Hospital Management Transformation
In the System Age
Dr. Eng. Samir Ismail. Mostafa*
Key words: management philosophies, System approach, organizational change
Abstract: Limited success is reported from most of the projects of new management philosophy
such as Total Quality Management, Business Process Reengineering, Information Technologies,
and Continuous Improvement. The reason was attributed to the way these initiatives were
structured and implemented. Most of the implementations of these transformational strategies are
found to concentrate on process improvement instead of dealing with the interacting subsystems
of the organization. Hospitals and health-care organizations require more attention in their
transformation efforts to guarantee error free operations, with the highest quality service. To get
the maximum benefits and to guarantee successful transformation, hospitals and health-care units
need to adopt a systemic approach during their reform and transformation. New management
skills should also be developed for doctors to be able to lead these changes in the new era of the
system age. The present article discusses stages, elements, and methodology space need to be
applied in hospital management reengineering, with its associated tools and techniques. Also,
integration of reengineering efforts with Health Care Accreditation activities and Information
Technology implementation is reviewed with findings from a real-life situation. A new
methodology to integrate all improvement projects is also proposed.
1. Introduction:
For many years health care organizations in Egypt have been run and managed based on
internal measures, mostly driven by clinicians, and ignoring external factors such as
competition and global standard measures. In many countries around the world hospitals
have recognized the need to cope with the increasing operating cost and support a decent
level of service quality to become on the competitive edge of the health care industry.
Managers and hospital administrators adopted many of the new improvement philosophies
to lower operating cost without compromising the service quality improvement dynamics.
New management philosophies as Total Quality Management (TQM), Business Process
Engineering (BPR), Restructuring and Downsizing (RD), and Continuous Improvement
(CI), in addition to various implementation of Information Technologies (IT) can be found
to be applied now in many hospitals with various levels of success. Chau Fournier and St.
Ander (1993) reported that about 44 per cent of 1083 hospitals in US have already embraced
the continuous improvement approach to improve the care delivery process. Walston (2000)
examined the effect of reengineering on the competitive position of hospitals on USA, by
reviewing data and study setting from 30 percent of all US hospitals in metropolitan service
area combined with the American Hospital Association annual survey. The study concluded
that reengineering alone was not enough for improvement, and without integrative and
coordinated efforts ree1ngineering may damage the hospital organization’s cost position.
Also, it was reported that most of the private sector downsizing fail to meet organization
objectives, and downsizing of the public sector hospitals resulted in higher operating cost
and poor services (Flint, 2003). Concerning restructuring, a survey on 50 hospitals in USA
indicated that most of the changes were reversed or significantly worked back (Lazes et. Al,
2003). Regarding the introduction of information technologies (IT) in hospital management,
a comment made by Smith (2003), stating “hospital sometimes make the mistake of
* Consultant and systems developer, Email: info@analysthome.com
* Visiting Professor at National Educational Technology Program, Cairo University, Egypt
assuming that the introduction of this technology will automatically eliminate all workflow
problems,” may best describe the complexity of management improvement.
The fact that none of the previously mentioned management change philosophy could bring
an appreciative long-term improvement is attributed to the way it was structured and
implemented. Unfortunately, none of these approaches addresses the total corporate needs.
Regarding IT there are now greater understandings for more rigorous systemic approach
needed for its implementation, (Samir, 2002).
In Egypt, most corporate organizations, or healthcare facilities efforts are directed towards
ISO 9000 certification, and few others adopted other standards or healthcare facility
accreditation where in both cases the processes are reviewed and documented as is, with no
reengineering or subsystems design. For most of these organizations systemic thinking for
transformation were not adopted or found its way to become part of the strategic vision of
their administrators and management change leaders (Samir, 2004). It is clear that the future
of the healthcare facilities in Egypt depends on the successful implementation of
institutional reform to its business environment, and on its ability to raise the efficiency of
its management mechanisms within the present cultural and economic constraints.
