Dr. Ashfaq Ahmed BhuttoMBBS, MBA, MAS, DCPS, MRCGP, (PhD) Friday, February 10, 2012
What we will do today 1. Our curriculum2. Plan of study3. Define a hospital4. Define Health system5. System theory6. Organization of Hospital 2
Managing a Modern Hospital – Our curriculum Quiz 1 Quiz 2 Quiz 3 Date Time TopicSession 1 Friday, February 10, 2012 9.00 am to 1.00 pm Introduction to hospitalSession 2 Monday, February 13, 2012 9.00 am to 1.00 pm Organization & functioning of HospitalSession 3 Tuesday, February 14, 2012 9.00 am to 1.00 pm Planning and building of a HospitalSession 4 Wednesday, February 15, 2012 9.00 am to 1.00 pm Hospital Building Notes- ER, OPD, WardsSession 5 Thursday, February 16, 2012 2.00 pm to 6.00 pm Hospital Building Notes- OT, ICU, CCSD, Day careSession 6 Friday, February 17, 2012 2.00 pm to 6.00 pm Inventory ManagementSession 7 Saturday, February 18, 2012 2.00 pm to 6.00 pm Waste ManagementSession 8 Tuesday, February 21, 2012 2.00 pm to 6.00 pm Performance measurement of a hospitalSession 9 Thursday, February 23, 2012 2.00 pm to 6.00 pm Patient Safety, HSE, Infection controlSession 10 Friday, February 24, 2012 2.00 pm to 6.00 pm Disaster & change Management
Plan of study-Course Requirement Attending interactive sessions & discussion Learn tools and practice Getting Three quizzes and SEQ Final assignments to be completed during supervised learning period. (Full prospect and requirements of assignments will be given later) 4
Plan of study-Session routine One day before new session visit web site and attempt pretest Discuss test findings of last session - five minutes Interactive sessions, Discussion and presentations Just before the conclusion: Post-test for five minutes in the class room 5
Method of assessmentContinuous assessment Attendance and Participation 5 Marks Pre and Post test 5 Marks Three quizzes and/or SEQ: each carries 10 Marks 30 Marks Final Assignments report 20 Marks Total 60 MarksFinal examination Total 40 Marks Grand Total 100 Marks 6
Study materials Managing a Modern Hospital, 2nd Edition (Indian Print), Edited byA.V. Srinivasan (Free) New ways to improve services in Indonesia A Text Book and Guide - First Edition Hospital Management Training Adi Utarin, Gertrud Schmidt-Ehry, Peter Hill (Free) District health facilities: Guidelines for development and operation-WHO Publication (Free) WHO MAKER(URL: http://www.who.int/management/en/) (Free CD) Textbook of Management for Doctors by Tony White (Old Book Free for PC) Wolper, Lawrence F., Health Care Administration: Planning, Implementing, and Managing Organized Delivery Systems, Fourth Edition, Jones and Bartlett Publishers, Boston, MA, 2004. $100 Management of Hospitals & Health Services by Rockwell Schulz & Alton C. Johnson Healthcare Management: Organization Design and Behavior by Kaluzny & Shortell Modern Healthcare online(URL: http://modernhealthcare.com) Handouts 7
What is a hospital? Roots of word Hôpital (Fr); hospitale (L): an inn, hospice. Definition„An institution which provides:1. Beds,2. Meals, and3. Constant nursing care for its patients while they undergo4. Medical therapy at the hands of professional physicians. In carrying out these services, the hospital is striving to5. Restore its patients to health‟ (Miller 1997). 10
Comprehensive definition is difficult Diversity of financial budgets in Europe from €50 other spend €14000 per bed The type of hospital can be difficult to classify. Small acute care service to a larger long term care facility? E.g.Dervla Murphy Many buildings, or hospitals on different sites may merge into one organizational structure. Does the definition of a hospital cover only the activities undertaken within its walls? Hospitals in USA have embarked on vertical mergers that incorporate other service types such as rehabilitation and post-discharge care. Advances in short-acting anesthetics create opportunities for free-standing minor surgical units offering day surgery. 11
The development of hospital systems Hospitals have changing roles over the centuries:1. Shelters for the poor attached to monasteries in the Middle Ages.2. Feared last resort for the dying in the eighteenth century.3. Shining symbols of a modern health care system in the twentieth century. Present-day hospitals reflect a combination of the legacy of the past and the needs of the present. Huge advances in knowledge and technology has shaped present hospital. A doctor 50 years back will never recognize hospital of today. 12
