hospital management essay

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Hospital Management Essays Examples

Type of paper: Essay

Topic: Victimology , Health , Discrimination , Sexual Abuse , Medicine , Criminal Justice , Nursing , Hospital

Published: 08/02/2021

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Executive Summary

Over the past few years, there has been a notable increase in the number of car accidents on our road leading to an increase in Emergency cases in the hospitals. The emergency section of the hospital has proven to be a little bit small for these increased cases; as it was not designed to suit that high number of patients at once. With this in mind, the purpose of the project would be to create a wing that would be specifically designed to handle such cases. This will result in effective health care delivery to the patients and utilization of the limited available health practitioners in the hospital (Sullivan, Eleanor and Decker, 2009). As a result, congestions in the emergency room will be minimized and operations will be streamlined. This purpose of the project will be to enable the hospital to be in a better position to attend to the increasing case of the road accidents as well as other emergency cases all together hence providing quality health services to all those who need it.

The program will be targeting the accident victims who are directed to this hospital by the ambulances and relatives. It is noted that the accidents victims have increased over the past few months making our current emergency room unable to cope with this influx. This means there will be a diversion of all ambulances carrying such victims in this wing of the hospital as it will be equipped with the handling of such cases most effectively. This program will focus on the minimizing of errors caused by doctors and nurses due to confusion in the emergency rooms. With this project in place, service delivery to the ER victims will be greatly improved as there will be a split between accidents victims and other emergency related victims. In general, the quality of health care delivery will increase making it the secondary objective of the project. This in turn will increase the number of customer’s since they will be in a position to attend to the increased numbers and delivering quality services as the same cost. The project once completed will result in a new hospital wing equipped with all the necessary equipment and staff. This will enable the hospital to be in a better position to respond to the emergency cases. The hospital will be having all the equipment and space to efficiently carry out their tasks. As the hospital has been criticized by many for the poor services it offers in case of emergency, the objectives of the program will be to minimize such scenarios and make the hospital the first choice of all the locals in terms of emergency response. The question of space will be solved as the patients will be moved to better wards. According to hospital management (2010), the expansion of the hospital will impact greatly on the hospitals image which is good for business as it will attract more customers to the hospital.

In terms of budgeting for the project, proper budgeting will be required so as to lure investors and the board to finance the project. For the new wing to be as effective as possible, there will be a need for the management to ensure that the appropriate equipment are installed and up to date technologies are used in all areas of the hospital’s service lines. One should not just look at the cost associated with the project; one should look at the positive image the program will create of the hospital in general. The program will result in increased in-patients visiting the hospital meaning more and more revenues to the hospital. This increases profitability hence fulfilling the major goal of most organization. The program will also result in better health care delivery to its clients putting the interest of all its patients into consideration irrespective of their situation. The program also can be seen as a community outreach program as it is mainly focused with keeping the society safe. There will be increased life expectancy in the community due to proper medical care. Job opportunities will also be availed to the community members hence increasing their life standards. Over a period of two to four years once the project has been completed, the revenues for the hospital would be expected to have doubled meaning that the payback period of the initial investment will be in a short period of time. This means that the project will benefit the hospital in the long-run as will increase profitability of the institution.

In order to establish whether or not the objectives of the project are being met, there will be need for the project evaluation to be conducted at least twice in a year. This will enable the management to be in a position to rectify any problems that may have arisen and correcting them in time to increase the project’s effectiveness. One of the ways through which the program can be evaluated is through the monitoring of revenue increase. This will show whether the project resulted in benefits to the hospital or not. Another way of evaluating the project will be the determining of the rate at which the patients are increasing, both out-patient and in-patient. With this, one can be in a position to determine whether or not the projected has been successful or just a waste of the investors’ funds.

Hospital Management. (2010). Chicago, etc: Clissold Pub. Co., etc. Nursing Management. (2012). Harrow: RCN Pub. Co. Sullivan, E., & Decker, P. (2009). Effective Leadership and Management in Nursing. Upper Saddle River, N.J: Pearson/Prentice Hall.

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Hospital Strategic Management and Planning: Adding Value Essay

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Pre-Service Value-Adding Strategies

Point-of-service value adding techniques, after-service value-adding strategies.

There is an urgent need for adding value to services because of the high competitiveness in the market. The chain of adding value includes two major components: delivery strategies, which are mainly clinical operations, and support strategies that incorporate organizational structure and culture as well as strategic resources (Healey & Marchese, 2013). The development of value-adding strategies starts with singling out the requirements and the analysis of the quality of services. Next, these requirements and analysis are compared with the aim of identifying which of the strategies should be kept and which ones should be altered (Ginter, Duncan, & Swayne, 2013). Adding value can be implemented at all stages of service delivery: pre-, point-of-, and post-service (Ginter et al., 2013).

Activities performed before the actual service delivery give healthcare companies an opportunity to verify their clients and the services which will be suggested to them. These strategies include performing marketing research, determining the target market, choosing the services to be offered, deciding the prices, planning the logistics, and designing the promotional activities (Ginter et al., 2013). Market research and target marketing are essential elements of pre-service value-adding as they help to plan the organization’s services and customers (Lambin & Schuiling, 2012). Verifying customers allows the healthcare company to select the groups on which it should concentrate. The most common groups pertaining to the healthcare market are patients, doctors, and third-party payers (Ginter et al., 2013).

Promotion strategies include advertising and public relations technologies (Ginter et al., 2013). With the help of these methods, healthcare companies can make their potential customers aware of their services and benefits over other organizations.

These are the activities that create value the direct time of service delivery. They include clinical operations and marketing (Ginter et al., 2013). Marketing technology is applied to obtain a better notion of the current market situation. With the help of this strategy, healthcare organizations are able to perceive the staff’s and patients’ satisfaction and predict further steps (Ginter et al., 2013).

Clinical operations are the endeavors that transform the human and nonhuman reserves into healthcare services. They presuppose the actual supply of health services to specific patients. Clinical operations comprise two significant elements: quality and clinical process innovation (CPI). Quality is concerned with the endeavors arranged to enhance the quantity and quality of health services such as patient-focused and family-concentrated care (Ginter et al., 2013). CPI includes the activities aimed at suggesting new products, looking for new clients, and providing a higher quality of service delivery (Ginter et al., 2013).

Here belong three types of activities: follow-up, billing, and follow-on. Follow-up procedures are divided into clinical and marketing (Ginter et al., 2013). The first one is employed to ensure patients’ positive impression by suggesting a sense of caring. The second one is aimed at checking the customers’ satisfaction (Ginter et al., 2013). Billing activities are concerned with the financial side of the treatment process (Zuidweg, 2015). The problems concerned with billing may leave an unpleasant impression and discourage customers from using the organization’s services in the future. Follow-on services help customers to pass the transition into a different value chain, for instance, from hospital to home (Ginter et al., 2013).

Value-adding strategies have the utmost importance for the successful operation of any healthcare organization. Adding value may take place at any of the healthcare delivery stages. The purpose of this process is to provide the best services for the customers and sustain the company’s image so that new clients would wish to use its services.

Ginter, P. M., Duncan, W. J., & Swayne, L. E. (2013). Strategic management of health care organizations (7th ed.). San Francisco, CA: Jossey-Bass.

Healey, B. J., & Marchese, M. C. (2013). Foundations of health care management: Principles and Methods . San Francisco, CA: Jossey-Bass.

Lambin, J. J., & Schuiling, I. (2012). Market-driven management: Strategic and operational marketing (3rd ed.). New York, NY: Palgrave Macmillan.

Zuidweg, J. (2015). Creating value-added services and applications for converged communications networks . Norwood, MA: Artech House.

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Strategic Management in Healthcare: A Call for Long-Term and Systems-Thinking in an Uncertain System

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Strategic management is becoming increasingly important for sustainable management in healthcare. The reasons for this can be seen in the increasing complexity, dynamics and uncertainty of the system’s regimes and the resulting need for strategic thinking in a long-term period. The scientific discussion of this issue is the aim of the present analytical framework. The starting point is the definition of the term strategic management itself, followed by a reflection on the requirements resulting from the changes in the political, social and economic value systems of our post-industrial society. In this context, Dynaxity Zone III is used to explain the long-term perspective, the high levels of complexity and uncertainty and the responsibility of strategic management as important parameters. For a practical illustration, we demonstrate two selected applications (German hospital financing systems and development process of implants) and how the implementation of strategic management in the health care system shows success.

1. Introduction

“Strategy” and “strategic management” have become buzzwords that are frequently used in the practice and theory of healthcare. However, the terms are not as simple as they might seem, and in reality, many managers are still micromanaging without a strategic perspective. Consequently, it is worthwhile to unfold the meaning of the terms and to analyse their relevance in healthcare.

