CHAPTER 1 INTRODUCTION

1.1. INTRODUCTION
the management asp The researcher, a student of Master of Hospital Administration has been introduced to ect of a 350 bedded hospital called Samaritan Hospital, Pazhaganad. Health is the fundamental right in the world. WHO defines Health is a state of complete physical, mental and social well being not merely an absence of disease or infirmity. Hospital as a complex organization has captured the imagination of the modem people-professionals and non-professionals alike. At one time, hospitals were more a refuge for the ill and needy than places for medical treatment. From these early beginnings the hospital continued through the nineteenth century to be a haven for the homeless and impoverished. The dramatic developments in medical science and technology in the late nineteenth and early twentieth centurys revolutionized the role and functions of the hospital. No longer is it a place for the ill and poor to go to die; it became the primary institution for treatment . Hospitals belong to that class of organisations which attempt. as their primary task, to alter the state of human material. Humans are self-activating, potentially recalcitrant, fragile and are invested with all sorts of characteristics provided by cultural definitions. Their self- activating naiure means that the work done on them must be performed under special circumstances designed to limit their ability to frustrate efforts to change. '' A hospital is basically, fundamentally and above all, a man system. It is a complex, human-social system. Its raw material is human. its product is human, its work is mainly done by human hands, and its objective is human-direct service to people, service that is individualised and personalised(Basi1 Georgopoulous, 1964). In this context hospitals definitely fall in the category of human service organisations. Basically the goals of the hospital can be classified as central goal, supportive

goals and extended goals. Central go31 is the ultimate goal of providing care to patients. Supportive goals are care and custf~dyw hich help to achieve therapeutic goal. The extended goals are education and research which we find in teaching hospitals. In an ideal hospital situation we need a suitabl: mix of custody, care, education and research to facilitate therapy. Advancing technology together with changing medical practices have created new and exciting goals. Hospitals typically employ a large number of professionals, both physicians and experts and have a high degree of specialisation of labour. They have developed distinctive structures, psycho social systems and management practices in order to accomplish their goals. Because of increasing need for coordination of specialised activities, managerial systems in hospitals have become more comprehensive. It is this factor that promoted the researcher to select the topic in the area of hospital administration. Hospitals are influenced by three factors: the cultural system which sets legitimate goals, the technology which determine:; the means available for reaching these goals, and the social structure of the hospital in which specific techniques are embedded in such a way as to permit goal achievement. The three factors are found interdependent(Char1es Perrow 1961). Technology influence structure- the arrangements necessarj to implement goals. Tasks are embedded in a structure. Structure too, can be a relatively autonomous element in organisations, just as belief' system and technology are relatively autonomous Structure can operate in an autonomous fashion, resisting or bringing about changes in

technology and in goals. In the present study this perspective is adhered to .Thus in this discussion, we can say hospital which is viewed as a complex organisation is concerned with three variables, goals( or in a broader sense, belief systems and values),technology (techniques necessary for the execution of the task) and structure (the arrangement of tasks and persons including lines of authority, responsibility and communication). They are interdependent rather than strictlj. independent or dependent upon one another. A probe into the organisational charactelistics both structural and functional aspects seems to be imperative at this juncture ba:jed on the assumption that apparent changes in structural and functional aspects woulc reflect in the functioning of the hospital. Present situation of Hospitals in India There are opinions that allege that hospitals are gradually becoming impersonal despite the fact that its purpose, approach and the main objective is to alleviate human sufferings. In some cases, it is argued that impersonaiity of this institution is due to higher dependency on technological sophistic:ation. From the administrative angles. hospitals in India are more tradition bound in their outlook and their approach to problen~sw hich they confront. The organisational structure c~fth e present day hospital is more monolithic and rigid in nature which does not lend itself to meet the changing demands of the medical care. These different versions of functioning of the present day hospital are indications to the fact that hospitals are becoming increasingly important centres for health care. The administrators or medical superintendents of the present day hospitals have

