Iranian Expert Opinion about Necessary Criteria for Hospitals Management Performance Assessments

Abstract

Background: Managers in the hospital should have enough managerial skill to be coordinated with the complex environment. Defining a competency framework assessment for hospital man-agement will help to establish core competencies for hospital managers. The aim of this study was to develop concrete and suitable performance assessment criteria using expert's view.

Methods: In this qualitative study in total, 20 professionals participated in the interview and Fo¬cus Group Discussions (FGD). Two of informants were interviewed and 18 professionals par¬ticipants in three focus group discussions. Discussions and interviews were well planned, the FGD environments were suitable and after interviews completion the notes were checked with participant for completeness. Thematic analysis method was used for the analysis of qualitative data.

Results: Findings from 3 FGDs and 2 semi structured interviews done with 20 professionals were categorized accordance to themes. The findings were classified in 7 major and 41 sub themes. The major themes include competency related to planning, organization and staff per-formance management, leadership, information management, and clinical governance and per-formance indicators.

Conclusion: All participants had hospital administration experience; so their explanation impor¬tant in identifying the criteria and developing hospital managers’ performance assessment tool. In addition to professional perspectives and studies done in other countries, in order to design this kind of tools, it is necessary to adopt the obtained findings to the local hospital conditions.

Introduction

Major economic, cultural, demographic and political changes are quickly occurring in society and are forcing a similarly rapid change in the organization, financing and provision of health care services. The effect is that health care organizations are facing economic pressure that demand further efficiencies and better clinical and organizational performance [1].

Developing countries are not immune from the wave of change. Most of them are faced with many challenges in health sector and are some way off meeting the health associated targets of the Millennium Development Goals. The key to these countries reducing the burden of disease and achieving these goals is partially dependent on how they improve their capacity to maximize the limited resources accessible to them [2].

An essential determinant of health organization performance is competence manager and Dracker has said that large healthcare organizations may be the most complex in human history and that even small health care institutions are barely manageable [3].

Managers in the health system should have enough managerial skill to be coordinated with the complex health environment. For these reasons some authors recommend that "there is not another industry where the understanding of care competence… is as vital as it is in healthcare today"[1]. In addition Griffith enforces that the amplified problems of a healthcare organization has led to the need for managers with more complicated skills [4]. The accomplishment of any structured health program related to effective management, but health systems widespread face a lack of competent management at all levels [5].

Managers need to improve several competencies that will empower them to perform these functions effectively and efficiently [6]. Some authors suggest competency is a set of associated skills, knowledge, and attitudes [SKAs] that affect a key part of one’s job, relate to performance on the job, can be measured, and can be improved by training [7]. Some authors express SKAs are collection of skills, knowledge and abilities that can be learned by students and tested in graduates [8,9].

Evenly confusing is the repeated referencing of SKAs with the “A” demonstrating diverse concepts [attitudes against abilities], depending on the user. For example some authors incorporate abilities with skills and use attitudes in the KSA acronym [10]. Harvey settled a KSAO model in which K represents knowledge; S refers to skills, A stands for abilities, and O representing other personal characteristics, such as motivation, independence, and commitment [11].

Thereby administrators should have a set of competencies. Managerial competency refers to necessary knowledge and skills required of an manager to perform his/her responsibilities or in other words managerial competency is defined as “the behavior of an administrator in doing his/her managerial duty and to achieve a positive level of work performance, which shows his/her motivation, personal characteristics, skills, self-image, social role, knowledge, experience and responsibilities” [5].

Defining a competency framework for hospital management will help to establish core competencies for hospital managers, which will not only strengthen their practice and provide further learning and development opportunities, but will also provide the basis to focus performance assessment [11,12].

Hence, various studies have been done around the world in order to identify the competencies required for hospital managers. For example Pillay in his article defined a list of hospital management competencies in 6 categories. These related to People related skills, Health delivery, Self-management, Task related skills, Strategic management and Need for future health care management program [13].

MacKinnon et al. classified these competencies in 9 categorized include Leadership, Communication, Lifelong Learning, Consumer/Community Responsiveness and Public Relations, Political and Health Environment Awareness, Conceptual Skills, Results Management, Resource Management and Compliance to Standards[14].