The term “strategy“ stems from ancient Greek word “στρατηγός“ (strategos) meaning “general” or “leader of an army”. Thus, the original meaning of strategy is the theory or study of warfare and everything a good leader of an army should know. Carl von Clausewitz (1780–1831) developed in his famous book “ Vom Kriege ” ( About War) the first (European) theory of strategy distinguishing between tactics and strategy [ 1 ]. The first term describes the organization and fighting of forces on or near the battlefield, while the latter term goes far beyond that and tries to utilize different instruments for the final objective of winning the war. This not only includes battles but also withdrawals, alliances, negotiations and circumventions. V. Clausewitz was a Prussian officer serving the Russian Czar during the Russian Campaign (1812–1813). He realized that the French army won all battles but finally lost the war. The strategy of Prince Mikhail Illarionovich Golenishchev-Kutuzov (1745–1813) was to withdraw and even avoid battles—an approach of warfare that was unusual at that time and even made some to accuse him as coward. His credo “We must win the war—not the battle” strongly influences the strategic thinking of v. Clausewitz in his later years as the director of the Prussian “Kriegsakademie” (college of war) and enfolded his theory of strategy.

For v. Clausewitz, strategy has four dimensions that are relevant not only for warfare but are widely applied in management today such that “ Vom Kriege ” is mandatory reading in many business schools until today. These dimensions are as follows [ 2 , 3 ]:

• Long-term: Strategy always focusses on the long-term consequences of actions. The manager—as the commander-in-chief—should pay more attention to the final result than to the intermediate gains.
• Strategic apex: Strategy is the main responsibility of the top-leaders as it always covers and affects the entire organization. There is no “middle-management strategy”.
• Complexity: As the strategy covers the entire organization and long-term consequences, many different elements and dimensions are involved, i.e., strategy has to deal with a high degree of complexity.
• Uncertainty: The long-term consequences of actions are highly uncertain.

The terms “complexity” and “uncertainty” are crucial for strategy and require more explanation. “Complexity” stems from Latin “cum plectrum“, meaning connected, interwoven or interdependent. Thus, a system is not complex because it consists of many similar elements, but because the elements are different and have a high number of relations between them. These relations are frequently non-linear or even non-monotonous. Consequently, complex systems cannot be described with all their behavior even if all information on each single component exists [ 4 ].

Uncertainty means that the conditions of the environment and system behavior are not known and/or their transitions are subject to certain probabilities [ 5 ]. The longer the distance between the point of planning and the point of action, the higher the degree of uncertainty. Some uncertainty (e.g., epidemics and crop failure) is external and cannot be influenced (“Act of God”); other uncertainty includes the consequence of many small decisions and events, which add up and result in chaotic system behavior. Frequently, this kind of uncertainty exists because we have a rational opponent or antagonist. This is the field of strategy seeking to achieve one’s own objectives while expecting countermeasures of the opponent but also building alliances with protagonists [ 6 ].

Consequently, a strategy is a long-term plan of action of the strategic apex of an organization that analyses the complexity and uncertainty of the system and makes decision under the consideration of all potential stakeholders [ 7 ]. For a business unit, we have to distinguish the following:

• Domaine: What is our business field, i.e., with what products to do want to serve which group of customers with which needs?
• Competition: How do we want to set ourselves apart from competitors (quality leaders, price leaders and niche)?
• Competence: What is our core competence and how can we develop it (resources and potentials)?
• Alliance: With whom do we want to achieve our goals and how strongly do we cooperate?

It was frequently stated that operational management means “to do things right”, while strategic management means, “to do the right things” [ 8 ]. With v. Clausewitz, we could argue that it is correct but insufficient. Strategic management means “to do the right things right” by focusing on the long-term consequences of our actions in an environment of uncertainty and complexity. While we develop strategies, we do not know all the parameters, we expect new interdependencies to arise and we have to deal with stochastics and decide on alliances and competition. Strategy is the supreme discipline of management.

Figure 1 shows the strategic management process. The starting point always involves strategic objectives including the vision and mission of the enterprise. This is the domain of business ethics, i.e., strategic management without ethical reflection on the value and resulting objectives is infeasible. Based on these objectives, we analyse the environment and the enterprise for chances and risk with respect to strengths and weaknesses. This includes the development of a strategy or a set of strategies. Based on the objectives, the strategic manager selects a strategic program and implements it. In principle, the strategic management process is similar to a general management process, but the time-frame, the degree of uncertainty, the relevance of the decisions and the number of sub-units of the environment and the enterprise involved are much higher [ 7 ].

Strategic Management Process. Source own, based on [ 7 ].

These days, many healthcare services are more influenced by etatism than many other fields of business administration. The traditional time-horizon of healthcare is the annual budget provided by governments or parastatals (e.g., social health insurances) [ 9 ]. The main purpose of the “traditional” administration of healthcare services is the compliance with laws and regulations, while the efficiency and long-term development of potentials are still less focused upon. Even if the first efforts towards a strategic approach have already been made by larger healthcare systems and individual profit-oriented institutions, strategic thinking and management have not yet been sufficiently recognized and implemented in most traditional healthcare systems and non-profit organisations. In this paper, we argue that more long-term systems thinking on the strategic apex with consideration of dynamics, complexity and uncertainty are crucial for the healthcare system.

For this purpose, the next two sections discuss the characteristics of healthcare systems in the post-industrial era. Afterwards, we analyse the instruments and personal characteristics required to implement successful strategic management in the healthcare field. This knowledge is applied to examples, namely hospital financing in Germany and research and development of implants. The paper closes with some conclusions on how strategic thinking and management can contribute to the health and wellbeing of human beings.

2. Dynaxity

There seems to be general agreement that the last decades have witnessed tremendous changes in political, social, economic and value systems of our societies. The development from the industrial era to the dominance of service industries, globalisation and individualisation has frequently been discussed [ 10 ], but their impact on healthcare systems is insufficiently reflected. Rieckmann introduced the term “Dynaxity” as an artificial construct to describe the economy and society of the new millennium with the three characteristics: dynamics, complexity and uncertainty [ 11 , 12 ]. In this section, we will unfold these dimensions of Dynaxity and analyse their relevance for healthcare systems and management.

The term Dynaxity describes the dynamics, complexity and uncertainty of a system. Every an open system has a tendency to restore its steady-state-equilibrium and avoid changes because any alteration requires energy and induces uncertainty; i.e., open systems are usually homeostatic [ 13 ]. Only when the differences between goals and outcomes of the system are so strong that the formal and material structure cannot be maintained is the system has to react and adjust its structure. Otherwise, homeostasis will lead to the extinction of the system. Economic systems are constantly under the pressure to change as the environment changes frequently. Under the pressure of change, they will only survive if they can expand beyond their original limitations.

2.1. Transformation

Originally, the system is in a steady-state equilibrium. It fulfils its function in its environment and is able to absorb smaller internal or external perturbations (synchronic systems regime). If the perturbations grow so strongly that they cannot be absorbed any longer within the existing structures, the system begins to fluctuate until it reaches a bifurcation point where it is obvious that the system will never be the same again. In most cases, the system will find a new equilibrium, which is adjusted relative to the new environment and usually on a higher energy level ( Figure 2 ).

Transformation into a new systems regime. Source own, based on [ 13 ].

Changes in the environment are first absorbed by the microstructure (e.g., personnel, customers). Only if the perturbations are rather strong such that the microstructure cannot handle it will the meso structure (entire system) become involved. Moreover, the mesostructure will be passed onto the macrostructure, i.e., the economic or political system, only if it cannot absorb the fluctuations. A stable mesostructure can absorb quite an amount of pressure, but if the necessary changes are blocked by the macrostructure, the mesostructure might become inflexible or even fragile.

The development of new structures and functions of systems require a steady flow of energy. Ecological systems are finally based on the flow of energy from the sun, but social systems can utilize the creativity of human beings as the ultimate source of energy to adjust the systems. With creativity, humans develop innovations to respond to changes of the environment and survive them. Thus, innovations are the foundation of the survival of open systems, and their evolution is the condition for survival. However, innovations are not only the solution for problems but also the cause of perturbations. In a dynamic economy, an innovation will prosper the innovative enterprise but challenge other organisations based on old standard technology. As Schumpeter showed more than a century ago, competition usually means “creative destruction” [ 14 ]. One enterprise solves its challenges by an innovation, and others are driven in a crisis by exactly this innovation. They require further creativity and innovation to respond to this crisis and develop another innovation, which will then become the new standards again and cause another crisis in other enterprises.

2.2. Zones of Dynaxity

The sequence of synchronic and diachronic system regimes is not only accompanied by an increase in energy but also an increase in complexity and dynamics. Depending on the degree of complexity and dynamics, different zones of Dynaxity (I-IV) can be derived [ 15 ]. In zone I, the system consists only of a few elements and the number of interdependencies and relations between these elements is small. The number of relevant changes within a time interval (dynamics) is rather limited at well; i.e., the system can be called static. Consequently, almost all elements, their behaviour and the interdependencies are well-known; there is little uncertainty within the system. Zone I is typical for pre-industrial organisations, but even today, some private practitioners work in zone I with a small number of staff, clear hierarchies, strict control of processes and a stabile function within the village where they are located. According to Mintzberg, this is a simple structure [ 16 ].

If complexity and/or dynamics increase, simple structures will be insufficient for survival in an altered environment. Consequently, zone II is an industrial era with big organisations comprising many hierarchical levels. These organisations follow strict rules of the division of labour, leading to efficiency gains that are previously unknown. However, they are also slow because the flow of information through the different layers of hierarchy takes some time. Thus, these technocracies and bureaucracies [ 16 ] are inadequate if the dynamics or complexity grow even stronger.