much less authority, power and discrelion than what is being enjoyed by his managerial counterparts in industry because hospilal is not and cannot very well be organised on the basis of single line of authority. The si~nultaneousp resence of lay, semiprofessionals and professional lines of authority in hospital create a number of administrative and managenlent problems. It is in this perspective that hospital is visualised as formal quasi-bureaucratic and quasi-authoritarian organisation which heavily relies on conventional hierarchical work arrangements rather than on rigid impersonal rules, regulations and procedures. But it is a highly departmentalized, highly professionalised and highly specialised organisational that cannot function effectively without relying heavily for its internal coordination the modification, action, self discipline and voluntary informal adjustments of many of its members. It is said that coordination of efforts in any hospital is in dispensable to organisational functioning , because no st of the work in the hospital situation is highly interaction in character. a. D~fferenriationo factivirie.~ Extensive differentiation and specialisation of activities are evident in the hospital. To do its work, the hospital relies on an extensive division of labour among its members. upon a complex organisational structure which encompasses many different departments, staffs, offices and positions, and upon an elaborate system of coordination of tasks. functions and social interactions". The tasks of the hospital are carried out by a large number of co-operating participants whose educational background. training, skills and functions are diverse and heterogenous. Much of the treatment task is performed by

the doctors , who require the ccllaboration and assistance of many paramedical professional personnel. The medic:al staff is specialized because of the growing complexities of medical technology. The nursing staff includes graduate professional nurses in various supervisory and non-supervisory positions, practical nurses and nurse's aides. In addition there are the hospital administrator and his staff, which include a number of supervisory personnel heading such departments and services as dietetics, admissions, maintenance, pharmacy, medical records, house keeping and laundry. Also, there dre medical technicians who work in the laboratories, x-ray departments and other units. Apart from these direct particip.mts in the hospital system, there is usually a board of trustees that has overall, institutions1 responsibility for the organisation. b. Administrative organisation and medical staff A major differentiation of acivities occurs because of distinction between the administrative organisation and the medical staff The administrative organisation is headed by the board of trustees, which appoints the hospital administrator as the chief executive. Under him are the various departmental directors who are in charge of functional activities such as medicztl records ,laboratories. dietetics. house keeping personnel records, public relations and accounting. The other part of dual differentiation is the medical staff, which is engaged in treatment or cure process. The medical staff is made up of licensed, practising, self governing physicians who are engaged in independent practice and are really "guests" of the hospital .The functions and relationships of the medical staff to other segments of the hospital are based on legal position of the doctor. The hospital as an organisation cannot

practice medicine. Only physicians are legally licensed to practice medicine on patients. The medical staff in the various hospitals are in almost complete charge of medical policies and medical practice. They have their own organisation within the overall hospital organisation, have their own constitution. rules and regulations and are in the main: self-disciplining bodies. They do have, however to abide with certain fundamental hospital policies and generally operating in a manner that would not jeopardize the accreditation of the hospital. c. Coordination ofactivities A high degree of differentiatifsn and specialisation creates critical problems of coordination in the hospital. Georgopoulos and Mann (1962) say "because of this extensive division of labour and accompanying specialisation of works, practically every person working in the hospital depends upon some other person or persons for the performance of his own organisationsl role". Specialists and professionals can perform their functions only when a considelable array of supportive personnel and auxiliary services is put at their disposal at all t mes. Doctors, nurses and others in the hospital do not and cannot function separately or independently of one another. Their work is mutually supplementary. interlocking and interdependent. In turn, such a high interdependence requires that the varicus specialized functions and activities of the many departments, groups and individual members of the organisation be sufficiently coordinated, if the organisation is to function effectively and attain its objectives. Consequently the hospital has developed a rather intricate and elaborate system of internal coordination. Without coordirlation, concerted effort on the part of its different members and continuity in organisational operations could not be ensured. The hospital is dependent very greatly upon the motivation of its members for the