2. Systems Age:
The term age is generally used to describe a period of time in which there is a common
view regarding a certain aspect of life. Russ Ackoff (Akoff, 1981) was the first to refer to
the present period as the “system age”, to distinguish it from the previous machine period
or “machine age”, which occupied the previous 300 years before the World War II. This
emerging system age is characterized by a different way of thinking and scope about
problems, with the transition from the “reductionism” to the “holism” in approaching
problem solving. The following lines introduce some of the system fundamentals to shed
more light on the way problems should be structured and handled systemically.
2.1. System
There are many definitions for “System” the simplest is “a set of parts or collection of
components linked together according to a plan, which constitute an indivisible whole.
System has to satisfy four conditions:
• System should have a purpose (or set of objectives)
• The performance of the whole is affected by every one of its parts.
• Interdependency and interrelationship exist among system’s parts.
• Combination of parts into subgroups will cause them to form a system themselves
or have the same conditions as subsystems.
With this definition everything becomes connected systems, within a larger whole, and
complexity becomes a norm of system behavior. In the mind of system’s thinkers and
researcher’s “system” as a word has many implications, it simply means a different way
of life and concept. Systems’ concept is a way of thinking about organizations and
their problems, irrespective of its field of applications, or its business domain. With
this concept it becomes possible to address problems in any domain, in hospital as
whole, or its subsystems as clinic, operating theatre, or hospital catering, and in all
other parts. The system movement, which started in the forties of the last century, is
seen now similar to the scientific movement started around 1817 (in the eighteenth
century). With systems ideas it has become possible now to store the entire hospital on
a hard disk!
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System
Boundary
Subsystem
Component
Fig. (1): System representation
For our mind to deal with the complexity of systems interaction, a system (virtual)
boundary is used to limit our analysis and to define our system and its environment.
System boundary and environment constitute two of the system’s elements. Each
purposeful system can perform its functions through a number of elements each has a
specific function. These elements are input/output, processor, feedback and control
boundary and interface. In social and human activity systems culture becomes one of
its elements.
2.2. Systems Thinking:
Systems ideas had evolved from the work conducted to formulate a general theory to deal
with all arrangements in a universal way. It was Bertalanffy (the Biology scientist) in
1945 that brought the concept of generalizing these ideas and later recognized as the
system’s movement founder. System’s movement is linked with two main elements
namely systems thinking and systems approach. Systems approach is an approach to a
problem or situation, which takes a broad view, taking all aspects of the problem into
account and concentrating on the interactions between various parts or subsystems. This
leads us to the importance of adopting system thinking in formulating the problem.
Systems’ thinking is founded on two pairs of ideas, those are emergence - hierarchy, and
communication - control and utilizes number of tools and techniques in problem solving.
(1) emergence and hierarchy:
The emergence of systems thinking came from a debate between reductionism and holism.
Reductionists dealt with living systems as complex machines and believe that every
problem should be broken down into separate simple parts in which the diagnosis may
become simpler and its solution can be easily managed. With the holism thinking, the
new emerging properties come from the integrated effect of parts, and the sum of parts
will not always give the same effect as their whole. This view led to the concept of
organized complexity. With the general model of organized complexity there exists a
hierarchy of levels of organization, each more complex than the one below and the
properties at the higher levels will not be thought off at the lower levels.
(2) communication and control:
Systems’ thinking is based on communicating information and/or energy between
systems and its environment, and between its parts. With living systems DNA is regarded
as ‘storing’ and ‘coding’ information (in 46 chromosomes stored thousands of chemical
words), which is chemical ‘messages’ carry instructions to activate or to repress some
reactions. This mechanism forms a control and messaging or communication processes,
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which guide the development of the organism, and not only carried out within the
organism but also with the environment. In man-made systems information and control
form an important part of its existence.