In Iran, Ministry of Health and Medical Education uses a tool to hospital manager performance assessment which a prominent feature of this tool is subjective. It is necessary to provide list of objective competencies for hospital managers in Iran. It is, however, also important to contextualize the tool to local needs as the economic and sociopolitical context of health care system in Iran. To the best of our knowledge no published data are available about defining necessary competency for hospital managers in Iran. Thereby in this study we aimed to identify competencies necessary for Iranian hospital managers.

Methods

This research was a qualitative study using thematic analyses which identifies and analyzes the themes related to aim of the study. Statistical population included 20 hospital managers and informant academic members. All participants must have had a degree in hospital management and at least 5 years hospital management experience.

Sampling method was purposeful sampling. Using selection sampling method and semi structured interview, 2 of informant were interviewed and 18 professionals participated in 3 focus group discussions. In total, 20 professionals’ were interviewed and participated FGDs. Discussions and interviews were well planned, the FGD environments were well suited and after interviews completed the notes were checked with participants for completeness. Each interview took 40-60 min and each FGDs lasted about 90-120 min.

Data analysis

All interviews and FGDs were recorded by MP3 player and then typed word by word. Before analysis all recorders were double-checked with the notes to assess respondent validity. All of the notes were read several times and themes were given codes in order to make them as meaningful as possible. All notes were checked for correctness with participants too. In order to assess expert validation, interview contents were already checked with two academic members in qualitative research and then combined.

Ethical consideration such as keeping findings confidential and giving the choice to participants to withdraw from study any time they want were conveyed to participants.

Results

Findings from 3 FGDs and 2 semi structured interviews done with 20 professionals were categorized accordance to themes. The findings were classified in 7 major and 41 sub themes [Table 1].

Table 1. Expert opinion about necessary criteria for hospitals management performance assessments.

Theme	Sub theme
Planning	• The existence of the hospitals’ strategic plan
	• Participation of all stakeholders in the program [staff, patients, students, etc.]
	• Situational analysis based on the data before strategic planning
	• The existence of the hospitals' operational plan
	• Regular assessment of program implementation and progress
	• Hospital senior management commitment to the program
Organization and employee performance management	• To be a written job description of employees at work
	• To be delegation in the hospital
	• To be codified system of performance assessment
	• To be codified system of performance-based pay
Guide and Leadership	• Devotion meetings with the staffs
	• Devotion the participatory management system
	• Regular meetings with centers of decision-maker
	• The existence of evidence-based appreciated of personnel system
Information management	• The existence of registration and reporting of medical errors system
	• The existence of registration and reporting of hospital infections system
	• The existence of the daily satisfaction of patients and their relatives in the HIS system
	• The existence of Medical record system
	• Easy access to patient’s records as needed
Resource management	• Medical Equipment
	• The existence of the maintenance and development program for medical equipment
	• Guiding and coordinating the purchase and development of medical equipment
	• The existence of supervision and control system of medical equipment
	• The existence of property offices or electronic systems for material control and warehouse equipment
	• Physical space
	• Suitable arrangement of physical space
	• The appropriateness of space with standards
	• Budget and Finance
	• Analysis of hospital monthly costs and income
	• The existence of a program for increasing of revenue
	• The existence of a program for reducing of costs
Clinical governance	• Identify unsafe cases in hospital
	• The existence of intervention programs for reducing unsafe in hospital
	• The existence of warning system in case of fire in hospitals and warehouses
	• The existence of proper system of waste management
	• The existence of registration system of reference
	• The existence of registration system of patient complaints
	• The existence of clear instructions for referring patients
Performance indicators	• The average waiting time for outpatient after reception
	• The average waiting time for inpatients after reception
	• Patient satisfaction rate
	• Staff satisfaction rate
	• Ratio of personnel to existing standards
	• Hospital infection rate

Planning

All participants believed that planning is one of the key duties of hospital managers. Based on the participants' ideas, a manager, with the participation of staff, should write strategic plan based on context analysis and make it operative in order to be implemented. Then s/he should control the progress of plan in identified time periods using related indicators. The participants also said that, the chief manager of a hospital should have a deep believe in it to implement such a plan. In my opinion, existence of a strategic plan is a pivotal item for evaluation of a hospital manager [P.1]. Plan should be edited in a group and with staff participation as they should be wholly devoted to implement it [P6]. We should consider its progress level; we should ask that how much it has been progressed in the specified time period? Then we must determine review the amount of time managers put into the planning and their devotion to implement strategic plan.