attainment of good coordination. Formal organisational plans, rules, regulations and controls may ensure some minimum coordination, but of themselves are incapable of producing adequate coordination, for only a fraction of all the co-ordinative activities required in this organisation can be programmed in advance. One of the primary forces ensuring voluntary coordination is the overall value system emphasizing the patient's welfare. Changing scenario in hospitals The technological revolution c.arried with it a revolution in structure and goals (Berheim 1948; Freeman 1956; Lentz 1956; Perrow 1960; Wessen 195 l).Technological developments however had two cons:quences. First the new treatment and diagnostic facilities become the key resources of the hospital and had to be controlled by those who understood and used them - the doctors. Second with medical advancement, more private patients were treated in hospitals. Since doctors brought them in, he came to play a financial role in the hospital and coilld demand more say about hospital operation. Following the shift in power from trustees, representing community goals (charity goals), to doctors, representing the interests of their- business profession, there appears to be a of power to the administrative staff, perhaps in uneasy alliance with a revitalised trustee group. This shift in power (Perrow 1960, 1963) would appear to be a logical transformation for many hospitals, since the growing complexity of medical techniques requires increasing differentiation and nterdependence of units, coordination of resources

and personnel and rationalisation of -:he supportive structure. This leads to increasing importance of agency contacts, so that the administrator is in a position to influence internal affairs of the hospital through manipulating external relations (Perrow 1961, 1963). Finally with the growing impo-tance of administration, there has been a growing professionalisation of administrators. Social work professional are also working as administrators in hospitals. This theon:tical context emphasis the relevance of the present study on organisational climate in hojpital settings. This research work is based on the present situation of the hospital. The rtsearcher has attempted to understand the structural and functional factors of the hospital and felt that fostering changes in this direction aimed at realisation of the hospital goal would be meaningful and relevant in the area of hospital administration. Apparent changes in structural and functional factors of the hospital would help the hospital employees not to be impersonal in the behaviour and work in consensus with the main purp3se of hospital that is to alleviate human sufferings. Undoubtedly for the efficient running of hospitals it requires a great amount of resourcefulness, imagination , innovation and administrative tactics on the part of the staff or in other words, many problem may arise due to lack of proper planning, real motivation, proper communication and co-ordination among the team of personnel-in charge. Thus it is presumed that a systematic study and adequate understanding of the organisational characteristics would bc of immense use to practitioners and administrators in increasing the organisational effect..veness of the hospitals.

Friedson(l963) noted in his preface to a group of studies on the hospital that virtues of studying the hospital for social scientists are that it is ubiquitous, varies widely and significantly in its characteristics and is more accessible than most organisations. He said that variations in hospitals should provide an attractive impetus to comparative studies , although in fact there has been very few of these.

1.2.

THE PROFILE OF THE HOSPITAL

Samaritan Hospital situated 10 Kms east to Aluva and 25 Kms north east of Kochi in the state of Kerala. This hospital is the biggest unit of service in the medical field owned by religious congregation of the Sisters of the Destitute In our country, three quarters of our population are rural, yet three quarters of medical centers are spent in cities, where three quarters of the doctors live. So when the Sisters of the Destitute decided to enter the medical field, they close the villagers as their areas of their activity. From their past experiences they convinced that it is one of the best ways of sharing the love of God to the developing communities. Back in 1962, when sisters started a small dispensary in Pazhanganad, it was a remote village with little village road or transport facilities. Most of the villagers were agricultural labourers or farmers with small holdings of land. This