The post-industrial era is characterised by very high complexity and dynamics leading to high uncertainty. The “dinosaur” organisations with long information pathways cannot adjust sufficiently rapid to survive the ongoing changes. Instead, organisations must be networks with a tremendous number of interrelations, institutional memory and intrinsic motivation of co-workers who are able and willing to sense changes of the environment early, adapt the structure of the network accordingly and develop innovations to keep the original function of the enterprise [ 11 ].

Finally, if dynamics and complexity increase even further, uncertainty will grow to a degree that makes any prediction or separation of diachronic and synchronic phases impossible. Rieckmann calls this system “Chaos” (χάος) in the sense of a state of complete disorder [ 12 ]. Proactive management becomes impossible as there is no reliable information on the interdependencies and behaviour of the multitude of different elements of the system with a complete tohu wa-bohu (( תֹהוּ   וָבֹהוּ , Genesis 1:2) without any predictability. Figure 3 shows the four zones of Dynaxity.

Zones of Dynaxity. Source own, based on [ 12 ].

The zones I-IV can also be interpreted as development pathways of systems regimes, as shown in Figure 4 [ 9 ]. In a system of zone I, the systems regime changes only rarely, i.e., the synchronic phase has a duration of at least one generation. In zone II, the synchronic phases are shorter than in zone I, but they are long enough to permit a complete stabilisation. Traditional change management includes the final stage of “freezing” which makes only sense if the period of stability is sufficiently long to establish stabile meta-structures with organisational designs, regulations and hierarchies [ 17 ]. In zone III, however, stabile phases are so short that no steady-state equilibrium is possible at all. Instead of freezing the organisational structure at the end of the diachronic systems regime, a new and fundamental perturbation waits for the system. Consequently, no fixed rules can be developed and implemented, but ad hoc decisions and structures are required to deal with a steady flow of fundamental changes. However, the decision in a highly complex environment needs a high density of information requiring turbo networks without hierarchies and with a broad span of interaction instead of slow hierarchies. The chaotic system, finally, does not allow distinguishing phases or predicting the pathways of development.

Dynaxity and Systems Regime. Source own, based on [ 9 ].

For the longest period of time in human history, societies and economies persisted in zone I. Most severe perturbations were external shocks such as famines, epidemics or wars, which could have disastrous consequences such as the medieval plague epidemic (1346–1353) that killed about 1/3 of the population in Europe. For the individual and for enterprises, these shocks were “act of Gods”; i.e., they could not proactively take action or make fundamental changes as they did not have the knowledge how to alter their fate. After the external shock was no longer a threat, life continued—in principle—unchanged, with only a few innovations of limited relevance for daily life within a lifetime. Innovations were seen for the longest period by human beings as something negative—a swear word challenging the (God-given) order of the society. For instance, Wilhelm von Conches (1080–1154) expressed his own mission with the words “sumus relatores et expositores veterum, non inventores novorum” [ 18 ] (we are the mediators and explainers of the old, not the inventors of something new). The technology and regulations of the past were right—innovations were seen with suspicion.

Several basic changes increased the speed of economies and societies and opened the doors for industrial revolution, bringing unknown dynamics and complexity until then. At least for Europe, we can state that the reformation and the age of enlightenment together with the French revolution and liberalism (for instance, Adam Smith) made it possible for innovations to become the driving force of development. “Creative destruction” started and constantly increased the speed of changes [ 19 ].

2.3. Uncertainty

In zone III, we face all forms of uncertainty: We do not know which elements of the system are relevant to us, because while we observe the system, it is changing dramatically with new elements coming up and others being left out. We do not know the interdependencies between these elements as the system has become so complex that it cannot be described in its system behaviour even if we can describe each element. Moreover, all behaviours of the elements and the system are stochastic processes with fairly unknown probabilities. There is even a risk that the system becomes chaotic where no trends can be determined and even minor changes of seemingly irrelevant parameters have major impact on the entire system.

A major cause of uncertainty is the complex system of side effects, feedback effects and knock-on effects ( Figure 5 ). Any action has a primary effect, i.e., an intended effect of a parameter A at the time of intervention. At the same time, the action has a side effect on another parameter B at the same time as the action but without any intentions. This change of parameter B might have an impact on parameter A, which can be delayed, accelerated or decelerated and is called feedback effect. Furthermore, a change of parameter B can have an impact on parameter C (knock-on effect), which will itself induce side effects, feedback effects and other knock-on effects resulting in a chain reaction, which is highly uncertain.

Side, feedback and knock-on effects. Source own, based on [ 6 ].

Summarizing these findings, we can state that the post-industrial society and economy are in Dynaxity zone III characterised by high dynamics and complexity resulting in high uncertainty without stable phases. Change is the “new normal”, and peaceful stability is the exemption. The system cannot be described or analysed to the full extent as many new elements and interdependencies develop and any action has an impact on many elements now and in future. These characteristics constitute major challenges to our ability to design systems and make meaningful decisions because our brains are not designed for systems with these characteristics.

Dörner demonstrates that the human capability to understand complex, dynamic and stochastic systems and make rational decisions within such systems is limited. Without referring to Dynaxity or the post-industrial age, Dörner shows that human beings have, in particular, problems in understanding the dynamics of exponential developments. The human brain thinks linearly, but nature grows exponentially. He shows that human brains are overburdened with increasing growth rates and systematically under-estimate the increasing speed of exponential processes. In addition, uncertainty with incomplete information (because of complexity) leads to false hypotheses about causal connections. The more complex, dynamic and uncertain a decision situation is, the more likely human beings make poor decisions, and the overburdening grows itself exponentially with the size of these three parameters.

Consequently, management in zone III is bound to fail unless it explicitly considers dynamics, complexity and uncertainty. Traditional management was short-term, comprised rather limited sub-systems and ignored uncertainty. However, the more intensive zone III becomes, the less it will be functional. Instead, managers have to develop a strategic mindset with explicit considerations of these three dimensions, the appropriate instruments for strategic leadership and a strategic leadership style with a strategic leadership personality.

3. Management in the of Post-Industrial Era

Management in Dynaxity zone III must be different from management in zone II. In principle, management in zone II focused on operational management, but during the short diachronic phases, the elements of strategic management were added. During the fluctuations, the existing structures were broken-up (unfreezing) and new elements were designed so that the enterprise fits again with respect to the changed environment (moving). Afterwards, everything was fixed again (freezing) with the aspiration that this condition should last as long as possible. During the synchronic phase, strategic management was grossly neglected.

In zone III, there are no synchronic regimes; thus, change is an ongoing process without freezing. Consequently, managers have to perform strategic management permanently and not only during certain phases. Instead, they are constantly seeking for challenging changes of the environment and upcoming innovations, risks and potentials. Thus, strategic and operational management are not contradictory but have to be implemented simultaneously and have to be synchronised constantly. However, their instruments are quite different and this requires a completely new armamentarium of the manager.

Table 1 shows the differences between operational and strategic management. It is obvious that successful instruments and approaches of operational management are quite different from what is needed for strategic management. If the environment does not change strongly during a synchronic phase, the organisation can focus on short-term plans, leave decisions to middle- and lower-level management and limit the decision-field to a few alternatives. The main instrument here is managerial (cost) accounting, expressing business success in currency units. However, when the environment becomes turbulent, this approach is likely to fail. Adoption and adaption, changes and evolutionary jumps are required to survive in diachronic phases. Thus, accounting and focusing on finances are insufficient to conquer the future. Instead, potentials have to be developed in the end, and chances and risks as well as strengths and weaknesses have to be analyzed.

Operational and Strategic Management. Source own, adapted from [ 20 ].

Typical instruments of strategic management are portfolio analyses, causal-loop diagrams and simulations/scenarios. A portfolio analysis is a visual presentation of the different products and their relevance for the achievement of the long-term targets. Based on the classic BCG-matrix [ 21 ], many portfolio analyses have been suggested for different purposes. For instance, Schellberg designed a portfolio matrix for nonprofit organizations distinguishing the dimensions of “ethical call” and “finance ability” [ 22 ] ( Figure 6 ). The first dimension describes the relevance of a service for the achievement of the target system of the non-profit organisations (NPO); i.e., each NPO has to decide whether a specific service is crucial for the achievement of the target system of the NPO or not. The second dimension analyses whether an NPO can breakeven at a given financing regime. The arrows indicate that many products start as touchstones (high ethical call, but deficit), move towards stars (high ethical call, profit) and end as goiters (low ethical call, deficit).

Portfolio Matrix of a non-profit organisation. Source: own, based on [ 22 ].

The portfolio analysis reduces complexity by developing norm strategies for the four fields. It also allows analyzing the life cycle of products and, thus, reducing the perceived dynamics and uncertainty. Thus, it is an appropriate instrument of strategic management.

Causal loop diagrams are a visualisation of causes, consequences and interdependencies. Figure 7 shows a causal loop diagram for the infectious cycle of malaria [ 23 ]. An infected anopheles bites a non-infected human who might become infectious after some time. If another anopheles bites this infectious human, it can be infected and become—after some delay—infectious again so that the cycle starts anew. The autocatalytic cycle is the basis for exponential growth, which is very difficult to understand for human brains. However, the causal loop diagram clearly demonstrates the interdependencies between the variables. Thus, it reduces complexity and, consequently, uncertainty.

