Hospital Management

Session I – Introduction to Hospitals

Dr. Ashfaq Ahmed BhuttoMBBS, MBA, MAS, DCPS, MRCGP, (PhD)

Friday, February 10, 2012

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What we will do today

1.Our curriculum 2.Plan of study3.Define a hospital4.Define Health system 5.System theory6.Organization of Hospital

Managing a Modern Hospital – Our curriculum

  Date Time TopicQuiz 1

Quiz 2

Quiz 3

Session 1 Friday, February 10, 20129.00 am to 1.00 pm Introduction to hospital      

Session 2 Monday, February 13, 20129.00 am to 1.00 pm Organization & functioning of Hospital      

Session 3 Tuesday, February 14, 20129.00 am to 1.00 pm Planning and building of a Hospital      

Session 4Wednesday, February 15, 2012

9.00 am to 1.00 pm Hospital Building Notes- ER, OPD, Wards      

Session 5 Thursday, February 16, 20122.00 pm to 6.00 pm

Hospital Building Notes- OT, ICU, CCSD, Day care      

Session 6 Friday, February 17, 20122.00 pm to 6.00 pm Inventory Management      

Session 7 Saturday, February 18, 20122.00 pm to 6.00 pm Waste Management      

Session 8 Tuesday, February 21, 20122.00 pm to 6.00 pm Performance measurement of a hospital      

Session 9 Thursday, February 23, 20122.00 pm to 6.00 pm Patient Safety, HSE, Infection control      

Session 10 Friday, February 24, 20122.00 pm to 6.00 pm Disaster & change Management      

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)

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Plan of study-Course Requirement

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

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Plan of study-Session routine

Continuous 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 Marks

Final examination Total 40 Marks

Grand Total 100 Marks

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Method of assessment

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

Study materials

Facilitators meeting: on appointment only Facilitators designation: AMS (PS & QC) Facilitators office: 1st floor, Admin Block, Civil

Hospital Karachi Facilitators office phone number: 99215740 Ext:

1133 Facilitators cell phone number: 0300-9225378 Email: drashfaqbhutto@hotmail.com (use only

this) Web Page: http://cpsphm.wordpress.com/

Communication

What is a Hospital

What is a hospital?

Roots of wordHôpital (Fr); hospitale (L): an inn, hospice.

Definition‘An institution which provides: 1. Beds, 2. Meals, and 3. Constant nursing care for its patients while they

undergo 4. Medical therapy at the hands of professional

physicians. In carrying out these services, the hospital is striving to

5. 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.

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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.

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History of Hospitals

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.

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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.

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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.

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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

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19Cairo Hospital : 1248 AD

20Dar us Shifa Hospital, Turkey, 1471 AD

Hospitals in Medieval Europe

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Medieval hospitals in Europe followed a similar pattern. They were religious communities, with care provided by monks and nuns. (An old French term for hospital is hôtel-Dieu, "hostel of God.") Some were attached to monasteries; others were independent and had their own endowments, usually of property, which provided income for their support.

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A Christian Hospital ward

Hospitals have evolved over the centuries in response to social,

political & and medical knowledge changes Role of Hospitals Time Characteristics

Health care 7th century Byzantine Empire, Greek and Arabtheories of disease

Nursing, spiritual care 10th to 17th centuries Hospitals attached to religiousfoundations

Isolation of infectiouspatients

11th century Nursing of infectious diseases such asleprosy

Healthcare for poor people 17th century Philanthropic and state institutions

Medical Care Late 19th century Medical care and surgery; high mortality

Surgical Centers Early 20th century Technological transformation of hospitals;entry of middle-class patients; expansionof outpatient departments

Hospital-centered health systems 1950s Large hospitals; temples of technology

District general hospitals 1970s Rise of district general hospital; local,secondary and tertiary hospitals

Acute care hospital 1990s Active short-stay care

Ambulatory surgery centers 1990s Expansion of day admissions; expansionof minimally invasive surgery

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Business process

Value chain/Business Process

Strategy

• Management

Hospital as a System

SYSTEMS THEORY

Provides a general analytical framework (perspective) for viewing an organization.