2.3. Systems Classification
To be able to use systems thinking effectively one needs to familiarize himself with
different types of systems, or systems classifications. Systems are classified according
to its nature as physical (static or dynamic) or abstract (nonphysical), or according to
the way they are created as those found in nature or man-made systems, and those
which combined both as social and cultural systems. Systems are also classified
according to their behaviors (the way they react for the excitation or the change force),
which may become linear or nonlinear or complex, or to the degree of independence
with their environment (as open and closed systems). Hospital or corporate
organization when dealt with as a system becomes a collection of man-made social
highly dynamic open system that exhibits a complex behavior, and information within
this system acts as the biding field which links system’s parts together and constitutes
with other subsystems the information system.
2.4. Systems Language
With systems movement different techniques were used to express and describe the
system. Engineers were pioneered to use mathematical expressions and symbolic
drawings to represent their engineering systems. Systems engineering mostly deals
with well-defined problems, known as hard problems, witch mostly has one result. In
social, cultural, or human activity systems there is no one end solution for the problem,
and the end product is hard to define before the system itself does exist and known as
soft problems. System representation and analysis in this case uses more symbolic
forms and graphical tools. In both, systems engineering, and systems analysis number
of conventions and modeling techniques are used to describe the system. Systems
language extensively uses graphical or mathematical modeling tools to visualize the
system. With this new system languages, a number of methodologies evolved to deal
with system problems and complex situations.
2.5. Systems Application
There is no limit to practice with systems concept and thinking in any field of study or
discipline. It is analogous to using experiments either in laboratory or with analytical
model for problem investigation, and in different domain of knowledge. In his
comparison of the system movement and the scientific movement Checkland, (1981)
pointed out the similarity between systems thinking and scientific thinking, system
approach and scientific approach, also system applications and scientific applications in
solving problems. System science emerged now as an interdisciplinary meta-subject.
3. Hospital Transformation:
With system view organization becomes the main corporate processor, or its
transformational element, which executes its plans, functions, and missions, and the
traditional work of managers is to regulate the pattern of its activities around a predefined
objective. Traditionally, corporate functions are distributed among number of divisions
to facilitate and simplify its control, and ideally regulating and controlling organization’s
functions are continuously performed by changing the processing policies or by taking
actions to change its input or output. Hospitals are no exception. They are arranged in
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divisions and departments with hierarchical structure and conducting its functions in
successions of procedures and steps, which involve number of personnel in different
divisions, and with different specialization and qualifications. This view of management
has changed, as organizations must adapt to their changing environment by continuously
setting new objectives. Hospitals must cope with the pressure imposed by their
competitors, new regulations and standards, and health and economic indicators. For
these reasons management philosophies as TQM, BPR, Restructuring, and IT
implementation are adopted, as mentioned at the beginning of the article. Adopting any
of these philosophies will bring different levels of change. Change can vary in
complexity and extent depending on the change strategy involved. During this change
process managers cannot continue to carry out their normal administrative functions, they
become visionaries who lead, manage, and orchestrate the change.
Successful implementation of any of the earlier management philosophies depends on
many factors, and the most important ones are the scope of change addressed by this
philosophy, its strategy, the methodology used and how it is implemented. The following
sections examine each of this strategy and try to assess its system implications:
3.1. Total Quality Management (TQM):
TQM is a process-oriented improvement philosophy. Beginning in 19980s and through
the 1990s, quality became a major issue for managers in the USA and many parts of the
world. Recently, there has been increasing interest in applying TQM philosophy in
health care industry (Chow-Chua, 2000, Ho, 1999). Although quality improvement has
become one of the organizational initiatives, until now there are conflicting views about
total quality implementations (Denanona and Born 2000). There are mainly three
frameworks for total quality (TQ). These are of: Crosby (1979) who focuses on
reducing cost through quality improvement, Deming (1989) framework emphasizes the
system nature of organization, and the importance of leadership and the need to reduce
the variation in organizational process, and Jurans (1989) framework involves three sets
of activities: quality planning, control, and improvement emphasizing the use of
statistical tools. Another implementation of TQ brings more variations to its meaning
and objectives. Dean and Bowen (2000) see TQ as a philosophy or as an approach to
management that can be characterized by its principles, practice, and techniques. Its
three principles are customer focus, continuous improvement, and teamwork. Table (1)
shows principles and elements of TQ. Many researchers offer a step-by-step method for
TQ implementations in hospital and health care industry, and in all cases, efforts are
found to be directed to improve certain processes or set of processes.