Causal Loop Diagram of Malaria. Source own, based on [ 24 ].

The balanced score card (BSC) can also be described as a causal loop diagram as it connects the different dimensions of strategic business performance [ 25 ]. While operational management frequently focusses on one performance dimension (usually profit), a BSC includes other dimensions (such as potentials, customer satisfaction, etc.) and shows their interdependencies. This approach reduces complexity and uncertainty by indicating the respective causalities of strategic success.

Finally, the degree of uncertainty grows exponentially with the distance between the day of planning and the day of action, i.e., the higher the time horizon, the higher the uncertainty. Consequently, strategic planning is planning under uncertainty with many different alternatives that can occur. This is reflected by scenarios or simulations. Uncertainty can have different dimensions, i.e., we can have uncertainty concerning parameters (e.g., medical infectivity of a virus), uncertainty about certain structures (e.g., natural reservoir of a virus) and uncertainty concerning processes (e.g., impact of an intervention program on incidence) [ 26 , 27 ]. Consequently, we simulate the impact of changes of parameters, structures and equations on the long-term results of a system or an intervention in the sense of “What-if?” Furthermore, we analyse which parameters, structures and processes are necessary for achieving a certain result in the sense of “How-to-achieve?” Finally, we develop scenarios of constellations of parameters, structures and relationship, which are “worst”, “likely” or “best” in order to determine a corridor of potential developments of outputs. Thus, scenarios and simulations are instruments for reducing uncertainty and—partly—dynamics by developing a sensation of future realities and their probabilities.

In summary, we can state that strategic management is different from operational management. Strategic management has to deal with dynamics, complexity and uncertainty and requires a different set of instruments. However, strategic management is not primarily a question of a toolbox with strategic instruments. Instead, we see our organizations and the environment with a paradigm. This mindset must be future-oriented, risk-taking, cooperative and open for innovations. The strategic manager is constantly seeking new opportunities to serve the function of his organization better.

Henning and Rieckmann introduced the term “dynaxibility” to express the ability of an individual or an organisation to deal with Dynaxity [ 28 ]. In zone III—in terms of their conclusions—technical or hierarchical solutions are insufficient for achieving organisational objectives. Instead, the networks have to be viewed as “living systems” with human beings with personalities that go beyond the traditional assumption of the agent of production “labour”. Co-workers in zone III are seen as “complex men” [ 7 ] with their own feelings, aspirations, likes and dislikes. They cannot be fully “managed” but require identifying a valuable goal, sense the meaning of their work and have a chance of personal development [ 29 ]. Table 2 shows some characteristics of effective leaders in zone II. We allocate the terms given by Rieckmann to the characteristics of zone III. It becomes obvious that the characteristics of a “good leader” in Dynaxity zone III focus on the ability to deal with dynamics, complexity, uncertainty and people. It is also obvious that no single leader can have all these abilities; i.e., management in zone III has a tendency to result in team-effort.

Characteristics of high dynaxibility. The allocations to the terms dynamics, complexity, uncertainty and people-orientation are marked with an X. Source: own, based on [ 11 , 12 ].

4. Applications

The healthcare sector of many countries is now in Dynaxity zone III. In this section, we will present different examples from the healthcare sector to underline our statements and show the impact of zone III for the management of healthcare services and systems as a call for more strategic management.

The first example follows the synchronic and diachronic phases of the pathways of German hospital financing and demonstrates the relevance of the Dynaxity model for this development. The second example provides a model of the development of innovative implants and, in particular, the need to reflect on the lifelong consequences of implants as the strategic dimension.

4.1. Hospital Financing in Germany

Figure 8 exhibits the phases of German hospital financing. We can distinguish five major phases [ 9 ]. Until 1936, hospital financing in Germany was almost free and did not have to follow any Governmental regulations. Health insurances funds negotiated rebates with the hospitals, which were based on daily rates and covered all costs (monistic financing). The system was functional for decades, but medical and social progress required more Government interferences. More and more services could be provided by hospitals and the costs exploded such that the national socialists interfered in the previously free hospital market and ordered a price stop. Hospital financing instruments (monistic and daily rate) remained unchanged, but the Government fixed the rules of calculating the rates. A consequence was that German hospitals could not follow international medical and technical developments. In 1948, the Government of Western Germany attempted to return to the original free system, but the prices exploded. Consequently, only six months later, the government interfered again and fixed the prices.

Phases of German hospital financing. Source own, based on [ 9 ].

During the first years after World War II, the prospering economy provided sufficient funds to finance hospitals (at least in Western Germany). However, the rapid technological progress of medicine as well as the first economic crisis after WWII in the 1960s placed pressure on the government to support hospitals financially. The solution was dual financing (1972), where the health insurance funds refund current expenditure while the government is responsible for funding the buildings, equipment and vehicles of hospitals irrespective of ownership. At that time, some people preferred returning to a government-free system, but dual financing strengthened the role of the government.

The innovative financing system was quite successful, but German hospitals remained quite inefficient in comparison to other countries. After reunification, Eastern German hospitals (which had had a budget-based hospital financing system since 1946) required tremendous funds to reach the Western German level such that the inefficiencies became a challenge. Consequently, policy makers searched for alternative financing regimes. Some wanted to return to the monistic system prior to 1972, but it was agreed that the system should remain dualistic but based on flat rates, which involved the so-called German Diagnosis Related Groups (G-DRG).

One consequence of this system was that the payment of the insurance schemes is a price that need to be paid and the hospitals decided how they could use this price to recover their costs. For different reasons, nurses became the piggy bank of hospitals; i.e., the number of nurses and their salaries declined in comparison to other cost items and staff categories. The result was a “nursing crisis”, which placed strong pressure on politicians. Some wanted to return to monistic financing, and others wanted to return to daily rates. The selected solution is a mixed financing regime where the cost of nursing is taken out of the G-DRG system and financed by a specific nursing budget while other recurrent costs are financed by flat rates. This system (called aG-DRG) was introduced in 2019 [ 30 ].

Based on Figure 8 , we can conclude that German hospital financing went through a number of synchronic and diachronic system regimes. The solution of the old crisis was frequently the seedling for the new crisis [ 31 ]; i.e., it is likely that the fifth phase is not the final endpoint but new phases will occur. During the five phases, the hospital financing system developed from Dynaxity zone I to zone III. The number of changes (expressed in major regulations for hospital financing) has steadily increased in the last 100 years. While there were hardly any major alterations in the first decades, there are currently several major changes per year. The dynamics has proceeded from static to turbulent.

At the same time, the system has become increasingly complex. Until the year 1983, hospitals produced only one single service unit, the bed day. From 1983 to 2003, hospitals (with some exceptions) were also financed by daily rates, but they were not calculated per bed day for the entire hospital, but for each department; e.g., a hospital with 10 departments had 10 different services. Since the introduction of G-DRGs as a compulsory financing system, hospitals have more services (year 2022), with almost 1300 different services. Thus, not only has the technology of medical services become increasingly complex but also the financing regime. Instead of having a one-product enterprise, we have a complex multi-product enterprise. There is no doubt that German hospital financing is in zone III and uncertainty with unexpected frequent substantial changes is a constant threat for hospital planning.

The introduction of G-DRGs was a major call for strategic management in German hospitals. While the annual budget was the pivotal unit in German hospital management before, DRGs forced management to think years ahead and to develop a production plan that allows fulfilling the function of the hospital and its survival on the market. Until 1983, hospitals in Germany could not make up a loss because the costs of previous years were refunded in the new year by calculating the daily rate accordingly. Even until 2003, it was rather difficult to run into a loss because, in most cases, the daily rates of the departments were calculated accordingly. However, since the introduction of DRGs, hospitals have to decide on the service portfolio, i.e., what products they want to offer for certain customers with certain needs. This is a new challenge for hospitals, and the answer to these questions goes far beyond the one-year-perspective.

A service portfolio is a typical instrument of strategic management that has only become relevant for hospital managers in the last decades. Until 1993, hospitals could not specialize on certain services but had to provide every service in their catchment area, which was obligatory at the level of the hospital. Currently, hospitals can specialize as long as the needs of the populations are covered. In the example of Figure 9 , the portfolio covers three departments (ENT, orthopaedic surgery and paediatrics) and analyses the marginal contribution and the number of competitors in the catchment area. The circles represent services, and the area of the circles is proportional to the turnover of this service.

Portfolio of a hospital. Source: own.

In this example, ENT has three different services. All of them have positive marginal contributions and should be sustained. Paediatrics has three services; two of them have a positive marginal contribution and one has a negative contribution. However, the latter is a unique service in the catchment area; i.e., it cannot be closed-down without bringing problems to the population. The other two services will have to subsidize this service. Orthopaedic surgeries also have a negative contribution, but none of them are unique in the catchment area. They can be closed without making patients suffer.

Portfolio analyses reduce complexity because norm strategies can be utilized for different constellations. Such a portfolio is highly relevant in zone III where short-term and deterministic solutions are not sufficient to cover the complexity and dynamics of the system. Instead, portfolios can be used as instruments of strategic management to make evidence-based decisions relative to the services provided.