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system

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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

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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

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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

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system

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Closed system

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

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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.”

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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

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Organization of a Hospital

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 conditions 2. The demographic and cultural conditions 3. 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 assessment 1. 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 structure and be able to anticipate problems and take corrective action quickly. E.g. Problems like communication barriers, difficulties resulting from conflicting roles, employee turnover, and recruitment and selection problems

Factors that influence structure

Human resources 1. Capabilities and potential of key persons 2. Quality of performance of Senior and middle

management in meeting goals of organization and in implementing any propose change in organizational structure

3. 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 provide coordination of the work of the organisation; the vertical arrangement of job in the organisations.

Hodge and Anthony (1984)s.

Definition of Organization Structure

A formal system of interaction and coordination that links the tasks of individuals and groups to help achieve organisational goals.

Pugh et al. (1969)

Definition of Organization Structure

The formal allocation of work roles and the administrative mechanisms to control and integrate work activities, including those which cross formal organisational Boundaries.

Child (1972)

Definition of Organization Structure

Structure in terms of the skeletal organisation chart. Its underlying dimensions are the degree of vertical, horizontal, and spatial differentiation; the forms ofdepartmentation; and the allocation of administrative overhead.

De Ven and Ferry (1980)

Definition of Organization Structure

The organisation chart, when supplemented with the perceptions of informants on the question, “Who makes what decisions, where?”, provides an overallunderstanding of the structure of authority in an organisation.

Miles and Snow (1985)

Concerns regarding organizational designs

• Division of labour in terms of degrees of differentiation and forms of departmentation.

• Interdependence and sub-optimisation among organisational components that division of labour creates.

• Structure of authority.

Constitutional elements of structure

Formalisation Centralisation Specialisation Complexity Configuration

FORMALISATION

Formalisation represents the extent to which jobs are governed by rules and specific guidelines.

It is the degree in which policies, procedures and rules are formally stated in written form.

This aspect of organisation is typical of bureaucracies.

Greater the degree of formalisation, the lower is the rate of programme change. Rules and norms discourage a search 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 of decision-making in which they are involved, the more centralised is the organisation.

Higher the organisation’s degree of centralisation, the lower is its rate of programme change.

In a decentralised organisation, where decision-making power is more widespread, a variety of different views will emerge from different occupational groups. This variety of opinions can lead to successful resolution of conflict, and to problem-solving.

Decentralisation appears to foster the initiation of new programmes and techniques, 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 levels both in intensity and extent. Work in the system is highly specialised and divided among a great variety of roles and numerous members with heterogeneous attitudes, needs, orientations and values.

A certain degree of specialisation among and within organisations,and professions and occupation, is indispensable for efficient role performance, individual adaptiveness and organisational effectiveness.

In hospitals, medical and nursing specialisation undoubtedly lead to improved patient care, just as administrative professionalisation leads to improved hospital functioning.

A properly regulated specialisation in organisations with high internal social integration will eliminate the dysfunctional nature of the organisations.

COMPLEXITY

Complexity is the extent of knowledge and skill required of occupational roles and their diversity.

It is the degree of sophistication and specialisation that results from the separation of work units for the purpose of establishing responsibility.

Organisations employing different kinds of professionals are highly complex. Among the service organisations, the hospital is the most complex form of organisation.

One way to measure complexity is to determine the number of different occupations within an organisation that require specialised knowledge and skills.

An organisation is considered complex when it employs numerous kinds of knowledge and skills; and when these occupations require sophistication in their respective knowledge and skill areas.

In organisations where there is greater complexity, the greater is the rate of programme change.

CONFIGURATION

Organisation structures occur in a limited number of configurations. On what basis are these structures formed? Any structural configuration must include criteria by which various roles, activities and coordination mechanisms can be differentiated, as well as grouped together in the organisation.

Thus the terms organisational structure, design, hierarchy, chart, model, organogram are interchangeably used, since they are understood in a similar way.