By examining table (1) with various implementation schemes of TQM philosophy
together with its methods, one may present the following comments:
(1) TQM’s major focus is directed to customer satisfaction: One may question its
position regarding the uninformed or uneducated customer or market. Also, setting
the base for customer satisfaction may differ within one country from one city to
another or a district or a community. Setting the standard for healthcare is a major
step towards continuous improvement.
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Table (1): Principles, Practice, and Techniques of TQ (Dean and Bowen, 2000)
Customer focus
Principles
Practice
Techniques
Continuous
improvement
Organization-wide focus on Consistent customer
customer.
satisfaction only by
process improvement.
Collecting information
Process analysis,
about customer needs.
Reengineering,
Use information to design
Problem solving,
and deliver products and
Plan/do/check/act.
service.
Teamwork
Customer survey.
Quality function
deployment (QFD).
Organization
development methods.
Team building methods.
Flowchart,
Pareto analysis,
Statistical process,
control,
Fishbone diagrams.
Collaboration
throughout organization,
customers, suppliers.
Formation of different
types of teams.
Group skill training.
(2) In TQ, process is analyzed and designed based on quality factors: This brings two
issues: The first is related to the interdependence and integration of the process with
other related systems components or subsystems. The second is that the design
specifications of the process may have other requirements than those of the quality
measures, which need more parameters at the system and subsystems levels. Ignoring
those parameters would affect both process design and product quality.
(3) In TQ, the process is built around customer focus: In hospitals an extensive and
integrated efforts is necessary to guarantee the full integration of customer needs at
each of the processes of the healthcare service. TQ methods do not give clear
interpretations of those needs with respect to process specifications or quality
measures.
(4) TQ initiative asks for customer information analysis: This step needs a major effort
to identify requirements for such an analysis. In most cases this step is conducted on
the available information generated from the existing system, which proved to be
inefficient. Developing information systems to analyze customers and process
information requires true innovative development efforts beyond the process quality
improvement tasks.
(5) TQ asks for an integrated teamwork effort: Improvement of this nature requires a
multidisciplinary approach rather than just an integrated effort and team building
training. Various specializations are needed within the team and building internal
skills by learning and education becomes essential for such arrangement.
(6) All TQ techniques suggested for continuous improvement, shown in table (1),
address the cause-and-effect relation which characterizes linear change which
contradicts the nature and complexity of the integrated processes behavior. More
rigorous tools are needed to reveal the underlying behavior of processes and system
components in order to design the needed improvement.
Easton and Jarrell, (1998) defined TQM as one of the management systems and
examined the effect of its implementation on the performance in 108 corporations. It is
most wise to define TQM as one of the corporate management systems, to be integrated
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with all other processing functions of the organization, and to be used to complement
the culture of system improvement.
3.2. Business Process Reengineering (PBR)
BPR is defined as “the fundamental rethinking and radical redesign of business process
to achieve dramatic improvements in critical, contemporary, measures of performance
such as cost, quality, service and speed”, (Hammer, 1993). A number of researches
have looked at BPR as a method of planning and controlling the change and considered
it as one of the strategic change management, (Furey and Diori, 1994). Despite what
was promoted about this change strategy, a number of researchers have attributed its
weak record of success to its structure and character (Attran, 2003, Chan, et. Al., 1999).
According to Nwabueze (2000), examination of the underlying property of BPR
indicated that it is anti-systemic in character. He concluded that BPR lacked a clear
strategy for its implementation as it also does not address the numerous elements that
affect the work environment. For this reason, new approaches were introduced to guide
the implementation in business and healthcare facilities (Harrison, 1994, Armisted and
Rownals, 1994, Nwabaze, 2000).
To deal with the shortcomings of BPR Champy (2002) introduced X-Engineering as a
new reengineering initiative for corporate reengineering. X-Engineering is meant to
reengineer the process across the corporate boundaries and use the concepts of ecommerce and internet technologies.