4.2. Development of Innovative Implants

Therapy concepts with innovative implants are used more and more frequently in the treatment of chronic degenerative diseases, additionally reinforced by the high prevalence and further increasing incidence rate in the aging population [ 32 ]. In order to be able to meet these challenges adequately, a strategic approach in implant development management will be indispensable in the future.

From the initial idea of a physician or engineer of a new implant to the market-ready product and the implementation of the innovation as a standard therapy, there are many process steps to go through [ 33 ]. This includes phases of research and development, certification, reimbursement options and launch. The classic view of the implant development process ends with its adoption as a standard. However, improving the patient’s quality of life should play a decisive role in the development of innovative implants. Above all, the aim should be for the patient to use the implant for as long as possible after successful implantation. This adds a strategic dimension that expands the planning horizon by including the lifelong consequences of innovative implant.

For a long-term patient-centred perspective, specific aspects must be taken into account. First, the decision between doctor and patient of an implant must also be considered with regard to a benefit that may only occur later. Second, there should be an ethical assessment of the costs and benefits of current and future periods. Third, lifetime implants require more extensive clinical investigations and fatigue strength testing, which could create additional innovation barriers throughout the implant development process and need to be addressed.

In conclusion, a long-life perspective focused on the patient should be systematically integrated into the implant development process. This is based on several requirements for the implant, including durability, maintenance, interchangeability and compatibility with other implants and future therapies. In Figure 10 , an innovation model of the implant development process is shown, which embraced both strategic and operative management decisions. It enables a targeted orientation to the life perspective and an effective response to the high demands of an increasing residual lifetime after the first implantation.

Modified implant development process with long-life perspective. Source own.

Management in Dynaxity Zone III must take into account dynamics, complexity and uncertainty. As shown in the last section, this is already reflected in areas of healthcare. Another example is the high relevance of leadership in dealing with the COVID-19 pandemic. The greatly increased speed of interactions and the complexity of our societies require more strategic thinking when fighting pandemics than in previous centuries. Strategic COVID-19 management is not only a question of technical prognosis but also, in particular, is a question of communication, motivation and inspiration. The same applies to dealing with other “new” pathogens such as multi-resistant bacteria that healthcare facilities are confronted with today. A long-term strategy is required that takes into account the interactions between the various different health areas and the people actively addressed for networking.

5. Conclusions

It is obvious that the post-industrial society and economy are in Dynaxity zone III, which is characterised by high dynamics and complexity, which at the same time leads to an unknown degree of uncertainty without pausing stabilizing phases. Change is the “new normal”, and peaceful stability is the exception. The healthcare sector is no exception to this.

It must be understood that in today’s world is a system that cannot be fully described or analysed in a conventional manner as many new elements and dependencies are evolving and every action has an impact on many elements now and in the future. These challenges call for a response of the top management of nations, economies, health care services and all other institutions with a long-term perspective, consideration of interdependencies and synchronisation of different levels of plans. With the implementation of strategic management, the necessary long-term perspective is appropriately weighted and new analysis and planning tools are available. This has already been carried out in many areas of the health sector, as was demonstrated in this paper for several exemplifications. Other areas will inevitably follow.

At the same time, these new managerial and intellectual requirements pose a great challenge to our personal ability as human beings to design systems and organisations or to make meaningful decisions. The correct handling and use of information as well as the derivation of sustainable measures are prerequisites for strategic management, and employees are more indispensable than ever. Healthcare facilities such as hospitals must also be aware of this fact in their personnel policies and react to it. This includes investing in human capital by training and other educational opportunities to acquire comprehensive methodological and social skills. Ultimately, a completely new mindset and long-term and systematic thinking need to be established. What we require in health care—now more than ever—are co-workers with the ability to deal with complexity, survive under uncertainty, interrelate in networks and follow the values of health care with intrinsic motivation. Nobody has these strategic talents by nature, but we can foster, encourage and cultivate them in our collaborative cultures in the health care system.

Strategic management is based on strategic thinking. Consequently, any healthcare strategy must begin with a change in mindset or even the underlying paradigm. Strategic management is not primarily an application of management tools (although there is a lot to know and learn about these tools), but it is a mindset: the mindset for a dynamic, complex and stochastic postmodern world with ever-increasing speed, dependencies and uncertainty. These meta-parameters must come to mind for healthcare decision makers if they are to successfully manage change. Moreover, it helps to summarize these parameters in one concept or one word: Dynaxity. Therefore, knowing the fundamentals of Dynaxity can guide the thinking, decisions and actions of healthcare managers by directing their thoughts in the right direction.

Funding Statement

The project “Analyses of effectiveness and efficiency of regional MDRO-Networks—EARN” was funded by the BMG (grant: 2516FSB107). The ‘partnership of Innovation in Implant Technology (RESPONSE)’ was funded by the BMBF (grant 03ZZ0914C and 03ZZ0934A).

Author Contributions

Both authors have substantially contributed to the conception, writing and revising of the manuscript. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Data availability statement, conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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• Volume 4, Issue 9
• The role of hospital managers in quality and patient safety: a systematic review
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• Anam Parand 1 ,
• Sue Dopson 2 ,
• Anna Renz 1 ,
• Charles Vincent 3
• 1 Department of Surgery & Cancer , Imperial College London , London , UK
• 2 Said Business School, University of Oxford , Oxford , UK
• 3 Department of Experimental Psychology , University of Oxford , Oxford , UK
• Correspondence to Dr Anam Parand; a.parand{at}imperial.ac.uk

Objectives To review the empirical literature to identify the activities, time spent and engagement of hospital managers in quality of care.

Design A systematic review of the literature.

Methods A search was carried out on the databases MEDLINE, PSYCHINFO, EMBASE, HMIC. The search strategy covered three facets: management, quality of care and the hospital setting comprising medical subject headings and key terms. Reviewers screened 15 447 titles/abstracts and 423 full texts were checked against inclusion criteria. Data extraction and quality assessment were performed on 19 included articles.

Results The majority of studies were set in the USA and investigated Board/senior level management. The most common research designs were interviews and surveys on the perceptions of managerial quality and safety practices. Managerial activities comprised strategy, culture and data-centred activities, such as driving improvement culture and promotion of quality, strategy/goal setting and providing feedback. Significant positive associations with quality included compensation attached to quality, using quality improvement measures and having a Board quality committee. However, there is an inconsistency and inadequate employment of these conditions and actions across the sample hospitals.

Conclusions There is some evidence that managers’ time spent and work can influence quality and safety clinical outcomes, processes and performance. However, there is a dearth of empirical studies, further weakened by a lack of objective outcome measures and little examination of actual actions undertaken. We present a model to summarise the conditions and activities that affect quality performance.

• HEALTH SERVICES ADMINISTRATION & MANAGEMENT
• Systematic literature review
• Patient Safety

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/

https://doi.org/10.1136/bmjopen-2014-005055

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Strengths and limitations of this study

This is the first systematic review of the literature that has considered the evidence on Boards’ and managers’ time spent, engagement and work within the context of quality and safety. This review adds to the widely anecdotal and commentary pieces that speculate on what managers should be doing by presenting what they are actually doing.

The review reveals conditions and actions conducive to good quality management and offers a model to transparently present these to managers considering their own part in quality and safety.

The search for this review has screened a vast amount of the literature (over 15 000 articles) across a number of databases.

The small number of included studies and their varied study aims, design and population samples make generalisations difficult. With more literature on this topic, distinctions could be made between job positions.

The quality assessment scores are subjective and may not take into consideration factors beyond the quality assessment scale used.

Introduction

Managers in healthcare have a legal and moral obligation to ensure a high quality of patient care and to strive to improve care. These managers are in a prime position to mandate policy, systems, procedures and organisational climates. Accordingly, many have argued that it is evident that healthcare managers possess an important and obvious role in quality of care and patient safety and that it is one of the highest priorities of healthcare managers. 1–3 In line with this, there have been calls for Boards to take responsibility for quality and safety outcomes. 4 , 5 One article warned hospital leaders of the dangers of following in the path of bankers falling into recession, constrained by their lack of risk awareness and reluctance to take responsibility. 6 To add to the momentum are some high profile publicity of hospital management failures affecting quality and safety, eliciting strong instruction for managerial leadership for quality at the national level in some countries. 7 , 8

Beyond healthcare, there is clear evidence of managerial impact on workplace safety. 9–12 Within the literature on healthcare, there are non-empirical articles providing propositions and descriptions on managerial attitudes and efforts to improve safety and quality. This literature, made up of opinion articles, editorials and single participant experiences, present an array of insightful suggestions and recommendations for actions that hospital managers should take to improve the quality of patient care delivery in their organisation. 13–17 However, researchers have indicated that there is a limited evidence base on this topic. 18–21 Others highlight the literature focus on the difficulties of the managers’ role and the negative results of poor leadership on quality improvement (QI) rather than considering actions that managers presently undertake on quality and safety. 22 , 23 Consequently, little is known about what healthcare managers are doing in practice to ensure and improve quality of care and patient safety, how much time they spend on this, and what research-based guidance is available for managers in order for them to decide on appropriate areas to become involved. Due perhaps to the broad nature of the topic, scientific studies exploring these acts and their impact are likely to be a methodological challenge, although a systematic review of the evidence on this subject is notably absent. This present systematic literature review aims to identify empirical studies pertaining to the role of hospital managers in quality of care and patient safety. We define ‘role’ to comprise of managerial activities, time spent and active engagement in quality and safety and its improvement. While the primary research question is on the managers’ role, we take into consideration the contextual factors surrounding this role and its impact or importance as highlighted by the included studies. Our overarching question is “What is the role of hospital managers in quality and safety and its improvement?” The specific review research questions are as follows:

How much time is spent by hospital managers on quality and safety and its improvement?

