and imagination; in many instances, simply identifying what may be a critical success factor and carefully examining why it is indeed “critical” to the firm suggests the way in which it should be handled.
While there are some data management and other analytical tools that can help in selecting CSFs – for example, DEMATEL (Decision-Making Trial and Evaluation Laboratory) software applications – the majority of the process is good old-fashioned intuition and discussion. But there are a number of conventions that should be followed to give the selection and analysis process the best chance of success. First, CSFs should be assessed in a “top-down” fashion; the analysis is not one that is ideally-suited for ‘horizontal’ or ‘collaborative’ organizational structures. Success factors should be judged according to the relevance to the business as a whole, then individual business units or departments, then down to the individual level; if at some level the success factor is not “critical”, then it needs to be reassessed. The reason for this is that the number of CSFs should be kept to an absolute minimum. This prevents conflicts in objectives and processes and helps to prevent a dilution of effort among too many factors.
Second, to avoid overlooking any factors that should be considered “critical”, potential CSFs should be assessed according to the “five sources of organizational success”, a methodology developed in the early 1980’s by MIT researcher John Rockart. Industry CSFs are conditions and operational circumstances that are common to firms within the same sector. Peer CSFs are critical success factors for one’s competitors; this obviously requires an accurate and detailed competitive analysis to be done as a prerequisite to the CSF analysis. Environmental CSFs are related to the firm’s political, economic, and market environment, and can be identified by a method such as a PEST analysis. Temporal CSFs are success factors that are only important at particular times – such as in crisis situations as described earlier – and are most likely to change. And finally, Managerial CSFs are success factors relevant to the management of the firm at different levels; identifying these may seem to run counter to the “top-down” process, but in reality actually helps to focus it by revealing internal conflicts in objectives.
ObjectiveTo define clinical and laboratory features that identify patients with neurosyphilis
MethodsSubjects (n=326) with syphilis but no previous neurosyphilis who met 1993 Centers for Disease Control and Prevention criteria for lumbar puncture underwent standardized history, neurological examination, venipuncture, and lumbar puncture. Neurosyphilis was defined as a cerebrospinal fluid (CSF) white blood cell count >20 cells/μL or reactive CSF Venereal Disease Research Laboratory (VDRL) test result
ResultsSixty-five subjects (20.1%) had neurosyphilis. Early syphilis increased the odds of neurosyphilis in univariate but not multivariate analyses. In multivariate analyses, serum rapid plasma reagin (RPR) titer ⩾1:32 increased the odds of neurosyphilis 10.85-fold in human immunodeficiency virus (HIV)–uninfected subjects and 5.98-fold in HIV-infected subjects. A peripheral blood CD4+ T cell count ⩽350 cells/μL conferred 3.10-fold increased odds of neurosyphilis in HIV-infected subjects. Similar results were obtained when neurosyphilis was more stringently defined as a reactive CSF VDRL test result
ConclusionSerum RPR titer helps predict the likelihood of neurosyphilis. HIV-induced immune impairment may increase the risk of neurosyphilis
Treponema pallidum the bacterium that causes syphilis, invades the central nervous system (CNS) early during the course of infection and may elicit meningeal inflammation. The results of studies from the early 1900s [1–5] showed that up to 70% of patients with early-stage syphilis had cerebrospinal fluid (CSF) abnormalities, including pleocytosis, increased protein concentration, and reactive Wasserman test results. T. pallidum could be identified by rabbit inoculation test (RIT) in approximately one-fourth of samples, even in the absence of other abnormalities. In patients with later-stage disease, CSF abnormalities and the detection of T. pallidum were less common. These results formed the basis of the axiom that T. pallidum is cleared from the CSF and CNS in some patients, even without therapy. More recently, Lukehart et al.  identified T. pallidum in CSF by RIT in 12 (30%) of 40 patients with primary and secondary syphilis and in 0 of 17 patients with early latent or late latent disease. CSF pleocytosis, defined as >5 white blood cells (WBCs)/μL was seen in 16 (40%) of 40 subjects with primary and secondary disease and in 7 (39%) of 18 with latent disease. Similarly, results of the CSF Venereal Disease Research Laboratory (VDRL) test were reactive in 8 (20%) of 40 subjects with primary and secondary syphilis and in 5 (28%) of 18 with early