Table (2) shows a comparison between BPR basic principles with systems concept and
thinking in dealing with its structure and implementation process. The table shows that
addressing the processes separately will not bring the required improvement and may
bring difficulties in other parts of the system.
Table (2): BPR principles in contrast with systems thinking.
No.
PBR concept
Contradiction with Systems thinking
1
Redesigning critical process.
Ignoring the system parts contradicts the
indivisible property of the system.
2
Improving one process at a time.
3
Introduce radical change in one
process
4
Improving one process or set of
processes.
workers could change consensus
decisions at any point.
5
6
7
Changes are carried out along
the implementation.
This does not guarantee improvement in any
of the interdependent subsystems
This may bring disappointing results in
another process (known as shifting the
burden in the system, Senge, 1990 )
This ignores the interdependency between
subsystems, (limit to growth, Senge, 1990).
This may bring potentially unmanaged
situation. Decision analysis should identify
the exact points of empowerment.
No references to the verification, validation,
and testing which ignore the knowledge of
system behaviors and dynamics.
3.3. IT Implementation and Change:
It is surprising how long it should take, after these large numbers of failed IT projects,
before our managers can look back and realize the fundamental reason for launching
the PBR initiative in the 1990s. The purpose was not to automate the existing process.
Hammer (1990) message was “Do not automate, obliterate”. Grover (2003) indicated
that “if you automate a mess, all what you get is an automated mess”. For this reason,
it was realized that system change should not be driven by IT implementation, and
information systems development researchers spent the last thirty years (started by De
Marco in 1968) to develop new development methodologies. Process redesign was part
of many of these methodologies before PBR was launched. Now with the present shift
to Internet technology with its associated business in all fields, Enterprise Resource
Planning (ERP) has emerged as one of the tools for corporate redesign and alignment.
It is understood now that because IT implementations go in separate way, and not
considered to be part of organizational alignment efforts, most of its power was lost.
This also explains why we have a very high rate of IT project failures and gives the
main reason for the low level of its full utilization, if implemented.
It should be noted here that IT implementation should not be looked at as just a
computerization project, it should be built on a solid foundation of the hospital (or
corporate) information system (IS). As we do not manage the patients or the hospital
facilities themselves, but the information associated with its subsystems’, introducing
IT is more of a cultural and hospital-wide development, and need a systemic view for
its successful implementation.
3.4. Restructure and Downsizing (RD):
Organizational restructuring and downsizing are complex processes, difficult to
implement successfully (Bruke and Nelson, 1998). Downsizing refers to the
“elimination of specific jobs or positions rather than discharge individuals for cause, or
individual departure via normal retirement or voluntary resignation” (Greenberg, 1990),
if in turn the process itself needs to be redesign, then restructuring the process and the
organization should take place. The main purpose is to eliminate jobs and reduce cost.
Several studies conducted over the past ten years have shown that restructuring and
downsizing often have a negative effect on the work force. One half of its efforts did
not meet their objectives. Also, hospitals restructuring shows similar negative results
(Bruke 2004).
Downsizing and structuring can be implemented using different strategies and
approaches ranging from ad-hoc, contingency management, to systemic step-by-step
methods. No specific pattern can be traced between the implementation methodology
and the outcome of the downsizing and restructuring in hospitals, and more studies
should be conducted.
To improve the success of (RD) a number of guidelines were identified and most of
them were to improve communication with the staff and to gain their support. The
entire RD process seems to be highly dependent on the vision and the leadership skills
of the hospital executive manager who should lead this change (Flint, 2003).
3.5. Continuous Improvement (CI):
Continuous improvement (CI) as a philosophy for change encompassing organizationwide process by systematic improvement of process, product, and service, is one of the
tenets of the quality management ideology (Savolainen, 1999). CI normally introduced
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in cycles and can be implemented to go deep into the cultural levels of the organization
and becomes parts of the renewal process, or just to touch the processing functions and
becomes part of downsizing and structuring or just a change. Renewal encompasses
managerial ideological thinking and organizational practice and is linked to the
organizational adoptive behavior. Renewal requires a management transformation that
bringing learning ability to the organization.
