Hospital Management

17 June 2016

Hospital • An institution that provides medical, surgical,

or psychiatric care and treatment for the sick or the injured

• A hospital, in the modern sense, is an institution for health care providing patient treatment by specialized staff and equipment, and often, but not always providing for longer-term patient stays

WHO’s Hospital

WHO defines the term “hospital” as an institution that provides in-patient accommodation for medical and nursing care. It further elaborates the definition to cover hospital that assume additional functions – curative, rehabilitative and preventive services – directly or in a consultative capacity, also participating in the training of personnel and in research work.

Terminologies

The word hospital comes from the Latin hospes, signifying a stranger or foreigner, hence a guest.

Another noun derived from this, hospitium came to signify the place or establishment where a guest is received. Hospitium - Hospitale

Hospes is thus the root for the English words hospital, hostel and hotel.

Changing role of Hospitals

With emphasis shifting from• Acute to chronic illness• Curative to preventive medicine• Restorative to comprehensive medicine• Inpatient care to outpatient and home care• Isolated function to area-wise or regional function• Tertiary and secondary to primary health care• Episodic care to total care

Factors Changing role of Hospital

The important factors which have led to the changing role and functions of the hospital are as follows:

1.Expansion of the clientele from the dying, the destitute, the poor and needy to all class of people

2.Improved economic and social status of the community

3.Control of communicable diseases and increase in chronic degenerative diseases.

Factors Changing role of Hospital contd.

4. Progress in the means of communication and transportation

5. Political obligation of the government to provide comprehensive health care

6. Increasing health awareness7. Rising standard of living (especially in urban

areas) and sociopolitical awareness (especially in semi-urban and rural areas) with the result that people expect better services and facilities in health care institutions

Factors Changing role of Hospital contd.

8. Control and promotion of quality of care by statutory and professional associations

9. Increase in specialization where need for team approach to health and disease is now required

10. Rapid advances in medical sciences and technology

11. Increase in population requiring more number of hospital beds

Factors Changing role of Hospital contd.

12. Sophisticated instrumentation, equipment and better diagnostic and therapeutic tools

13. Advances in administrative procedures and management techniques

14. Reorientation of health care delivery system with emphasis on delivery of primary health care

15. Awareness of the community

Hospital from different perspectives1. Client-oriented perspective: which is that of access to services, use of service, quality

of care, maintenance of client autonomy and dignity, responsiveness to client needs, wishes and freedom of choice

2. Provider-oriented perspective:that of the physician, nurses and other professionals working for the hospital, and include freedom of professional judgment and activities, maintenance of proficiency and quality of care, adequate compensation, control over traditions and terms of practice and maintenance of professional norms.

Hospital from different perspectives contd.

3. Organization-oriented perspective:which covers cost control, control of quality, efficiency, ability to attract clients, ability to attract employee and staff, and mobilization of community support

Group dynamics in Hospital

• The First Group is the providers of medical care, viz. the doctors, nurses, technicians and paramedical personnel

• The Second Group is management, administrative and support group comprising of personnel dealing with non-clinical functions of the hospitals, such as diet, supplies, maintenance, accounts, housekeeping, security etc.

Group dynamics in Hospital contd.

• The Third Group and the most important one for whose benefit the first two groups exist in the first place, is that of the patients, who seek hospital service and their attendants, relatives and associates who, along with patient come in close contact of the hospital. This group is broadly termed as the Community

Group dynamics in Hospital contd.• It is not unusual to expect conflict between the

two groups – the providers of care and intermediate support group on the one hand and the patient and the community on the other. The nature of relationship between the two groups influences community relationship, and on this relationship depends the image of the hospital. To better this image, hospitals have to re-orientate themselves to the expectations of the community

Group dynamics in Hospital contd.

Relevant communication and information must reach the user community in order to promote their participation and involvement. A community that is well-informed and aware of its social responsibilities can become an effective instrument of cooperation and support.

However, the unpleasant fact that this community participation can be distorted by sectional interests trying to use the community as a pressure group (to attain specific objectives which are not always compatible with the paramount aims of the hospital programs) need also to be remembered.

Expectations in Hospital

• People go to the hospital with high expectations believing that every disease is fully and quickly curable. The average health consumer regards contemporary hospitals as the panacea to all their health problems. They cannot appreciate the limitations of the hospital. There is an increasing demand for better and quick cure. Besides giving care to every patients public expects sympathetic understanding of the behaviour of the patient and his/her attendants and relatives. This shift has necessitated a new approach to doctor-patient and hospital-community relationship.

Expectations in Hospital contd.

• On the other hand, some questionable assumptions on which the value system in hospital is based are still prevalent among medical personnel. These are that cure is more important that the care of patients, and the staff assume power over the patients, that every problem has a solution, and that death is the worst thing that can happen to a person.

Expectations in Hospital contd.

• Respect for the dignity of the patient is one of the most basic rights and needs of the patients. Concerns for care of the human being as a whole needs contribution from everyone working in the hospital. The hospital is like a federal system with several departments each enjoying considerable autonomy and discretion in its management of work. The great challenge is one of coordination.

Realities of Hospital OrganizationThe following differentiates the hospital as an organization in

comparison to other service organizations:1. Every organization has a head. In every organization there

should be a clear line of authority for every individual. In a hospital, there are a number of important people who consider themselves as heads. Bringing together highly skilled professionals to work in a bureaucratic organization has in-built organizational conflict.