10

dispensary could handle minor medical needs of the locality. The needs of the community challenged the sisters to bring medical facilities to the villagers. Thus in 1969 a 70 bedded hospital, christened Samaritan Hospital was inaugurated in Pazhanganad. Fr. George Valyarambath and mother Rose Mary are considered as the founders of this hospital. The main objectives of the hospital are the following: To cater the health needs of the people without discrimination of caste, creed and religion. To give best possible health care facilities to all at affordable cost. The name Samaritan Hospital reminds one of the parables of Jesus told to teach us what kind of a neighbour and friend one ought to be. The hospital took the words of Jesus Christ, As you do unto the least of your brethren, you do it unto me (Mt.25/40) as its motto and guiding principle. Though it was initially planned to be a general hospital, the needs of people of the locality forced the management to extend the facilities to the specialties. Gradually separate departments of Internal Medicine, General Surgery etc. were started. The beginning of this well equipped hospital did not deter the sisters from their primary aim of serving the villages. They were conducting medical camps, health camps, immunization programmes etc. During these medical camps, the most important finding was that the incidence of heart disease, especially rheumatic heart disease, was high in the

11

villages. Poverty, lack of qualified medical aid in the rural areas are the reasons for such diseases. The hospital authorities after much deliberation and planning, decided to develop, the departments of Cardiology and Cardiac surgery in 1972 and these departments started providing much needed cardiac care which was not then available anywhere else in the state of Kerala. Open heart surgery was also done here for the first time in the state in that year.

1.2.1. LOCATION
The hospital is located in village Kizhakambalam, 10 km, from Alwaye, on the Alwaye Thripunithura road and about 25 km from Cochin. Public transport facility to reach the hospital is available from Alwaye, Cochin, Perumbavoor and Thripunithura.

1.2.2. MISSION OF THE HOSPITAL

The mission of the congregation is the care of the destitute and the care of the destitute and the sick irrespective of their religious convictions. The sisters began their ministry by setting up homes for the destitute, the aged and the sick. The congregation also operates homes for the dying and the terminally ill and for the rehabilitation of the mental and physically challenged. More than 300 members of the congregation are engaged in teaching in educational ministry.

1.2.3. OBJECTIVES
1. To make quality health services available affordable and accessible to all, especially in the underserved areas. 2. To promote health education, training and research.

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3. To manage, maintain and develop Samaritan Hospital and any other hospital or dispensary as a charitable organization and on a non-profit basis in the true spirit of Christian services, ideals and principles. 4. To co-operate and collaborate with the government and other agencies to make health care accessible to all. 5. To encourage multi dimensional programs on promotion of health and prevention of diseases in communities.

1.2.4. STRATEGIES
1. Effective collaboration with the government national and international agencies for accessing vaccines and medicines and for participating the various diseases control programs will be encouraged. 2. Patients and families will be counseled and enabled to comply with treatment regimens and prevention methods to control the transmission of disease. 3. Patients with HIV/AIDS, Tuberculosis, Leprosy and other debilitating diseases will be admitted and treated in the health care institutions with provision for treatment, including surgery. 4. The health care institutions will conduct awareness programs against smoking, alcohol and drug abuse. 5. The institution will encourage their staff and students to have a multi disciplinary approach to health care.

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1.2.5. PRESENT STATUS OF THE HOSPITAL

Bed strength of the hospital Number of departments in the hospital Number of Doctors 350 21 36 204 150275 16501 120 50 60

Number of staff including paramedical staff Average OP per month Average IP per month Major operations per month Minor operations per month Labour cases per month -

1.2.6. EDUCATIONAL INSTITUTIONS

School of Medical Laboratory Technology (1972) School of Nursing (1976) College of Nursing (2002)

1.2.7. ADMINISTRATIVE PROFILE

The administration of the hospital is done through different bodies.

1.2.7.1. GOVERNING BODY

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It consists of Superior General and General Council, Provincials, medical counsellors, director, administrator, Medical Superintendent, Nursing Superintendent, Principal of college of Nursing and Principal of Medical Lab Technology.

1.2.7.2. ADMINISTRATION BODY

The members of the administration body are Director, Administrator, Medical Superintendent and Nursing Superintendent.