3.6. Organization and Management Transformation:
From the earlier review, it becomes clear that all new organizational management
philosophies are centralized around “bringing change into action”. Change process can
be described in terms of its type and mode (Anderson, 1994). The type of change
process depends on the speed of change, and there are two broad categories of speed of
change as incremental-evolutionary where the reshaping of organization and
management take a stepwise implementation either horizontal or vertically or both, or
radical change which is introduced in a swift move. The mode refers to the means of
affecting organizational change, or the mechanism through which change becomes real
(Solvinen, 1999). Now effective change referred to in the literature as transformational
and renewal. Transformation implies deeper change while renewal becomes the
continuous and moving transformation to adopt with the changing environment. Tichy
and Devanna, (1986) defined organizational renewal as “the new way of thinking
becomes day-to-day practice. New realities, actions, and practice must be shared so
that change becomes institutionalized. At the deepest level this requires shaping and
reinforcing a new culture”. Organizational renewal can be easily linked to a number of
capabilities and properties as innovative, learning and self-organizing, and all related to
systems’ ideas.
Transformational change is also characterized by the following (Cummings, 1997):
(1) Revolutionary and systemic
(2) Triggered by the changing environment.
(3) Driven by senior executives and line managers (together)
(4) Continuous
(5) Requires and induce culture change.
Finally, transformation change is characterized by radical changes in how its ember
perceives, thinks, and behave at work. It goes far beyond making existing organization
better or fine-tuning its status.
4. Hospital Managers and Systems Education
It is clear now that the present era is characterized by its vast pace of change, and with its
dynamic nature. For this reason, management concepts and functions have changed.
Management of change becomes one of the management functions. Managers in all
fields, especially in hospitals, should master different approaches to identify risks and
challenges facing their organizations and develop the necessary skills to structure and
lead its change journey. Our managers need to deal with this highly dynamic changing
environment differently than they did in the 1970s and 1980s. There are many research
and studies about the needs for different management education, by introducing systems
thinking (). It is a fact now that it must be a sufficient level of knowledge for managers
to effectively engage in system-based initiatives. As a minimum, basic systems
knowledge should cover the familiarity with systems language, concept, and thinking to
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define the root cause of their organizational problems before thinking in a solution.
Mitroff (1999) stated that “all serious errors of management can be traced to one
fundamental flaw: solving the wrong problem precisely”. Forrester (2000) commented
on those managers working with quick fixes rather than manager-owner approach as
“corporate problems take year to develop, and the fixes take years to repair the damage”.
In complex systems we may see that policies that are good in the short run produce
trouble in the long run”. Managers need to understand the techniques of systems
dynamics to be able to go deep in problem analysis and synthesis to know how problems
are generated, how it evolved out of the past policies, and how alternative policies would
improve its behavior. A manager with an understanding of systems sees how complexity
has evolved and identifies similar patterns in different problem domains rather than
focusing on differences and wasting his effort with isolated solutions.
5. The Need for a Methodology
Whatever the change is, managers should not only design the new shape of their
organization but also the path they need to take to get there. With the complexity of
today’s organization and the size and type of change needed, expected change should not
be straightforward, linearly achievable tasks. Also, as we deal with so many aspects of
the organization on the technical, social, and human dimensions, no one group should
dominate the change process. Change should be guided within the scope, boundary, and
the environment of our system of problems, and address all interactions and
interdependencies of the hospital (corporate) components. All those require knowledge,
expertise, and teamwork with a multidisciplinary approach. On any level, change needs to
be engineered.
Now systems engineers, systems developers, and system analysts are needed to work
together with System-oriented managers to guarantee the correct and successful
deployment of the change. They should use system methods, which utilize a number of
tools and techniques, for development. Systems thinking requires more than development
methods, or step-by-step linear approach, it requires methodologies which are far more
general and systemic than the systematic application of change. Each methodology space
covers roles (of team member), the activities to be carried out, the scope within the
development phases (known as system development life cycle), starting from strategic
planning to post-implementation phase (Cockburn, 1999). Throughout the years many
methods have been developed, and now more than a thousand exist (Bubenko, 1986).