2. The hospital organization is besieged with absence of single line of authority and with two chains of command. On the one hand, there is the chief executive or medical superintendent. This authority flows to the matron, housekeeping, accounts etc. from

Realities of Hospital Organization contd. the top to the bottom (scalar chain). On the other hand, there is the hierarchy of the doctors and consultants. The smallest gradation of rank and status in the hierarchical character of medical and nursing organization is notorious.

3. The hospital organization is characterized by high interdependence. Because of the extensive division of labour and accompanying specialization of work, particularly every person working in the hospital depends upon some other person or persons for the achievement of his/her own organizational goal. Specialists and professionals can perform their functions only when a considerable array of supportive personnel and auxiliary services are put at their disposal at all times. For example, a surgeon cannot operate on a heart case unless catheter studies have

Realities of Hospital Organization contd. been completed. Even before that, other investigations have to be available from the respiratory laboratory and biochemistry laboratory.

4. The timing of the movement of patients through the systems in largely controlled by chance or by a set of uncoordinated, individual decisions.

• Organization of universities and research institutions have some semblance to hospital organizations in looseness of formal structure and in the degree of independence by their staff. In industry, the levels of authority , width of the span of control, ratio of managerial to total staff and indirect to direct labour can easily be determined. There is extensive division of labour in hospital, but at the same time great interdependence of special skills. A hospital has been

Realities of Hospital Organization contd.

described by an industrialist as a wildest kind of jobbing shop.• However, two additional factors characterize hospitals and

hospital organizations. As opposed to other organizations, the individual goals of staff coincide more with hospital goals, and most of the hospital staff will identify themselves with hospital goals.

• Hospitals organization is both authoritative and permissive, highly formalized yet loose-knit. The reason is the very special nature of hospital work. The crisis nature of work demands from a number of people – collaborative performance. Hospitals are extreme cases of an organization peculiarly dependent for effectiveness on people, although crisis nature of work demands collaborative performance in other industries as well.

Realities of Hospital Organization contd.

• To the sick, a hospital is a place where they will receive treatment. To the domestic staff, it is a special kind of hotel with rooms to be cleaned and meals to be prepared. To all the staff, it is a place of employment, and to the junior doctors and nurses, it is a temporary home. Hospitals may mean different things to different groups of people at different times. But to the hospital administrator, it is an organization, a consciously designed arrangement for management of people, services and things for a purpose. From the organizational point of view, the question to ask what is a hospital for, is more meaningful than what is a hospital.

Multiple Pyramid of Hosp. OrganizationThe salient characteristics of hospital is the absence of a single line of authority in the organization; the authority does not flow along a single line of command as it does in most formal organizations. A dual and at times multiple pyramid of organization because of the relationship of medical component to administrative component, is a peculiar characteristic of hospital organization. The ultimate authority is vested in the policy making body – the governing board – which provides leadership and direction to the organization. The board appoints the chief executive officer (administrator) as well as the chiefs of medical services, who are two different streams of authority. The chief executive officer (called superintendent, director, administrator or by some other title depending upon local preference) who is charged with the responsibility of

Multiple Pyramid of Hosp. Organization contd.

of effectively managing the administrative components of the institution in turn delegates authority to each department head in the administrative component. A typical pyramid organization, with a unified chain of command results within the administrative component. But a second conglomerate of organizational pyramids results from the organization of the medical staff into clinical services, with each having a chief of service. Had this been also a pyramidal structure with one single chief or director of medical staff, it would result in only a second pyramid in the organization structure. However, seldom is it possible to have a medical staff organization where there is only one chief with other clinical service heads directly under him/her in the line of command.

Multiple Pyramid of Hosp. Organization contd.

At the same time, none in the administration hierarchy gives command to the medical staff. Often, doctors give command to those in administrative hierarchy, but this is also is not direct. Therefore, full responsibility gets divided or blurred.In matters of direct patient care, the physician exercise professional authority, in matters of administrations the chief executive exercise authority. Thus, many employees (such as nurse) are subject to more than one line of authority. Line officers in the administrative units may find that their authority is limited in some areas because of the specific jurisdiction of the medical staff. The multiple pyramidal structure therefore calls for a lot of coordination. This is achieved through the extensive use of committees to bridge the gap.

Suggestive Hospital Organization

Looking at the differences in task complexity within the hospital, departments performing routinised activities (CSSD, laundry, kitchen) have more task-oriented workers, more formalized structure than those having different levels of task complexity (wards, ICU, laboratory) who are informally structured and more interpersonally oriented.Experts in the hospital field have recognized that complex tasks and highly skilled professional workers call for a colleagueal participatory structure, while the repetitive tasks performed by semiskilled and unskilled workers call for a hierarchical formalized structure. At one extreme are the physicians with their loose organic structure and at the other end relatively unskilled workers of housekeeping, dietary, laundry and maintenance, with more hierarchical centralized supervision.

Suggestive Hospital Organization contd.

Nurse and skilled technicians fall in between. The colleaguely structured medical staff structure, coupled with hierarchically controlled nonprofessional departments is fundamentally the appropriate form of organization for a hospital, given the tasks it is faced with. Nevertheless, a difference of opinion still exists among two major schools of thought: (i) those who consider the formal organization with its associated hierarchical authority structure as superior, and (ii) those who differ as to the degree to which procedures should be specified hierarchically and imposed on organization’s members.