1.2.7.3. INTERNAL MANAGEMENT BODY

Internal management body includes the Director, Administrator, Medical Superintendent, Nursing Superintendent, Principal of College of Nursing, Principal of Medical Lab Technology, Principal of School of Nursing and canteen-in-charge. The day to day activities of this hospital is running under the leadership of Director, Administrator, Medical Superintendent and Nursing Superintendent.

1.2.8. MAIN

CLINICAL

DEPARTMENTS

IN

THE

HOSPITAL
Cardiology Department Super specialty

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 General Medicine Department of Gynaecology Department of General Surgery Department of Ophthalmology Department of ENT Department of Paediatrics Department of Orthopaedic Surgery Department of Anesthesiology Department of Urology Department of Radiology Department of Dentistry Department of Emergency Medicine Department of Dermatology Department of Psychiatry Department of Pain and Palliative These are the main clinical departments in Samaritan Hospital Pazhanganad. These departments are functioning well.

1.2.9. SUPPORTIVE FACILITIES IN THE HOSPITAL

16

 Laboratory Pharmacy Physiotherapy Casualty House keeping ICU ICCU Neonatal ICU Surgical ICU Medical ICU Blood Bank Pathology CSSD Securities Ambulance Canteen Central Store X-ray

17

 ECG EEG Endoscopy Linen and Laundry Auditorium Hostels PRO TMT MRD These are the supportive facilities and departments in Samaritan Hospital, Pazhanganad. These departments and facilities help the doctors and clinical departments for their smooth functioning.

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CHAPTER 2 REVIEW OF LITERATURE

19

2.

REVIEW OF LITERATURE

2.1. INTRODUCTION
The role of the hospital has changed dramatically over the last two centuries. In the beginning, the aim was to isolate the sick and to protect the healthy from infection. By the nineteenth century, with the development of anesthetic, and antiseptic, the idea that hospitals were about life, care and cure, began to drawn. In any hospitals the inpatient services are of prime importance. Every in-patient unit should be designed to serve the functional goals. It should ensure The lowest possible operating cost The most efficient operation Provision for highest quality patient care

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 Provide the most desirable patient comfort and environment

Greatest degree of satisfaction for patient, relatives and staff.

2.2. EMERGING

TREND

OF

CHANGE

IN

THE

DELIVERY OF HEALTH CARE

During the current century, four major events have occurred to bring about to bring about a dramatic change in the delivery of health care. Economic and evolving payment mechanisms for health care. The explosive development in the knowledge base of the basic sciences upon which medicine rests. Rapid advances in medical technology. The increased sophistication, knowledge and behavior of patients. There are a number of change factors that will have a significant impact on the provision of health facilities in future such as biotechnology, information technology, medical technology, consumer expectation and new disease. The likely impact of these change factors can be explored at the level of the individual hospital departments, for example inpatient wards, hospital level or local district health authority level.

2.3. FUNCTIONS

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The functions of an inpatient unit are better understood by looking at the three primary components that constitute the unit, namely the patient rooms, the nurse control station and service areas. The patient area, which may consist of private and semi-private rooms and multi-bed general wards, is designed to be safe and aesthetically pleasing treatment area that is conducive to speedy recuperation. It must contain space for equipment, staff and the various needs of the patients. It should be located and designed in such way that the nurse can observe patient rooms and direct the traffic entering and leavening the unit and at the same time carry on the activities associated with the care and safety of the patients. The functions of the work area relate to handling materials necessary for the s have a patient care, handling and maintaining communications and patient records ,social and physical needs of patients and the specific needs of staff.

2.4. LOCATIONS
In patients units have a close with the operating rooms, pharmacy, central stores, laboratory and the dietary. In maintain this relationship; there highly depended on vertical transportation and an efficient communication system. The location of these facilities must be considered form the point of view of their relationship to the inpatient units.