Review of these methods can be found in (Samir, 2002, p. 77), and more management of
change methodologies can be found in (Holmn, and Devan, 1999). Figure (3) shows an
outline for action flow diagram for a system development method known as Total Unified
Methodology (TUM), developed to manage the requirements for problem definition,
reengineering, process design with performance and quality measures, and system
implementation. It can also integrate all development projects as ISO certification, BPR,
and TQM which should be conducted under one umbrella of systems development. More
about this methodology can be found in Samir (2002).
6. The Hospital:
There are many commonalties between hospitals everywhere in structure and
administration, only culture makes them different. Also, all hospitals undergo changes
in response to the increasing cost of its operations and to improve its service quality,
people who run and operate these hospitals take different paths, which end up with
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different results. When the customer focus becomes the center of attention, teamed with
additional efforts to adopt with the continuously changing environment more variables
should be considered which make the chance of success extremely difficult for those
managers who are not up to the challenge. The traditional management structure, found
to exist in most of our hospitals, which is built with separate departments and
specialization, as shown in fig. (2), may not be suitable for the present era.
Medical
Nursing
Supporting staff
Fig. (2): Management structure, (Ho, 1999)
This fact is supported by the information collected from a number of surveys conducted
by the authors. One of these surveys was carried out as part of a computerization project
for a Hospital Management System with a budget of over 2 million Egyptian L.E.
(approximately $ 0.4 million Dollars). Computerization had to be completed within a
period of 6 months, with 30 program modules covering all functions of the hospital. The
survey results can be outlined in the following lines.
6.1. Hospital Business and Healthcare Areas:
Hospital was divided in departments and activities which cover emergency clinic and
reception, outpatient clinics, inpatient treatment, operating theater, sterilization,
laboratories, diagnosis, maintenance and engineering, biomedical engineering, nursing,
financials, administration, pharmacy, and medical supplies. The hospital has 14
outpatient working clinics and more than 300 inpatient beds, just to give an idea about
the size of activities involved. All the departments surveyed used a paper-based system
evolved by each department personnel either created from their needs or brought from
their previous work. That explains why records and circulating forms between
departments were not consistent and the information they carried was not integrable
from the start. All the employees interviewed did not have a formal training about their
workflow and their manual system. On the administrative level strong centralized
financial control and budget planning was found. Although budget planning was based
on what is available (money), not on what is needed (patient), the investment for such
an amount of money for computerization was taken. About the actual personnel who
run the work in each business area, it was found that the purpose of computerization
was not clear for them, and the need for its introduction was not obvious. It was clear
that the decision for computerization was taken on a higher level of management and
employee requirements were not defined or analyzed based on their actual needs. It
was concluded that there was a cultural gap between the decision for computerization
and the actual state of the work environment.
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Figure (3): Action flow diagram for TUM methodology, Samir (2002)
6.2. Analysis
In addition to earlier social and cultural factors presented before, analysis of the
hospital business and medical areas showed a large gap of integration. System
reengineering was considered essential before any computerization. New business
model was needed, and more exhaustive analyses to cover the entire hospital were a
must. To give an idea about the importance of such a system view for improvement,
one may consider only the X-ray operation as an example. With X-ray functions
analysis of the following areas of activities was needed:
(1) waiting list and appointment procedure
(2) reception and patient preparation procedures
(3) in-process patient care procedure
(4) Patient record creation and maintenance
(5) X-ray devices technical instruction and operations, with updates
(6) X-ray dose specification procedure, with updates
(7) X-ray devices and instrumentation maintenance may need updates.
(8) X-ray devices calibration program and certification, with updates
(9) X-ray clinic safety measures and safety procedures, with updates
(10) X-ray materials handling, storing, and disposal procedures, with updates.
(11) X-ray patient diagnosis procedure may require updates.