Oldest Hospital Heinz E Müller-Dietz (Historia Hospitalium 1975) describes in Mihintale Sri Lanka at the foot of the mountain are the ruins of a perhaps the oldest in the world hospital. A medical bath (or stone canoe in which patients were immersed in medicinal oil) and a stone inscription and urn were excavated. According to the Mahavamsa, the ancient chronicle of Sinhalese royalty written in the 6th century A.D., King Pandukabhaya (4th century BC) had lying-in-homes and hospitals (Sivikasotthi-Sala) built in various parts of the country. This is the earliest documentary evidence we have of institutions specifically dedicated to the care of the sick anywhere in the world. 14
Hospitals in India In India much before the birth of Prophet Essa Institutions were created specifically to care for the ill. King Ashoka founded 18 hospitals c. 230 BC. There were physicians and nursing staff, and the expense was borne by the royal treasury.Reference:Roderick E. McGrew, Encyclopedia of Medical History (Macmillan 1985), p.135. 15
Hospitals in China and Persia State-supported hospitals later appeared in China during the first millennium A.D. The first teaching hospital where students were authorized to methodically practice on patients under the supervision of physicians as part of their education, was the Academy of Gundishapur in the Persian Empire. Elgood has argued that "to a very large extent, the credit for the whole hospital system must be given to Persia".Reference:C. Elgood, A Medical History of Persia, (Cambridge Univ. Press), p. 173. 16
Hospitals in Muslim world The first Bimaristan was founded in 86 AH by the Muslim caliph al-Waleed bin Abdel Malek in Damascus. At that time, most hospitals had doctors that diagnosed and treated all patients, but the Bimaristan was unique in that it had doctors that specialized in certain diseases. Once admitted into a Bimaristan, the patient can stay for as long as she/or he needed; there was no time limit. Once the patient has fully recovered, they were provided, not only with clean clothes, but with pocket money.Reference: al-Hassani, Woodcock and Saoud (2007), Muslim heritage in Our World, FSTC Publishing, pp.154-156 17
Hospitals in Medieval Europe Medieval hospitals in Europefollowed a similar pattern. Theywere religious communities, withcare provided by monks andnuns. (An old French term forhospital is hôtel-Dieu, "hostel ofGod.") Some were attached tomonasteries; others wereindependent and had their ownendowments, usually of property,which provided income for theirsupport. 21
Hospitals have evolved over the centuries in response to social, political & and medical knowledge changesRole of Hospitals Time CharacteristicsHealth care 7th century Byzantine Empire, Greek and Arab theories of diseaseNursing, spiritual care 10th to 17th centuries Hospitals attached to religious foundationsIsolation of infectious 11th century Nursing of infectious diseases such aspatients leprosyHealthcare for poor people 17th century Philanthropic and state institutionsMedical Care Late 19th century Medical care and surgery; high mortalitySurgical Centers Early 20th century Technological transformation of hospitals; entry of middle-class patients; expansion of outpatient departmentsHospital-centered health systems 1950s Large hospitals; temples of technologyDistrict general hospitals 1970s Rise of district general hospital; local, secondary and tertiary hospitalsAcute care hospital 1990s Active short-stay careAmbulatory surgery centers 1990s Expansion of day admissions; expansion of minimally invasive surgery 23
Characteristics of Organizations as Systems Input-Throughput-Output Inputs Throughput (System parts transform the material or energy) Output (System returns product to the environment) TRANSFORMATION MODEL (input is transformed by system) Feedback and Dynamic Homeostasis Positive Feedback - move from status quo Negative Feedback - return to status quo Dynamic Homeostasis - balance of energy exchange 30
General Theoretical Distinctions Classical and humanistic theories prescribe organizational behavior, organizational structure or managerial practice (prediction and control). MACHINE Systems theory provides an analytical framework for viewing an organization in general (description and explanation). ORGANISM 31
Principles of General Systems Theory Laws that govern biological open systems can be applied to systems of any form. Open-Systems Theory Principles Parts that make up the system are interrelated. Health of overall system is contingent on subsystem functioning. Open systems import and export material from and to the environment. Permeable boundaries (materials can pass through) Relative openness (system can regulate permeability) Synergy (extra energy causes nonsummativity--whole is greater than sum of parts) 32