Organizing and employee performance management

Organizing is a process in which job allocation between individuals and working groups happens and then coordination among them to obtain desired aims. Participants believed that staff work lists should be presented to them in a clear, written way. Delegation process must be transparent and staffs’ performance evaluation should be carried out periodically. Moreover existing payment system must be performance oriented one in hospitals.

Having duties explanation, which is one the important items to evaluate hospital managers, helps to emphasize and make it clear to a person that he will be evaluated at the end of year [P.12]. It should be considered that how much delegation actually happened? If jobs were delegated to staff or not; or whether authority and action is determined or not? [P.6]. Performance evaluation system is one of the most sensitive and crucial problems to which a manager should focus [P.2]. Manager should act in a way that payment system would be based on performance in hospitals so that staffs would have enough motivation to perform excellently [P.13].

Guidance and leading

According to participants' ideas, hospital manager must be a good leader at first hand. He or she must communicate with others and propagate cooperative managing system by committees established by hospital staffs. S/he must also establish evidence based recognition system in hospital. In my opinion we should ask about a manager from his working sub-units that how is the relationship of manager with you? Should you make an appointment to see your manager? And does s/he speak with you indirectly or vice versa? [P.1]. A manager should have punishing and encouraging criteria in hospital and should appreciate his staffs based on evidences and proofs [P.11]. Decision making process should be cooperative and it is important to determine that how much decision making bodies or hospital committees are active? [P.7].

Information management

The organization of a manager's activities is information. Information is vital issue during planning process. Today's information and data subject matter is considered as one of the power resources in all over the world. Without complete information about a subject matter a manager cannot make effective decision. Participants believed that existence of a recording and reporting system of medical mistakes, recording and reporting system hospital infection, continuous opinion polling system from patients and their relatives and medical evidences to put in archive and patients' case re-finding are all unavoidable in hospitals. There are so many mistakes which happen by medical staff in hospitals which are not reported. It is an issue which is so effective during the process of medical treatment. There should be a recording system for these mistakes upon which a manager can decrease mistakes rate [P.5]. One of the most important indicators about managers' effecting activities is infection rate in hospitals. This indicator also needs a recording system to be established [P.9]. Customer plays an important role in hospital if we take it as an economic center. Therefore manager should regularly do opinion polling from his customers and consider their ideas to improve the performance of his office [P.7]. One of the issues through which I have been harmed in hospital running is medical documents problem. To evaluate a manager we should scrutinize medical documents. We should ask for a case randomly and then observe it. All managers' personality and his staff can be revealed from these documents [P.8].

Resource managements

Participants all were in agreement on the issue that they should examine all hospital resources like medical instruments, physical space, financial resources and budget. There are important issues in hospital managers’ evaluation. Firstly to have an edited plan in the field of medical instruments to buy and retain and develop them, second existence of a supervision system, third having properties notebooks to control materials and instruments. In terms of instruments, we should see whether such equipments have been supported in radiology or lab, before buying them, they must be scrutinized and then deliver to warehouse. If they are recorded appropriately in literatures?[P.18]. As a manager, I myself tried to examine and then send to services the equipments which need to be repaired through the official corporations. In my opinion it is one of the most fundamental duties of a manager [P.16]. Finding appropriate location and physical space allocation are so effective upon the routine costs of a hospital. As a manager, I should know what and how much space is available [P.20]. In addition to making arrangements for available space, it is important to know that every space of hospital is evaluated against available standards [P.13]. I prefer myself to be evaluated in terms of financial issues, because finance is closely associated with management, for example to evaluate cost analysis, in come, having plan to decrease total costs, increase in hospital earning [P.10].

Clinical governance

Clinical governance is of a great importance. Health activities should try to teach and administer such issue. A manager should identify unsecure points and then design a plan to decrease them [P.5]. Existence of various alarming tools like fire alarm, warding of hospital residue system are also considered as having great importance to evaluate a manager [P.17]. A manager should a system to record readmissions and patients’ complaints [P.9].

