At The physician’s “management” of a case has

At the end of each such description, the key element is highlighted.

1. Working with People:

The administrator has no direct clinical responsibility for any patients that rests firmly on the members of the medical staff who have the clinical freedom to decide who shall be treated for what, by what means and for how long. Because doctors are responsible in this way, they are in a unique position to influence the work and development of the hospital.

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The physician’s “management” of a case has an effect far beyond the clinic or ward situation, on the work of the other staff, and in the functioning of other departments remote from his sphere of action.

Thus, the clinicians to a very great extent call the tune for all the services which contribute to patient care not only for nursing, pathology, radiology, and pharmacy, physiotherapy and the rest of the professions supplementary to medicine, but also for the cook who makes the salt-free diet, the technician who maintains the dialysis machine, the ward boy who fetches the oxygen cylinder or the nurse who sets up as IV line.

Dictum:

Balance the goals of the hospitals by working with patient care teams where physician is the kingpin (who in turn works with others in rendering patient care). Understand workers, their motivations and aspirations, and knit them together as a team.

2. The Enabling Role:

One of the prime roles of the administrator is to enable the doctors, nurses and patient-care team to do their job efficiently. He “enables”, “sees” to and “ensures”.

All this is part of his enabling job, but not the whole of it. He must concern himself also with creating and maintaining the nonmaterial conditions in which the professional staff can do their work best morale, atmosphere, the spirit of the place is as much of his business as the water supply and electricity.

Dictum:

Ensure the provision of necessary physical facilities and ensure that the supportive services are available in the right amount, of the right quality, and at the right time and place.

3. Hospital Administration and Staff:

Running any hospital calls for a great deal of tact and ingenuity. This is because there are many types of staff who are specialists in their own sphere and departments, which function more or less as autonomous units.

Workers at the operational level, e.g. nursing personnel, feel that more than one authority controls them—firstly the head of the clinical service, secondly the head of the nursing department and thirdly the administration. This multiplicity of reporting and regulating authority is a source of constant trouble.

Dictum:

Understand the staff and understand variations in styles of administration.

4. Staff Motivation:

Expensive facilities and equipment do not necessarily make for a good hospital; it is the people who operate them that make the hospital go.

This function is one of the most challenging functions of a hospital administrator.

The staff needs to be motivated to give their best at all times even in trying situations. Many discouraging factors and stress situations, in which hospitals abound, tend easily to lead to erosion in motivation.

Dictum:

Develop measures to keep up motivation of all categories of staff, and be constantly on the look-out for cases of dissatisfaction and conflict.

5. Facilitating Decision Making:

A great part of the job of a hospital administrator concerns decision making. There are several kinds of decision making in a hospital.

The most characteristic are the technical decisions about the treatment of patients, with which he is not directly associated, but which influence overall decision making, with which he is concerned.

Whether he recognises it or not, the clinician, no less than his colleagues who run the X-ray or pathology departments, is also a manager the most common decision about which patient to admit and for how long should he be kept in hospital can be taken only by individual physicians.

To them these may seem to be purely clinical decisions, but these are also management decisions.

To admit Mr. A rather than Mr. B or to keep Mrs. C in hospital a few days longer, or to send Ms. D home early to free a bed for someone else, all these are decisions which influence use of resources.

Within a particular specialty the chief of that specialty exercises a sort of coordinating function. However, between specialties, there is some element of confusion.

Various department beads may find themselves in a competitive relationship. Although each chief is entitled for help from the common services, and has a right to get it, this does not happen automatically.

Dictum:

Provide appropriate inputs to decision making at the clinical departmental level, and coordinate decision making at the interdepartmental level.

6. Management of Resources:

All decision making is limited by the human and material resources the hospitals has.

The variety and quantum of the pressures and constraints on hospital administration is best seen when it comes to deciding between competing claims for manpower and financial resources.

How does one compare the need for a new lift to replace a very old one with that for a set of ventilators for the ICU? Or the requirement of two data entry operators for the computer section with extra technician in the laboratory for a new oncology programme?

The cost of some of them could be met from capital account, of others from revenue surplus and some may involve development expenditure requiring a decision of the board. The competition between them is not equal. But who decides this?

Decisions of this kind which together affect resources- decision to spend money, involving a choice among alternatives even where such choices are unrecognized must be made by the administrator.

The hospital administrator as an expert in the art of getting things done does not arbitrate on this or that, but assimilates, reconciles and synthesizes all the views of those who put up competing demands.

Nevertheless, in making decisions, at times, he may have to succumb to what is expedient.

Dictum:

His judgment may not necessarily be superior to that of the experts who propose the case, but his position is the most appropriate one from which to make it.

7. Negotiating:

The administrator spends considerable time negotiating both with agencies outside the hospital and with staff members within, especially regarding their working arrangements and conflict resolution.

This is not to be confused with nego­tiating with workers’ unions which is a collective bargaining process.