Characteristics of Organizations as Systems Role of Communication Communication mechanisms must be in place for the organizational system to exchange relevant information with its environment Communication provides for the flow of information among the subsystems Systems, Subsystems, and Super systems Systems are a set of interrelated parts that turn inputs into outputs through processing Subsystems do the processing Super systems are other systems in environment of which the survival of the focal system is dependent Five Main Types of Subsystems Production (technical) Subsystems - concerned with throughputs-assembly line Supportive Subsystems - ensure production inputs are available-import raw material Maintenance Subsystems - social relations in the system-HR, training Adaptive Subsystems - monitor the environment and generate responses (PR) Managerial Subsystems - coordinate, adjust, control, and direct subsystems 33
Characteristics of Organizations as Systems Boundaries The part of the system that separates it from its environment Four Types of Boundaries Physical Boundary - prevents access (security system) Linguistic Boundary - specialized language (jargon) Systemic Boundary - rules that regulate interaction (titles) Psychological Boundary - restricts communication (stereotypes, prejudices) The „Closed‟ System Healthy organization is OPEN 36
Contingency Theory There is no one best way to structure and manage organizations.Structure and management are contingent on the nature of the environment in which the organization is situated.Argues for “finding the best communication structure under a given set of environmental circumstances.” 37
Pragmatic Application of Systems Theory The Learning Organization An organization that is continually expanding its capacity to create its future Key attribute of learning organization is increased adaptability 38
Hospitals and Health Care Organizations are unique Defining and measuring the output is difficult. The work involved more highly variable and complex . Much of the work is of an urgent and non-deferrable nature. The work permits little tolerance for ambiguity or error. Activities are highly interdependent, requiring a high degree of coordination among diverse professional groups. The work involves an extremely high degree of specialisation. Hospital personnel are highly professionalised, and their primary loyalty belongs to the profession rather than to the organisation. There exists little effective organisational or managerial control over the group most responsible for generating work and expenditures: physicians and surgeons. In many hospital-organisations, there exists dual lines of authority, which create problems of coordination and accountability and confusion of roles.
Factors that influence structure External Environment (PEST)1. The economic, political and legal conditions2. The demographic and cultural conditions3. New organizational forms, like multi-institutional arrangements(mergers, corporate structures, health insurance arrangements, and so on)4. The latest developments in medical technology that need to be acquired by the hospitals
Factors that influence structure Organizational assessment1. Mission and Goals are aligned2. The quantity, quality and type of services to be provided must respond to problem faced.Hospital may develop problem related to current structureand be able to anticipate problems and take corrective actionquickly. E.g. Problems like communication barriers,difficulties resulting from conflicting roles, employeeturnover, and recruitment and selection problems
Factors that influence structure Human resources1. Capabilities and potential of key persons2. Quality of performance of Senior and middle management in meeting goals of organization and in implementing any propose change in organizational structure3. Human resource development (HRD) strategy
Factors that influence structure Political process The informal internal dynamics of the hospital (need systemic assessment). Identification of the informal groups and leaders who influence the programmes Those may be incorporated in planning and decision making
Definition of Organization Structure The hierarchical pattern of authority, responsibility,and accountability relationships designed to providecoordination of the work of the organisation; thevertical arrangement of job in the organisations.Hodge and Anthony (1984)s.