2.5. DESIGN

22

The size of inpatient unit and the distribution of different categories of beds should be decided during the planning stage. Whether or not the unit should be a unitary ward serving one clinical unit under one consultant should also be decided at that time. Consideration should be given to the cost of construction of the unit, staffing requirement and the distance between the nursing station and patients rooms and supply points. Any duplication of facilities and equipment should be avoided. In short the unit should function efficiently.

2.6. PATIENT ROOMS

It is recommended that minimum size of a one- bed patient room be not less than 11.61 sq. meters (125sq.ft.) with a width of at least 3.81 meters (12.ft and 6 in). Many hospitals find it advisable to keep all one-bed rooms sufficiently large to accommodate two beds should be exigencies arise. This also provides flexibility to increase the bed capacity in the future. The two bed rooms should be at least 1.86 sq meters (160sq.ft.) in size and provided with cubicle curtains for visual privacy. The four bed rooms should have a minimum floor area of 29.722 sq. meters (320 sq. ft.) There should be at least 0.37 sq. meters (four feet) of space between the beds, and sufficient space between the bed and the wall to allow the nurse and equipment to pass. As a rule, patient bed should be placed parallel to the exterior window wall so that patient cannot only have visual contact with the outside world, they can also avoided looking at the wall or facing outside glare from the window .This principle is often given the go by for the sake of expediency.

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2.7. THE NURSES STATION

The nurses station is the pivot of the in-patient around which all the activities of the unit revolve. It should therefore be located as centrally as possible to the activities of the unit. It should be located near the entrance, elevator, stairway and the corridor, and provide optimal visibility of the patient wings.

2.8. WARDS SIZE AND CONFIGURATION

It is common to plan ward accommodation in multi-storied buildings, each floor plan resembling a template of the plan on the floor above. However many hospitals have inpatients areas horizontally spread in single or two story buildings linked by horizontal corridors. Although horizontal planning has limitations, it saves time in internal movements than is possible with a vertical inpatient block.

2.9. PROGRESSIVE PATIENT CARE

Due to increasing complexities of nursing procedures, technical advancement in medicine ,understanding the concept of hospital infection and changing expectations of patient, the nursing organization have undergone considerable change during the recent past; the design of the nursing unit has changed accordingly.

24

Nursing supervision is deliberately maximized in critical care units, where the patient is very ill and need for privacy is reduced. When the patient is getting better, observation can be reduced. Gradually, the recovering patient is transferred to a medically less sophisticated unit. Different kinds of units that offer varying degrees of patient adjusted care are replacing standard nursing units. A system of progressive patient care has been adopted in most hospitals which has a considerable effect on nursing unit design. Under the system, the inpatient area is divided into various sections based on the intensity and type of nursing care required which are as follows.

2.9.1. Intensive care

The intensive care unit is for patients in acute stage of illness who are unable to communicate their needs. They require continuous observation and extensive nursing care with personnel specially trained for the job. The aim is to first support life in crisis, prevent threat to life, and then to eliminate the cause of dysfunction by specialized treatment and extensive nursing care. There for, the unit is equipped with life saving equipment, and all necessary life saving drugs and supplies are immediately available.

2.9.2. Intermediate care

The intermediate care unit is for patients who are moderately ill including patients transferred from intensive care unit who require moderate amount of nursing care. A large proportion of all hospital patients will be directly admitted to this unit.

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2.9.3. Self care

The self care unit is for those patients who, after acute phases of illness is over, or are admitted for diagnostic procedures and are able to look after themselves. Nursing care required for this category of patients will be minimal.

2.9.4. Long time care

The long time care unit is for patients requiring prolonged nursing care and services not normally available at home, including adjustment to disabilities by physical and rehabilitation therapy. The basis of progressive patient care system is the amount of and type of nursing care required and the degree of dependence of the patient on others. The design of the nursing unit and facilities to be provided differ from intensive care through intermediate, self and long term care units. However it is debatable whether the system results in economy in bed utilization because, if each section is capable of taking only patients of a particular category, bed utilization would get adversely affected due to fluctuations in demand in each category.