What are the managerial activities that relate to quality and safety and its improvement?

How are managers engaged in quality and safety and its improvement?

What impact do managers have on quality and safety and its improvement?

How do contextual factors influence the managers’ role and impact on quality and safety and its improvement?

Concepts and definitions

Quality of care and patient safety were defined on the basis of widely accepted definitions from the Institute of Medicine (IOM) and the Agency for Healthcare Research and Quality Patient Safety Network (AHRQ PSN). IOM define quality in healthcare as possessing the following dimensions: safe, effective, patient-centred, timely, efficient and equitable. 4 They define patient safety simply as “the prevention of harm to patients”, 24 and AHRQ define it as “freedom from accidental or preventable injuries produced by medical care.” 25 Literature was searched for all key terms associated with quality and patient safety to produce an all-encompassing approach. A manager was defined as an employee who has subordinates, oversees staff, is responsible for staff recruitment and training, and holds budgetary accountabilities. Therefore, all levels of managers including Boards of managers were included in this review with the exception of clinical frontline employees, e.g. doctors or nurses, who may have taken on further managerial responsibilities alongside their work but do not have a primary official role as a manager. Those who have specifically taken on a role for quality of care, e.g. the modern matron, were also excluded. Distinction between senior, middle and frontline management was as follows: senior management holds trust-wide responsibilities 26 ; middle managers are in the middle of the organisational hierarchy chart and have one or more managers reporting to them 27 ; frontline managers are defined as managers at the first level of the organisational hierarchy chart who have frontline employees reporting to them. Board managers include all members of the Board. Although there are overlaps between senior managers and Boards (e.g. chief executive officers (CEOs) may sit on hospital Boards), we aim to present senior and Board level managers separately due to the differences in their responsibilities and position. Only managers who would manage within or govern hospitals were included, with the exclusion of settings that solely served mental health or that comprised solely of non-acute care community services (in order to keep the sample more homogenous). The definition of ‘role’ focused on actual engagement, time spent and activities that do or did occur rather than those recommended that should or could occur.

Search strategy

Literature was reviewed between 1 January 1983 and 1 November 2010. Eligible articles were those that described or tested managerial roles pertaining to quality and safety in the hospital setting. Part of the search strategy was based on guidance by Tanon et al . 28 EMBASE, MEDLINE, Health Management Information Consortium (HMIC) and PSYCHINFO databases were searched. The search strategy involved three facets (management, quality and hospital setting) and five steps. A facet (i.e. a conceptual grouping of related search terms) for role was not included in the search strategy, as it would have significantly reduced the sensitivity of the search.

Multiple iterations and combinations of all search terms were tested to achieve the best level of specificity and sensitivity. In addition to the key terms, Medical Subject Headings (MeSH) terms were used, which were ‘exploded’ to include all MeSH subheadings. All databases required slightly different MeSH terms (named Emtree in EMBASE), therefore four variations of the search strategies were used (see online supplementary appendix 1 for the search strategies). Additional limits placed on the search strategy restricted study participants to human and the language to English. The search strategy identified 15 447 articles after duplicates had been removed.

Three reviewers (AP, AR and Dina Grishin) independently screened the titles and abstracts of the articles for studies that fit the inclusion criteria. One reviewer (AP) screened all 15 447 articles, while two additional reviewers screened 30% of the total sample retrieved from the search strategy: AR screened 20% and DG screened 10%. On testing inter-rater reliability, Cohen’s κ correlations showed low agreement between AR and AP (κ=0.157, p<0.01) and between DG and AP (κ=0.137, p<0.00). 29 However, there was a high percentage of agreement between raters (95% and 89%, respectively), which reveals a good inter-rater reliability. 30 , 31 Discrepancies were resolved by discussion and consensus. The main inclusion criteria were that: the setting was hospitals; the population sample reported on was managers; the context was quality and safety; the aim was to identify the managerial activities/time/engagement in quality and safety. The full inclusion/exclusion criteria and screening tool can be accessed in the online supplementary appendices 2–3. Figure 1 presents the numbers of articles included and excluded at each stage of the review process.

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Review stages based on PRISMA flow diagram. 33

Four hundred and twenty-three articles remained for full text screening. One reviewer (AP) screened all articles and a second reviewer (AR) reviewed 7% of these. A moderate agreement inter-rater reliability score was calculated (κ=0.615, p<0.001) with 73% agreement. The primary reoccurring difference in agreement was regarding whether the article pertained to quality of care, owing to the broad nature of the definition. Each article was discussed individually until a consensus was reached on whether to include or exclude. Hand searching and cross-referencing were carried out in case articles were missed by the search strategy or from restriction of databases. One additional article was identified from hand searching, 32 totalling 19 articles included in the systematic review ( figure 1 ).

Data extraction and methodological quality

The characteristics and summary findings of the 19 included studies are presented in table 1 . This table is a simplified version of a standardised template that was used to ensure consistency in data extracted from each article. Each study was assessed using a quality appraisal tool developed by Kmet et al , 34 which comprised of two checklists (qualitative and quantitative). Random included articles (32%) were scored by Ana Wheelock for scoring consistency. All articles were scored on up to 24 questions with a score between 0 and 2; table 2 shows an example definition of what constitutes ‘Yes’ (2), ‘Partial’ (1) and ‘No’ (0) rating criteria. The total percentage scores for each study are presented in table 1 . All studies were included regardless of their quality scores. Some cumulative evidence bias may results from two larger data sets split into more than one study each. 35–38 Through a narrative synthesis, we aimed to maintain the original meanings, interpretations and raw data offered by the articles. 39

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Table of characteristics and summary findings of included studies

Example of rating criteria from Kmet's quality assessment tool 34

This section provides an overview description of the reviewed studies and their key findings. The findings are considered under four main headings: managerial time spent on quality and safety; managerial quality and safety activities; managerial impact on quality and safety; and contextual factors related to managers’ quality and safety role. The section ends with a proposed model to summarise the review findings.

Description of the studies

From the 19 included studies, the majority were carried out and set in the USA (14 studies) and investigated senior management and/or Boards (13 studies). Of these, 3 focused on senior managers alone (e.g. chief nursing officers), 9 concentrated on Board managers and 1 included a mixture of managerial levels. Only 3 investigated middle managers and 3 examined frontline staff (e.g. clinical directorate managers and unit nurse managers). The settings of the study were mostly trust or hospital-wide; a few articles were set in specific settings or contexts: elderly care, 40 evidence-based medicine, 41 staff productivity, 42 clinical risk management 43 and hospital-acquired infection prevention. 44 Two studies involved specific interventions, 45 , 46 and 7 studies concentrated specifically on QI rather than quality and safety oversight or routine. 35 , 40 , 45–49 There were a mixture of 6 qualitative designs (interviews or focus groups); 8 quantitative survey designs and 5 mix-methods designs. All but one study employed a cross-sectional design. 46 The primary outcome measure used in most studies was perceptions of managerial quality and safety practices. All reported participant perceptions and a majority presented self-reports, i.e. either a mixture of self-reports and peer reports, or self-reports alone. 41 , 43 , 45 , 46 Several studies asked participants about their own and/or other managers’ involvement with regard to their specific QI intervention or quality/safety issue. 40 , 41 , 44–47 With some variations, the most common research design was to interview or survey senior manager/Board members (particularly Board chairs, presidents and CEOs) perceptions on the Board/senior managers’ functions, practices, priorities, agenda, time spent, engagement, challenges/issues, drivers and literacy (e.g. familiarity of key reports) on quality and safety. 35–38 , 48–51 Five of these studies included objective process/outcome measures, such as adjusted mortality rates. 35 , 37 , 38 , 49 , 50 No other studies included clinical outcome measures.

The quality assessment scores ranged between 50% and 100%; one study scored (what we consider to be) very low (i.e. <55%), eight studies scored highly (i.e. >75%), two other articles scored highly on one out of two of their studies (quantitative/qualitative) and the remaining eight scored a moderate rating in-between. Almost half of the articles did not adequately describe their qualitative studies. Specifically, 8 failed to fully describe their qualitative data collection methods, often not mentioning a standardised topic guide, what questions were asked of participants, or no mention of consent and confidentiality assurances. In 7 studies there was no or vague qualitative data analysis description, including omitting the type of qualitative analysis used. Six of the studies showed no or poor use of verification procedures to establish credibility and 9 reported no or poor reflexivity. Positively, all study designs were evident, the context of studies were clear and the authors showed a connection to a wider body of knowledge.

Similarly to the qualitative studies, 7 quantitative studies did not fully describe, justify or use appropriate analysis methods. However, compared with the qualitative studies, the quantitative studies suffered more from sampling issues. Three studies had particularly small samples (e.g. n=35) and one had an especially low response rate of 15%. Participant characteristics were insufficiently described in 5 studies; in one case the authors did not state the number of hospitals included in data analysis. Several studies had obtained ordinal data but only presented percentages, and only one study reported to appropriately controlled for confounding variables. Across all articles, all but 3 studies reported clear objectives and asserted conclusions clearly supported by the data.