Administrators must negotiate with third party payers (insurance companies, employers) regulatory agencies, planning groups, equipment vendors and so on.

There are also elements of negotiation in the hiring of personnel and salary determination.

Ideally, the administrator should strive for a positive problem-solving situation. This implies moving away from a win-lose (I win you lose, or vice versa) situation to a win- win (I win-you win) end result.

Dictum:

Steer closer to “creative problem solving” situation, rather than turning to a “choice” situation. Emotions do play a part in negotiation sessions, but guard against them.

8. Containing Costs:

Being in-charge of the “business” side of hospitals management, a hospital administrator is responsible for the conduct of all the “business” aspects.

Although a hospital is not primarily a business institution, business matters are vital to its survival even though they may not be the reason for its existence.

With phenomenal rise in hospital costs, the administrator has to devote considerable time and energy to monitor and contain costs.

The medical staff knows very little or nothing about the economics of hospital care.

Therefore, it is necessary to make them cost-conscious, to reduce expenditure without jeopardizing patient care.

The hospital administrator achieves this through presenting them with different types of costing data, and seeking their cooperation in containing costs.

The administrator puts into practice his knowledge and skills in financial management to practical use in forecasting financial results as precisely as possible.

If the budgeting has not been carried out correctly, funds allotted for specific activities can only be diverted to other activities at the peril of smooth running of the hospital.

Dictum:

Exercise control over financial matters through costing, cost-control, budgeting and judicious investment of hospital funds.

9. Understanding ‘Efficiency’ and ‘Effectiveness’:

i. Efficiency is the rate at which inputs are converted into outputs. The emphasis is on qualitative measurement, and the objective is to secure maximum output from minimum input.

ii. Effectiveness is the extent to which purpose/goals are achieved. The emphasis is on qualitative measurement, and the objective is one of meeting customer needs and delivering service quality.

The distinction between efficiency and effectiveness has been described as ‘doing things right’ (efficiency) and ‘doing right things’ (effectiveness).

What this amounts to is that efficiency is ‘the rate at which inputs are converted into outputs’ and effectiveness is ‘the extent to which purposes are being achieved’.

10. Dealing with New Technology:

Hospital practice has become more and more dependent on high technology which can become rapidly outdated as the technological advance continues.

Medical staff is subjected to sales pressure from manufacturers of newer items, and they may tend to seek what is new without regard to cost because of the glamour attached with newer sophisticated equipment.

Dictum:

Strike a judicious balance between new technology and the hospital’s needs, cater for training and retraining to catch up with new technologies, innovations and improvements.

Organise such training at formal, informal, institutional and individual levels.

11. Establishing Managerial Climate:

One of the key responsibilities of the hospital administrator is that of establishing a “managerial climate”. Hospitals have their own “personalities” as people do.

This personality springs from value held by those running the hospital and the physicians who work in it, and governed by the sensibilities and impression of those who come in contract with the hospital.

Administrators and other staff both play a major role in the development of these values. Tradition and past history also bear upon the values held by the people.

Dictum:

Administrative personnel must be compatible with each other and with the organisation. Where a change in managerial climate is called for, be prepared to recognise the need and be capable of meeting it. Provide the lead in this direction.

12. Management Development:

The administrator cannot manage the institution single handedly by himself. There is ample need to strive for better management in a hospital, which has few trained managers.

Rapid changes are occurring which necessitate upgrading the knowledge, skills and attitudes in subordinate administrative positions.

Therefore, a part of the educational activities has to be directed to training and retraining of the administrative personnel, and even medical staff, in supervisory and managerial positions. Management development is a continuing activity.

Personnel are encouraged to attend various programmes of courses and workshops to improve their managerial and leadership skills.

Dictum:

The quality of patient care depends upon the quality of the hospital’s human resources, which in turn is determined by the quality of the leadership at various levels.

Facilitate this most critical input by planned leadership development at different levels.

13. Evaluation:

The ability to evaluate people, programmes and the overall effectiveness of the hospital is one of the competencies the administrator has to develop.

Evaluation includes evaluation of employee-clientele relationship and interpersonal behaviour. The judging ability of the administrator at times incorporates “intuition”.

Dictum:

Continuous, ongoing self-evaluation is a means of quality assurance.

14. Fact-finding and Investigation:

Whereas the administrator makes decisions mostly based upon his knowledge and experience, some will be made only after much fact-finding and analysis.

Managerial style is an important element in fact finding and investigation. Situations where consensus is important would call for attention to the group decision-making process, as opposed to situations calling for immediate decisions that cannot be delayed.

Dictum:

Fact-finding and investigation call for caution so that the workers sensibilities are not offended.

15. Social Commitment:

The hospital administrator is a part of the society in which the hospital functions. His vision therefore must not be restricted to the hospital in isolation.

He must be aware that he is a part of the wider health care system and serves the larger society through the hospital.

Dictum:

Balance the conflicting requirement of looking after the business interests of the hospital with the social obligations towards society.