latent or late latent syphilis. In 1 of 7 subjects in whom T. pallidum was identified in CSF before recommended treatment with intramuscular (im) benzathine penicillin G (BPG), the results of a repeat CSF examination 8 months later showed persistent pleocytosis and an increase in CSF VDRL titer. In a study of individuals with early syphilis, Rolfs et al.  identified T. pallidum in CSF by RIT or polymerase chain reaction (PCR) in 8 (40%) of 20 patients with primary syphilis, 15 (23%) of 66 with secondary syphilis and 9 (20%) of 45 with early latent syphilis; identification of T. pallidum in CSF did not influence the efficacy of therapy. CSF pleocytosis, defined as >5 WBCs/μL, was seen in 44 (30%) of 145 CSF samples, and reactive CSF VDRL results were seen in 14 (10%) of 144 CSF samples
In studies conducted during the preantibiotic era, the presence of conventional CSF abnormalities during any stage of syphilis increased the risk of development of symptomatic neurosyphilis . The relevance of these data to the current treatment era is not known, because modern studies have not assessed the influence of conventional CSF abnormalities on treatment response [6, 7]. Nonetheless, on the basis of clinical experience, the number of individuals with syphilis who develop neurosyphilis after recommended doses of im BPG is believed to be small . For this reason, the Centers for Disease Control and Prevention (CDC) publish guidelines to help identify those individuals with syphilis who are most likely to have neurosyphilis. Lumbar puncture is recommended for these patients, to allow for the rational use of health care resources. Guidelines published in 1993 were revised in 1998 and 2002 [9–11]. All 3 recent guidelines indicate that some experts recommend lumbar puncture for all HIV-infected individuals. This recommendation is based on reports of neurological relapse after appropriate doses of im BPG for early syphilis in HIV-infected individuals, which suggests that the clearance of organisms from the CNS may be impaired by concomitant HIV infection [12–18]
Since July 1996, we have enrolled subjects with syphilis into a study to determine how often CNS T. pallidum infection persists after therapy for neurosyphilis. We report here on an analysis of our baseline data to define the frequency of CSF abnormalities that are consistent with neurosyphilis and the influence of clinical and laboratory measures on the likelihood of such abnormalities
Subjects and Methods
Eligibility criteria and proceduresSubjects were eligible for enrollment if they had syphilis, defined as reactive serum nontreponemal and treponemal serological test results, and met one of the following criteria (based on the 1993 CDC guidelines) : neurological or ophthalmological symptoms or signs during any stage of syphilis, late latent syphilis or syphilis of unknown duration (particularly if the serum nontreponemal antibody titer was ⩾1:32), treatment failure, HIV infection (particularly in patients with late latent syphilis), or intent to begin nonpenicillin therapy. Subjects were enrolled at 8 sites: University of Washington, Seattle (132 subjects); Johns Hopkins University, Baltimore (53 subjects); Emory University, Atlanta (41 subjects); Washington University, St. Louis (37 subjects); State University of New York, Brooklyn (23 subjects); Cook County Hospital, Chicago (17 subjects); University of Mississippi, Jackson (15 subjects); and the Chicago Department of Health, Chicago (8 subjects). Subjects were recruited from outpatient sexually transmitted diseases, infectious diseases, ophthalmology, lumbar puncture, and general medical clinics; emergency departments; and in-patient medicine and neurology wards. The study protocol was reviewed and approved by the institutional review boards of each participating site. After written informed consent was obtained, a standardized medical history was obtained, and subjects underwent neurological examination, venipuncture, and lumbar puncture. The syphilis stage was determined according to CDC guidelines; patients with syphilis of unknown duration were included in the group with late latent syphilis . Results of HIV serological tests, plasma HIV-1 RNA copy number, and peripheral blood CD4+ T lymphocyte count were obtained from a review of medical records. Only plasma HIV-1 RNA copy number and peripheral blood CD4+ T lymphocyte count obtained within 90 days of the lumbar puncture (entry date) were used. We used a lower limit of detection for HIV-1 RNA of ⩽500 copies/mL, because that was the lower limit of detection when the study began