Managerial time spent on quality and safety

The studies on Board level managers highlight an inadequate prioritisation of quality and patient safety on the Board agenda and subsequent time spent at Board meetings. Not all hospitals consistently have quality on their Board agenda, e.g. CEOs and chairpersons across 30 organisations reported that approximately a third of all Board meetings had quality on their agenda, 35 and necessary quality items were not consistently and sometimes never addressed. 36 In all studies examining time spent on quality and safety by the Board, less than half of the total time was spent on quality and safety, 32 , 37 , 38 , 48–51 with a majority of Boards spending 25% or less on quality. 32 , 38 , 45 , 49–51 Findings imply that this may be too low to have a positive influence on quality and safety, as higher quality performance was demonstrated by Boards that spent above 20%/25% on quality. 49 , 50 Board members recognised that the usual time spent is insufficient. 48 However, few reported financial goals as more important than quality and safety goals, 32 and health system Boards only spent slightly more time on financial issues than quality. 51 Frontline managers also placed less importance and time on QI, 42 identified as the least discussed topic by clinical managers. 52

Managerial quality and safety activities

A broad range of quality-related activities were identified to be undertaken by managers. These are presented by the following three groupings: strategy-centred; data-centred and culture-centred.

Strategy-centred

Board priority setting and planning strategies aligned with quality and safety goals were identified as Board managerial actions carried out in several studies. High percentages (over 80% in two studies) of Boards had formally established strategic goals for quality with specific targets and aimed to create a quality plan integral to their broader strategic agenda. 32 , 37 Contrary findings however suggest that the Board rarely set the agenda for the discussion on quality, 37 did not provide the ideas for their strategies 32 and were largely uninvolved in strategic planning for QI. 48 In the latter case, the non-clinical Board managers felt that they held ‘passive’ roles in quality decisions. This is important considering evidence that connects the activity of setting the hospital quality agenda with better performance in process of care and mortality. 38 Additionally, Boards that established goals in four areas of quality and publicly disseminated strategic goals and reported quality information were linked to high hospital performance. 35 , 38 , 50

Culture-centred

Activities aimed at enhancing patient safety/QI culture emerged from several studies across organisational tiers. 44 , 47 , 48 , 53 Board and senior management's activities included encouraging an organisational culture of QI on norms regarding interdepartmental/multidisciplinary collaboration and advocating QI efforts to clinicians and fellow senior managers, providing powerful messages of safety commitment and influencing the organisation's patient safety mission. 47 , 53 Managers at differing levels focused on cultivating a culture of clinical excellence and articulating the organisational culture to staff. 44 Factors to motivate/engage middle and senior management in QI included senior management commitment, provision of resources and managerial role accountability. 40 , 46 Findings revealed connections between senior management and Board priorities and values with hospital performance and on middle management quality-related activities. Ensuring capacity for high-quality standards also appears within the remit of management, as physician credentialing was identified as a Board managers’ responsibility in more than one study. 38 , 48 From this review it is unclear to what degree Board involvement in the credentialing process has a significant impact on quality. 38 , 41

Data-centred

Information on quality and safety is continually supplied to the Board. 51 At all levels of management, activities around quality and safety data or information were recognised in 6 studies. 35 , 38 , 43 , 45 , 47 , 53 Activities included collecting and collating information, 43 reviewing quality information, 35 , 38 , 53 using measures such as incident reports and infection rates to forge changes, 53 using patient satisfaction surveys, 35 taking corrective action based on adverse incidents or trends emphasised at Board meetings 38 and providing feedback. 43 , 47 The studies do not specify the changes made based on the data-related activities by senior managers; one study identified that frontline managers predominantly used data from an incident reporting tool to change policy/practice and training/education and communication between care providers. 45 However, overseeing data generally was found to be beneficial, as hospitals that carried out performance monitoring activities had significantly higher scores in process of care and lower mortality rates than hospitals that did not. 38

Managerial impact on quality and safety outcomes

We have considered the associations found between specific managerial involvement and its affect on quality and safety. Here, we summarise the impact and importance of their general role. Of the articles that looked at either outcomes of management involvement in quality or at its perceived importance, 6 articles suggested that their role was beneficial to quality and safety performance. 32 , 35 , 38 , 40 , 49 , 53 Senior management support and engagement was identified as one of the primary factors associated with good hospital-wide quality outcomes and QI programme success. 35 , 38 , 40 , 49 Conversely, 6 articles suggest that managers’ involvement (from the Board, middle and frontline) has little, no or a negative influence on quality and safety. 35 , 38 , 41 , 42 , 44 , 49 Practices that showed no significant association with quality measures included Board's participation in physician credentialing. 35 , 38 Another noted that if other champion leaders are present, management leadership was not deemed necessary. 44 Two articles identified a negative or inhibitory effect on evidence-based practices and staff productivity from frontline and middle managers. 41 , 42

Contextual factors related to managers’ quality and safety role

Most of the articles focused on issues that influenced the managers’ role or their impact, as opposed to discussing the role of the managers. These provide an insight in to the types of conditions in which a manager can best undertake their role to affect quality and safety. Unfortunately it appears that many of these conditions are not in place.

Two studies found that a Board quality committee is a positive variable in quality performance, but that fewer than 60% had them. 38 , 50 Similarly, compensation and performance evaluation linked to executive quality performance was identified in 4 articles 35 , 37 , 38 , 49 and associated with better quality performance indicators, 38 , 49 but quality measures were insufficiently included in CEOs’ performance evaluation. 35 , 37 The use of the right measures to drive QI was raised in relation to Board managerial engagement in quality 35 and to impact on patient care improvement, 51 yet almost half of this sample did not formally adopt system-wide measures and standards for quality. To aid them in these tasks, evidence indicates the common use of QI measure tools, such as a dashboard or scorecard, 37 , 49 , 50 with promising associations between dashboard use and quality outcomes. 38 , 50

Other factors linked to quality outcomes include management–staff relationship/high interactions between the Board and medical staff when setting quality strategy, 49 and managerial expertise. Although a connection between knowledge and quality outcomes was not found, 38 high performing hospitals have shown higher self-perceived ability to influence care, expertise at the Board and participation in training programmes that have a quality component. 50 Disappointingly, there is a low level of CEO knowledge on quality and safety reports, 35 possibly little Boardroom awareness on salient nursing quality issues, 36 and little practice identified to improve quality literacy for the Board. 32 , 37 There is however promise for new managers through relevant training at induction and by recruitment of those with relevant expertise. 32

The quality management IPO model

The input process output (IPO) model is a conceptual framework that helps to structure the review findings in a useful way (see figure 2) . 54 , 55 This literature may be conceptualised by considering what factors contribute (input) to managerial activities (process) that impact on quality and safety (output). The three factors are inter-related and interchangeable, presented by the cyclical interconnecting diagram. This diagram enables a clearer mental picture of what a manager should consider for their role in quality and safety. Specifically, the input factors suggest certain organisational factors that should be put in place alongside individual factors to prepare for such a role (e.g. standardised quality measures, motivation, education and expertise, and a good relationship with clinicians). The processes present the strategy, culture and data-centred areas where managers (according to the literature) are and/or should be involved (e.g. driving improvement culture, goal setting and providing feedback on corrective actions for adverse events). The outputs identify managerial influences that are positive, negative or have little or no established association with quality performance (e.g. positive outcomes of care, achieving objectives and engaging others in quality of care). This helps to identify areas where it is possible to make an impact through the processes mentioned. With further empirical studies on this topic, this model could be strengthened to become a more robust set of evidence-based criteria and outcomes.

The quality management IPO model (IPO, input process output; QI, quality improvement).

Our review examined the role of managers in maintaining and promoting safe, quality care. The existing studies detail the time spent, activities and engagement of hospital managers and Boards, and suggest that these can positively influence quality and safety performance. They further reveal that such involvement is often absent, as are certain conditions that may help them in their work.