Performance indicators

One of the important subject matters in hospitals is the problem of efficacy and efficiency. For its sake, several indicators have been defined as performance indicators. By calculating and accounting such standards, one can evaluate profit in hospitals. Average time period which out patients' and bedridden stay in hospital should also considered in evaluation of a manager [P.13]. As an indicator, we should pay attention to satisfaction of internal and external customers of system. Staffs are also our customers. The common atmosphere would be faded away, if hospitals’ staffs do not satisfy. At this manner all services would be in a sense of formality [P.2]. I think relation between staffs and existed standards are effective in process of manager's evaluation. We should examine the correspondence between number of staffs and standards [P.18]. Infection rate is also fundamental in hospital and can be on appropriate indicator to evaluate a manager [P.10].

Discussion

The first and fundamental issue which has been raised during the evaluation of managers is planning. Several studies emphasis the importance of this factor as a fundamental duty of managers and the ability to plan which shows the qualification of a manager in hospitals. Fang has classified 18 characteristics and skills of managers into 5 groups. Second group of these characteristics is about planning [5]. Pillay indicated 39 necessary skills for hospital managers. He ranked those skills by means of 404 hospital managers’ opinion. According to participants’ view points, strategic planning is ranked as forth skill among hospital managers [6].

Second examined skill was organizing and managing staffs performances. Managers of health section, especially hospitals' managers should pay their attention to their staff as the most pivotal elements. They have the ability to analyze their performances and educating them. They should pay staff fairly and based on their performances. Fang indicated problem of organizing as fifth important skills in managers [5]. Moreover, Pillay classified staff management as one of the most important skill among managers' qualifications [6]. Shewchuck also classified 30 skills in 5 principle groups using the opinion of managers and 72 specialists; he tried to rank those skills. Staffs and physicians management, however, was considered as the first priority [1].

According to various literatures, effective leading and competent leaders with flexible leading ability are necessary to encounter present challenges in health sector. Mackinnon et al. also prioritize them as throughout basic groups, communication skill and understanding abilities. The capacity to make a team and work in group was considered as the most important skill among 31 competencies. Participants in their study also indicated the existence of appreciation system to be added as marginal themes [14], thereby all of items were listed were inside basic theme of leading and leadership ability.

Source of all managing activities, especially in health system, is acquiring a form of comprehensive, related and on time information. Inside health sector, implementing informational system to increase efficacy, efficiency, services quality and patients satisfaction are unavoidable. Pillary, considered data management as the most principal required skill to hospitals' managers and classified it as job oriented skill [6]. Filerman, mentioned the existence of an information system and its usage as one the requirements to manage hospital [15]. Moreover in the report by health care national leadership center, technology management and information management are considered to be managers' needed skills [16].

Furthermore skills related to maintaining medical equipment are considered priority issue since the treatment of some diseases without proper medical instruments is practically impossible. As a result, the importance of appropriate calibration of medical instruments seems to be more highlighted. Filerman mentions medical instruments managements and the necessity of having an edited system to buy and maintain medical instruments [15].

Rapid increase in hospital costs requires managers and financial counselors’ attentions in hospitals' efficiency. Pillay et al. [6], Stefl et al.[3], Shewchuck et al [1] Mackinon et al. [14] and Filerman et al. [15] have mentioned the necessity of acquiring skills in financial issues.

In different countries there are numerous methods and instruments to promote the quality of health care. For the first time, medical governance was presented in U.K NHS as a strategy. It was proposed by the government and its aim was to promote medical care quality [1998]. Kourt pointed out that the influence of a maintenance and security program on cost saving is equal to 5000000 pounds. Therefore existence of a hazard and emergency alarming system and taking necessary actions should be one of the hospitals' priorities [17]. Fire fighting plan existed in 92% of hospitals in Japan, which shows the importance of such a priority issue [18].

Conclusion

All participants had experience in hospital management to some extends. Therefore their opinions are being considered as an effective step to identify important criteria to develop a sound system in order to evaluate hospital managers’ performance. It is clear that in order to develop such a system in addition to taking into consideration the opinion; we must adopt and take the advantage of management performance assessment systems in other countries. Then based on context characteristics of that country, adequate and assessable criteria should be selected to evaluate hospital managers’ performance.

Furthermore, the number of those standards should be decreased to its possible minimum level and be defined clearly. So that evaluators should be able to grade managers' performances.