Basic elements of organization

1. The Strategic ApexTop-level management, which is vested with ultimate responsibility for organizational effectiveness. The top management could be a team or a single individual.2. The Operating CoreEmployees who perform the basic work related to the production of goods or services of the organization.3. The Middle LinePeople who connect the strategic apex to the operating core. These are intermediate managers who transmit, control and help in implementing the decision taken by the strategic apex.4. The TechnostructureStaff functionaries and analysts who design systems for regulating and standardizing the formal planning and control of the work. For example departments such as finance, production planning, human resources, and others.5. The Support StaffPeople who provide indirect support to the work process and are not involved directly in it. Services like the cafeteria, mailing and transport are considered to be a part of it.

Organization triad

Found in private and teaching hospitals. The triad includes:1. the governing body, 2. the chief executive officer and 3. the medical staff.

The triad permits sharing of power and authority among themselves. It is best characterised as an accommodation rather than sharing. The accommodation results from the independent status of the physicians and consultants who play a major role in treating patients in the hospital. Such accommodation will be much more effective when the governing body delegates responsibility to the Chief Executive Officer (CEO) and senior managers for the day-to-day operation of the hospital.

Organisational Designs

FUNCTIONAL DESIGN

Most hospitals are familiar with a functional design where the workers are divided into specific functional departments, for example, finance, nursing, pharmacy, housekeeping, and so on. This arrangement is more prevalent in relatively small hospitals with fewer than 200 beds, offering single specialty services, and this design is most appropriate in small organisations which provide a limited range of services and with only one major goal. The primary advantages of the functional design are that it facilitates decision-making in a centralised and hierarchical Manner.ever,

DIVISIONAL DESIGN

The divisional design is often found in large teaching hospitals and sometimes in a few private hospitals that operate under conditions of high environmental uncertainty and high technological complexity. It is most appropriate for situations where clear divisions can be made within the organisation and semi-autonomous units can be created. Units are grouped according to accepted medical specialties, such as medicine, surgery, paediatrics, radiology and pathology.

Divsionalisation decentralises decision-making to the lowest level in the organisation where key expertise is available. Individual decisions have considerable autonomy for clinical and financial operations. Each division has its own internal management structure. Difficulties with the divisional design tend to occur in times 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 information flow 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. This arrangement 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 for the standards of services provided by their department. Typically, functional heads bring stability 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 programmes and coordinate team functioning. It is the responsibility of the CEO to maintain balance between both sides of the matrix.This design is useful in highly specialised technological areas that focus on innovation. It allows programme managers to interact directly with the environment vis-à-vis technological developments. The disadvantages of this design are: (a) individual workers may find that having two bosses is untenable, since it creates conflicting expectations and ambiguity,(b) the matrix design may also prove to be expensive, since both functional heads and programme managers may spend a considerable amount of time in meetings, because of the frequent requirement for dual accounting, budgeting, control, performance evaluation and reward systems.

PARALLEL DESIGN

This is a design which has been developed as a mechanism for promoting the quality of work in the organisations. The bureaucratic or functional organisation retains responsibility for routine activities in the organisation, while the parallel structure is responsible for complex problem solving that requires participatory mechanisms. The parallel structure is a means of managing and responding to changing internal and external conditions. It also provides an opportunity for persons occupying positions at various hierarchical levels in the bureaucratic structure to participate in organisational decisions. It is on this basis that the parallel organisation has potential for building a high quality of working life. Within the parallel organisation, a series of permanent committees are established, with representation from all levels in the formal hierarchy, as well as from all departments, depending on the problemor task at hand.

A 1000 bedded Government Hospital

700 bedded University Hospital

1000 bedded Trust Hospital

250-bedded Corporate Hospital

Rationality of these Models

DIVISION OF WORK DIFFERENTIATION LINE AND STAFF FUNCTIONS SPAN OF CONTROL WORK LEVELS AUTHORITY, DELEGATION, RESPONSIBILITY,

ACCOUNTABILITY

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