Evidence from the review promotes hospitals to have a Board quality committee, with a specific item on quality at the Board meeting, a quality performance measurement report and a dashboard with national quality and safety benchmarks along with standardised quality and safety measures. Outside of the Boardroom, the implications are for senior managers to build a good infrastructure for staff–manager interactions on quality strategies and attach compensation and performance evaluation to quality and safety achievements. For QI programmes, managers should keep in mind its consistency with the hospital’s mission and provide commitment, resources, education and role accountability. Literature elsewhere supports much of these findings, such as the use of quality measurement tools 21 , 56 better quality-associated compensation, a separate quality committee, 16 , 57 and has also emphasised poor manager–clinician relationships as damaging to patients and QI. 58 , 59

Some of the variables that were shown to be associated with good quality performance, such as having a Board committee, compensation/performance and adoption of system-wide measures, were lacking within the study hospitals. There are also indications of the need to develop Board and senior managerial knowledge and training on quality and safety. Furthermore, this review indicates that many managers do not spend sufficient time on quality and safety. The included studies suggest time spent by the Board should exceed 20–25%, yet the findings expose that certain Boards devote less time than this. Inadequacies of time allocated to quality at the Board meeting hold concerning implications for quality. If little time is taken to consider quality of care matters at the highest level, an inference is that less attention will be paid to prevention and improvement of quality within the hospital. While the position that the item appears on the agenda is deemed of high importance, it is unimportant if the duration on this item is overly brief. In this vein, the inadequate time on quality spent by some may reflect their prioritisation on quality in relation to other matters discussed at the meetings or the value perceived to be gained from discussing it further. It might instead however be indicative of the difficulties in measuring time spent on quality by management. Some of these studies provide us not necessarily with Board managers’ time on quality and safety but their time spent on this at Board meetings. The two may not equate and time spent on quality may not necessarily be well spent. 36 The emerging inference that managers greatly prioritise other work over quality and safety is not explicit, with further research required to identify what time is actually devoted and required from managers inside and outside of the Boardroom. Perhaps encouragingly, the more recent studies present more time spent on quality and safety than the earlier studies. Yet even the most recent empirical studies not included in our review conclude that much improvement is required. 60

This review presents a wide range of managerial activities, such as public reporting of quality strategies and driving an improvement culture. It further highlights the activities that appear to affect quality performance. Priorities for Boards/managers are to engage in quality, establish goals and strategy to improve care, and get involved in setting the quality agenda, support and promote a safety and QI culture, cultivate leaders, manage resisters, plan ahead and procure organisational resources for quality. Again, much of the findings support the assertions made in the non-empirical literature. Above all, involvement through action, engagement and commitment has been suggested to positively affect quality and safety. 61 While researchers have stressed the limited empirical evidence showing conclusive connection between management commitment and quality, 21 some supporting evidence however can be unearthed in research that concentrates on organisational factors related to changes made to improve quality and safety in healthcare. 62–64 In addition to this evidence, a few studies have specifically investigated the impact that hospital managers have on quality and safety (rather than examination of their role). These studies have shown senior managerial leadership to be associated with a higher degree of QI implementation, 65 promotion of clinical involvement, 66 , 67 safety climate attitudes 68 and increased Board leadership for quality. 57 A clear case for the positive influence of management involvement with quality is emerging both from the findings of our review and related literature.

Key messages from the systematic literature review

There is a dearth of empirical evidence on hospital managerial work and its influence on quality of care.

There is some evidence that Boards’/managers’ time spent, engagement and work can influence quality and safety clinical outcomes, processes and performance.

Some variables associated with good quality performance were lacking in study hospitals.

Many Board managers do not spend sufficient time on quality and safety.

There is a greater focus on the contextual issues surrounding managers’ roles than on examining managerial activities.

Research is required to examine middle and frontline managers, to take into consideration non-managers’ perceptions, and to assess senior managers’ time and tasks outside of the Boardroom. More robust methodologies with objective outcome measures would strengthen the evidence.

We present a model to summarise the evidence-based promotion of conditions and activities for managers to best affect quality performance.

Review limitations

There are several limitations of the present review pertaining to the search strategy and review process, the limited sample of studies, publication bias, and limitations of the studies themselves. Specifically, the small number of included studies and their varied study aims, design and population samples make generalisations difficult. Grouped demographics, such as middle management, are justified by the overlap between positions. With more literature on this topic, distinctions could be made between job positions. Furthermore, more research on lower levels of management would have provided a better balanced review of hospital managers’ work and contributions to quality. Restricting the language of studies to English in the search strategy is likely to have biased the findings and misrepresent which countries conduct studies on this topic. There is an over-reliance on perceptions across the studies, which ultimately reduces the validity of the conclusions drawn from their findings. As most of the study findings relied on self-reports, social desirability may have resulted in exaggerated processes and inflated outputs. Although, encouragingly, one of the included studies found that managers who perceived their Boards to be effective in quality oversight were from hospitals that had higher processes-of-care scores and lower risk adjusted mortality. The quality assessment scores should be viewed with caution; such scores are subjective and may not take into consideration factors beyond the quality assessment scale used. Owing to the enormity of this review, the publication of this article is some time after the search run date. As there is little evidence published on this topic, we consider this not to greatly impact on the current relevance of the review, particularly as the literature reviewed spans almost three decades. However, we acknowledge the need for an update of the data as a limitation of this review.

The modest literature that exists suggests that managers’ time spent, engagement and work can influence quality and safety clinical outcomes, processes and performance. Managerial activities that affect quality performance are especially highlighted by this review, such as establishing goals and strategy to improve care, setting the quality agenda, engaging in quality, promoting a QI culture, managing resisters and procurement of organisational resources for quality. Positive actions to consider include the establishment of a Board quality committee, with a specific item on quality at the Board meeting, a quality performance measurement report and a dashboard with national quality and safety benchmarks, performance evaluation attached to quality and safety, and an infrastructure for staff–manager interactions on quality strategies. However, many of these arrangements were not in place within the study samples. There are also indications of a need for managers to devote more time to quality and safety. More than one study suggest time spent by the Board should exceed 20–25%, yet the findings expose that certain Boards devote less time than this. Much of the content of the articles focused on such contextual factors rather than on the managerial role itself; more empirical research is required to elucidate managers’ actual activities. Research is additionally required to examine middle and frontline managers, non-manager perceptions, and to assess senior managers’ time and tasks outside of the Boardroom. We present the quality management IPO model to summarise the evidence-based promotion of conditions and activities in order to guide managers on the approaches taken to influence quality performance. More robust empirical research with objective outcome measures could strengthen this guidance.

Acknowledgments

The authors would like to thank Miss Dina Grishin for helping to review the abstracts and Miss Ana Wheelock for helping to assess the quality of the articles.

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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Files in this Data Supplement:

• Data supplement 1 - Online appendices

Contributors All coauthors contributed to the study design and reviewed drafts of the article. The first author screened all the articles for inclusion in this review and appraised the study quality. AR and Dina Grishin screened a sample of these at title/abstract and full text, and Ana Wheelock scored the quality of a sample of the included articles.

Funding This work was supported by funding from the Health Foundation and the National Institute for Health Research (grant number: P04636).

Competing interests None.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement The extraction table of the included studies and individual study quality scores can be made available on request to the corresponding author at [email protected].

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Essay on Hospital

500 words essay on  hospital.

Hospitals are institutions that deal with health care activities. They offer treatment to patients with specialized staff and equipment. In other words, hospitals serve humanity and play a vital role in the social welfare of any society. They have all the facilities to deal with varying diseases to make the patient healthy. The essay on hospital will take us through their types and importance.

Types of Hospitals

Generally, there are two types of hospitals, private hospitals and government hospitals. An individual or group of physicians or organization run private hospitals. On the other hand, the government runs the government hospital.

There are also semi-government hospitals that a private and organization and government-run together. Further, there are general hospitals that deal with different kinds of healthcare but with a limited capacity.

General hospitals treat patients from any type of disease belonging to any sex or age. Alternatively, there are specialized hospitals that limit their services to a particular health condition like oncology, maternity and more.

The main aim of hospitals is to offer maximum health services and ensure care and cure. Further, there are other hospitals also which serve as training centres for the upcoming physicians and offer training to professionals.

Many hospitals also conduct research works for people. The essential services which are available in a hospital include emergency and casualty services, OPD services, IPD services, and operation theatre.

Importance of Hospitals

Hospitals are very important for us as they offer extensive treatment to all. Moreover, they are equipped with medical equipment which helps in the diagnosis and treatment of many types of diseases.

Further, one of the most important functions of hospitals is that they offer multiple healthcare professionals. It is filled with a host of doctors, nurses and interns. When a patient goes to a hospital, many doctors do a routine check-up to ensure maximum care.

Similarly, when there are multiple doctors in one place, you can take as many opinions as you want. Further, you will never be left unattended with the availability of such professionals. It also offers everything under one roof.

For instance, in the absence of hospitals, we would have to go to different places to look for specialist doctors in their respective clinics. This would have just increased the hassle and waste energy and time.

But, hospitals narrow down this search to a great level. Hospitals are also a great source of employment for a large section of society. Apart from the hospital staff, there are maintenance crew, equipment handlers and more.

In addition, they also provide cheaper healthcare as they offer treatment options for patients from underprivileged communities. We also use them to raise awareness regarding different prevention and vaccination drives. Finally, they also offer specialized treatment for a particular illness.

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Conclusion of the Essay on Hospital

We have generally associated hospital with illness but the case is the opposite of wellness. In other words, we visit the hospital all sick and leave healthy or better than before. Moreover, hospitals play an essential role in offering consultation services to patients and making the population healthier.

FAQ of Essay on Hospital

Question 1: What is the importance of hospitals?

Answer 1: Hospitals are significant as they treat minor and serious diseases, illnesses and disorders of the body function of varying types and severity. Moreover, they also help in promoting health, giving information on the prevention of illnesses and providing curative services.

Question 2: What are the services of a hospital?

Answer 2: Hospitals provide many services which include short-term hospitalization. Further, it also offers emergency room services and general and speciality surgical services. Moreover, they also offer x-ray and radiology and laboratory services.

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MyHealthONE allows you to manage all parts of your healthcare easily and securely

• View health records - lab results, physician notes, imaging reports and more
• View your post-visit summary
• Schedule a follow-up appointment
• Share your health records with a physician or caregiver

Download the MyHealthONE app on the App Store® or Google Play