Definition of Organization Structure A formal system of interaction and coordination thatlinks the tasks of individuals and groups to helpachieve organisational goals.Pugh et al. (1969)
Definition of Organization Structure The formal allocation of work roles and theadministrative mechanisms to control and integratework activities, including those which cross formalorganisational Boundaries.Child (1972)
Definition of Organization Structure Structure in terms of the skeletal organisation chart. Itsunderlying dimensions are the degree of vertical,horizontal, and spatial differentiation; the forms ofdepartmentation; and the allocation of administrativeoverhead.De Ven and Ferry (1980)
Definition of Organization Structure The organisation chart, when supplemented with theperceptions of informants on the question, “Who makeswhat decisions, where?”, provides an overallunderstanding of the structure of authority in anorganisation.Miles and Snow (1985)
Concerns regarding organizational designs • Division of labour in terms of degrees ofdifferentiation and forms of departmentation.• Interdependence and sub-optimisation amongorganisational components that division of labourcreates.• Structure of authority.
Constitutional elements of structure Formalisation Centralisation Specialisation Complexity Configuration
FORMALISATION Formalisation represents the extent to which jobs aregoverned by rules and specific guidelines.It is the degree in which policies, procedures and rulesare formally stated in written form.This aspect of organisation is typical of bureaucracies.Greater the degree of formalisation, the lower is the rateof programme change. Rules and norms discourage asearch for better ways of doing things.
CENTRALISATION Centralisation is a measure of the distribution of power within the organisation.The fewer the people participating in decision-making, and the fewer the areas ofdecision-making in which they are involved, the more centralised is theorganisation.Higher the organisation‟s degree of centralisation, the lower is its rate ofprogramme change.In a decentralised organisation, where decision-making power is more widespread,a variety of different views will emerge from different occupational groups. Thisvariety of opinions can lead to successful resolution of conflict, and to problem-solving.Decentralisation appears to foster the initiation of new programmes andtechniques, which are proposed as solutions to various organisational problems.
SPECIALISATION Specialisation is the extent to which an organisation favours division of labour.In hospitals, specialisation of roles and functions reach extremely high levelsboth in intensity and extent. Work in the system is highly specialised anddivided among a great variety of roles and numerous members withheterogeneous attitudes, needs, orientations and values.A certain degree of specialisation among and within organisations,and professions and occupation, is indispensable for efficient roleperformance, individual adaptiveness and organisational effectiveness.In hospitals, medical and nursing specialisation undoubtedly lead to improvedpatient care, just as administrative professionalisation leads to improvedhospital functioning.A properly regulated specialisation in organisations with high internal socialintegration will eliminate the dysfunctional nature of the organisations.
COMPLEXITY Complexity is the extent of knowledge and skill required of occupational roles and theirdiversity.It is the degree of sophistication and specialisation that results from the separation of workunits for the purpose of establishing responsibility.Organisations employing different kinds of professionals are highly complex. Among theservice organisations, the hospital is the most complex form of organisation.One way to measure complexity is to determine the number of different occupations withinan organisation that require specialised knowledge and skills.An organisation is considered complex when it employs numerous kinds of knowledge andskills; and when these occupations require sophistication in their respective knowledge andskill areas.In organisations where there is greater complexity, the greater is the rate of programmechange.
CONFIGURATION Organisation structures occur in a limited number ofconfigurations. On what basis are these structuresformed? Any structural configuration must includecriteria by which various roles, activities andcoordination mechanisms can be differentiated, as wellas grouped together in the organisation.Thus the terms organisational structure, design,hierarchy, chart, model, organogram areinterchangeably used, since they are understood in asimilar way.
Basic elements of organization1. The Strategic Apex Top-level management, which is vested with ultimate responsibility fororganizational effectiveness. The top management could be a team or a singleindividual.2. The Operating CoreEmployees who perform the basic work related to the production of goods orservices of the organization.3. The Middle LinePeople who connect the strategic apex to the operating core. These are intermediatemanagers who transmit, control and help in implementing the decision taken by thestrategic apex.4. The TechnostructureStaff functionaries and analysts who design systems for regulating andstandardizing the formal planning and control of the work. For exampledepartments such as finance, production planning, human resources, and others.5. The Support StaffPeople who provide indirect support to the work process and are not involveddirectly in it. Services like the cafeteria, mailing and transport are considered to be apart of it.