(12) cost estimate and billing procedure
(13) budgeting and planning
(14) training and education in X-ray functions and related operations
These procedures although carried out in one specific function or process of the
hospital (as X-ray clinic) it has its roots in other departments and subsystems. These
subsystems may include maintenance, engineering, safety, calibration, information
system, patient care, standards, document flow and control, finance, medical supplies,
and training. It is obvious that improvement of X-ray functions needs considerable
efforts on these related subsystems.
Extending our analysis to subsystems and processes by taking into consideration all of
its interacting components will produce an integrated business model. Building this
integrated system, which satisfies all business requirements and use performance and
quality indicators for improvement should automatically satisfy all quality standards.
This system is the hospital management system, and integrates the quality measures of
each process, which constitute its total quality system and becomes one of the
management subsystems. This system of quality should be seen as the conscience of
the hospital (corporate) management system, which guides other subsystems to perform
its healthy functions.
6.3. Logical Model
There are two stages before starting the reengineering process in the present
methodology. The first is to define improvement aims, the second is to analyze
business areas and extract the present model to decide on the new reengineering model.
Within the reengineering stage a new and modified logical model is developed and the
impact of the new change on the stakeholders is assessed before its final design and
implementation. Reengineering all the interdependent processes within and across the
subsystem boundaries will guarantee that the change will produce the required
improvement, and there is no need to specify the nature of the redesign before hand. If
improvement needs a radical process redesign, then it would be. The following may
describe the new conceptual system view of hospital by combining all processes, which
have the same origin and expect to give similar patterns.
Maintenance
Finance
account
Safety
Training
Education
Specification
Standards
Document
Control
Systems &
Engineering
Diagnosis
Administration
Clinics
Total
Quality
Patient
care
Medical
Supplies
Laboratory
exam
Treatment
Operation
Fig. (4): Hospital system
Personnel and staff shown in figure (2) should be distributed among all of the hospital
subsystems to perform all processing functions required for the proper operation of
each subsystem. Functions are performed by interdependent processes, which may
cross the boundary of its associated subsystems to transmit or receive information,
materials, or energy.
7. Opportunities and Challenge:
Hospital services in Egypt have traditionally been dominated by clinicians, doctors, and
nurses who are not necessarily acquainted with business values and customer concepts,
and systems development. They tend to focus on disease and sometimes ignore the
cultural and social needs of patients. Also, thinking about improvement and change in
hospitals should be based on information analysis and knowledge representation. Process
modeling and conceptualization of logical relation between data and process will ease the
successful design of the change. Now managing the change depends mostly on
information. Using information effectively requires familiarity with extracting relations
between elements, objects, and entities and thinks in terms of these relations. These
current trends are needed for today’s doctors to become successful managers and systems
thinkers. Also, our hospitals need to face the challenge of developing a new reform
methodology which integrate all available efforts for organizational transformational and
change. Doctors should lead the way to carry this reform by adopting systems thinking,
and systems science, which are recognized now as the most powerful tool in the present
system age. Doctors in Egypt should seize the opportunity that we still have many
hospitals’ organizations not touched and calling for change.
15
8. Conclusions
Limited success is reported from most of the projects of new management philosophy as
TQM, BPR, IT and CI. The reason was attributed to the way these initiatives were
structured and implemented. Most of the implementations of these transformational
strategies are found to concentrate on process improvement instead of dealing with the
interacting subsystems of the organization. Hospitals and health-care organizations
require more attention in their transformation efforts to guarantee error free operations,
with the highest quality service. To get the maximum benefits and to guarantee successful
transformation, hospitals and health-care units need to adopt a systemic approach during
their reform and transformation. New management skills should also be developed for
doctors to lead these changes in the new era of the system age. The present article
discusses stages, elements, and methodology space need to be applied in hospital
management reengineering, with its associated tools and techniques. Also, integration of
reengineering efforts with Health Care Accreditation activities and Information
Technology implementation is reviewed with findings from a real-life situation. A new
methodology to integrate all improvement projects is also proposed.
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