Laboratory methodsSerum nontreponemal (VDRL or rapid plasma reagin [RPR]) and treponemal (microhemagglutination–T. pallidum fluorescent treponemal antibody–absorbed test, T. pallidum particle agglutination or T. pallidum ELISA [Captia Syphilis IgG; Trinity Biotech]) serological tests and CSF glucose, protein, WBC count, red blood cell count, and CSF VDRL tests were performed using standard methods at each of the 8 participating study sites. RPR test titers were determined for all available baseline serum samples in a central laboratory using standard methods, and these values were used in the analysis. In 7 instances, no sample was available for testing in the central laboratory, and the RPR titer obtained by the participating study site was used in the analysis. The presence of T. pallidum in CSF was determined by reverse-transcriptase (RT) PCR, according to published methods , with minor modifications. Specifically, the primers were shortened in March 1999 (sense, 5′-CTCTTTTGGACGTAGGTCTT; antisense, 5′-TTACGTGTTACCGCGGCT), and the procedure was optimized for use in a Lightcycler (Roche) in October 2001. For all assays, the limit of detection was 1–10 T. pallidum organisms/mL
Design and statistical analysisThe analysis in the present article is restricted to subjects who met the following criteria: (1) the baseline serum sample was collected within 2 weeks of the lumbar puncture, and (2) the subject had never received a diagnosis of or been treated for neurosyphilis before study entry. We excluded individuals with a history of neurosyphilis because of concern that CSF abnormalities, particularly reactive CSF VDRL test results, might be related to a previous episode of neurosyphilis. Because HIV infection itself may be associated with mild CSF pleocytosis , for the purposes of our study, neurosyphilis was defined as a reactive CSF VDRL test result or CSF WBC count >20 cells/μL, which is above the mild level of pleocytosis usually seen with HIV alone
Associations between categorical variables were assessed by the χ2 test or by Fisher’s exact test. Associations between continuous variables and categorical variables were assessed by the Mann-Whitney U test. Associations between neurosyphilis and clinical or laboratory parameters were also evaluated using logistic regression to control for potential confounding variables. Two-tailed P values <.05 were considered to be significant
Characteristics of study subjectsThe characteristics of the 326 subjects are shown in table 1. Most subjects were men, were infected with HIV, and had late latent syphilis. The median age was 37 years (range, 18–89 years). Two hundred five subjects had received treatment for an episode of nonneurological syphilis before study entry. Of these 205, 49 subjects were treated within 14 days of study entry. As expected, early-stage syphilis was significantly associated with a serum RPR titer ⩾1:32 (P<.001). Early-stage syphilis was also associated with HIV infection (P<.001). Specifically, only 5 (6.0%) of 84 evaluable subjects not infected with HIV had early-stage syphilis, but 93 (44.7%) of 208 evaluable subjects with HIV infection had early syphilis. This disparity was expected, because patients with early-stage syphilis are more likely to have a lumbar puncture if they are HIV infected
Symptoms and signs were categorized into those most consistent with syphilitic meningitis (headache, stiff neck, photophobia, subjective hearing loss, or abnormal finger friction test result in either ear) and with syphilitic ocular disease (subjective decrease in vision, ocular inflammation, or abnormal visual acuity). Eighty-seven subjects (26.7%) met the definition of meningitis alone, 13 (4.0%) met the definition of ocular disease alone, and 25 (7.7%) met the definition for both conditions. The proportion of subjects with ocular disease was significantly greater in the HIV-uninfected group (26.4% vs. 6.0%; P<.001), but the proportion of subjects with meningitis was similar between the 2 groups. The greater proportion of HIV-uninfected subjects with ocular disease likely reflects the CDC criteria for lumbar puncture [9–11]—specifically, HIV-uninfected patients are less likely than HIV-infected individuals to undergo lumbar puncture if they do not have ocular or neurological symptoms
Neurosyphilis in HIV-uninfected subjectsFifteen HIV-uninfected subjects (16.5%) met our definition of neurosyphilis. Of these 15, 6 subjects had a reactive CSF VDRL test result only, 7 subjects had both a reactive CSF VDRL test result and CSF WBC count >20 cells/μL, and 2 had a CSF WBC count >20 cells/μL only. The median CSF WBC count in HIV-uninfected subjects with neurosyphilis was 29 cells/μL (range, 0–221 cells/μL). Neurosyphilis was significantly more likely in subjects with early-stage syphilis (primary, secondary, or early latent disease) and in those with a serum RPR titer ⩾1:32 (table 2). In a multivariate logistic regression model, syphilis stage was not significant after controlling for serum RPR titer ⩾1:32. Neurosyphilis remained significantly more common in subjects with a serum RPR titer ⩾1:32, with an odds ratio (OR) of 10.85 (95% confidence interval [CI], 2.69–43.80) (table 2). Neurosyphilis was not more common in subjects with meningitis or ocular syphilis (P=.59 and P=.75, respectively)