Organization triad Found in private and teaching hospitals. The triad includes:1. the governing body,2. the chief executive officer and3. the medical staff.The triad permits sharing of power and authority amongthemselves. It is best characterised as an accommodationrather than sharing. The accommodation results from theindependent status of the physicians and consultants whoplay a major role in treating patients in the hospital. Suchaccommodation will be much more effective when thegoverning body delegates responsibility to the ChiefExecutive Officer (CEO) and senior managers for the day-to-day operation of the hospital.
FUNCTIONAL DESIGN Most hospitals are familiar with a functional designwhere the workers are divided into specific functionaldepartments, for example, finance, nursing, pharmacy,housekeeping, and so on. This arrangement is moreprevalent in relatively small hospitals with fewer than200 beds, offering single specialty services, and thisdesign is most appropriate in small organisations whichprovide a limited range of services and with only onemajor goal. The primary advantages of the functionaldesign are that it facilitates decision-making in acentralised and hierarchical Manner.ever,
DIVISIONAL DESIGN The divisional design is often found in large teaching hospitals andsometimes in a few private hospitals that operate under conditionsof high environmental uncertainty and high technologicalcomplexity. It is most appropriate for situations where cleardivisions can be made within the organisation and semi-autonomous units can be created. Units are grouped according toaccepted medical specialties, such as medicine, surgery,paediatrics, radiology and pathology.Divsionalisation decentralises decision-making to the lowest levelin the organisation where key expertise is available. Individualdecisions have considerable autonomy for clinical and financialoperations. Each division has its own internal managementstructure. Difficulties with the divisional design tend to occur intimes of resource constraints
CORPORATE DESIGN There is an increasing use of the term „corporate model‟ in hospitals these days. It means any organisation which is legally incorporated. The true structure envisages: A governing body Top management The governing body, the board members include salaried corporate directors and executives. There is a full-time chairman of the board who functions as the executive of the corporation. The board members are elected and paid a fee for attending meetings. Top management, the chairman is a voting member of the board and the senior management is made up of general managers. There is a group of corporate staff who provide ongoing long-range support services to the general managers. Typically, they provide support in such functional areas as human resource, public relations, data processing, legal affairs and planning. There is a great emphasis on team approach to management and decentralisation of decision-making. This design is most useful in large, complex organisations which have several goals and which operate in changing environments.
MATRIX DESIGN A dual authority system, where individuals have two or more bosses.This design is evolved to improve mechanisms of lateral coordination and informationflow across the organisation . The structure is usually drawn in the form of a diamond,with functional heads and programme managers on the top edges of the diamond. Thisarrangement increases the opportunity for lateral coordination and communication,which frequently emerge as problems in other design configurations. Functional heads,for example, nursing, medical records, pharmacy and housekeeping are responsible forthe standards of services provided by their department. Typically, functional heads bringstability and continuity to the organisation and sustain the professional status of staff.Programme managers for departments such as oncology, nephrology, paediatrics,neurology, and so on bear the responsibility for individual multidisciplinary programmesand coordinate team functioning. It is the responsibility of the CEO to maintain balancebetween both sides of the matrix.This design is useful in highly specialised technological areas that focus on innovation. Itallows programme managers to interact directly with the environment vis-à-vistechnological developments. The disadvantages of this design are:(a) individual workers may find that having two bosses is untenable, since it createsconflicting expectations and ambiguity,(b) the matrix design may also prove to be expensive, since both functional heads andprogramme managers may spend a considerable amount of time in meetings, because ofthe frequent requirement for dual accounting, budgeting, control, performanceevaluation and reward systems.
PARALLEL DESIGN This is a design which has been developed as a mechanism forpromoting the quality of work in the organisations. The bureaucraticor functional organisation retains responsibility for routine activities inthe organisation, while the parallel structure is responsible forcomplex problem solving that requires participatory mechanisms. Theparallel structure is a means of managing and responding to changinginternal and external conditions. It also provides an opportunity forpersons occupying positions at various hierarchical levels in thebureaucratic structure to participate in organisational decisions. It ison this basis that the parallel organisation has potential for building ahigh quality of working life. Within the parallel organisation, a seriesof permanent committees are established, with representation from alllevels in the formal hierarchy, as well as from all departments,depending on the problemor task at hand.