2.10.

FACTORS LEADING TO EFFECTIVE OR

INEFFECTIVE HOSPITAL CULTURE

A review of studies made by several authors in India and abroad shows that there are some common characteristics of every effective and ineffective of

26

organization. In other words, presence of certain factors results in success and lack of these results in hospital failure. These factors are

2.10.1. Care of customers/patients

Excellent organizations take exceptional care of their customers, be they patients, or students in academic institutions or public, or industries for consumer and industrial product. These organizations believe in superior services, and superior quality. The organizational value systems from top to lower levels, encourage knowing the consumer or patient, invites their inputs in planning products or services, or various aspects.

2.10.2. Constant search for creativity and innovation

Excellent organizations constantly believe in creativity and innovation. The organizational leaders managers and professionals consistently keep in contact with the development in the environment and seek ideas from their employees and customers to upon the product and services. These organizations, continuously adapt to the changing environment in terms of introduction of technology, processes, packaging, distributions etc. They also continuously experiment with management and job, designs techniques which can result in more effective utilization of human resources, provide greater job satisfaction, and utilize more knowledge and skills.

2.10.3. Continuing planning process

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Effective organizations are continuously engaged in planning .solid planning is a necessity. Keeping in view the internal and external demands as well as resources, effective organizations continuously plan. To decide what the goals should be, what the priority should be, what new markets to reach, what new services to begin, how to introduce new technologies ,how to change the

processes, what new materials can be used, what additional sources of material are available? In what directions should the organization diversify? How to implement the governments policies and provisions? How best to exercise the social responsibility of the business?

2.10.4. Worker participation and worker commitment

Efficient organizations believe in creating a work environment and culture for a highly committed work force. Such hospitals are able to create work environment and culture where people like to work, realize their knowledge and skills, utilize their creativity and feel a sense of belongingness. This results in an atmosphere of turned on people. The organization constantly works with each employee as to how more or better the employee can contribute.

2.10.5. Sound financial controls

Excellent organizations have sound financial controls. Since financial are limited and are the determining factors in the nature and extent of operations, sound financial planning is necessary.

2.10.6. Leadership

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Excellent or effective organizations have leadership at various levels which enables planning and implementations of the above factors- a leadership which has values of the leaders result in utilization of the resources and adaptability to the environment .the leaders provide the hospital with a vision that the hospital may be able to achieve. Leadership means vision, trust, compassion and developing leadership in the younger generation for the organizational renewal and continuity.

2.10.7. Organizational results

structure

for

Excellent organization have organizational structures which are appropriate to the needs of the organization, which are goals and objective oriented ,which enable effective communication, coordination, delegation, effective utilization of resources , feedback, adaptability and flexibility.

2.11.

CHANGING SYSTEM OF HEALTH SERVICES

CONCEPTS
Hospitals have undergone a remarkable change both in the industrialized nations and developing countries. They are, or should be dynamic institutions and in any society the only thing constant are change. The hospitals have to adopt a concept of providing Primary Health Care (from the centre of excellence to community support). Directly or indirectly, every person from birth

29

to death, at one time to another, pins hope on the positive outcome of the health services, these institutions provide. There has been very rapid change in last three decades in functioning of hospitals due to technological advances and knowledge explosion which had direct bearing on patient care. For example Emergence of corporate hospitals. Hospital-based approach to group practice and Role of hospital in primary health care. Now- a-days lot of importance is to quick turnover of patients to reduce cost and thus to save many. To supplement the hospital cost, various types of insurance programmes are also offered. Costly diagnostic services cannot be provided, in all hospitals. Thus, there should be proper choice of place and services to be rendered. Tertiary care cannot be provided in all places due to high cost and lack of availability of trained manpower.

2.12.

PATIENT SATISFACTION
Patient satisfaction can be the ultimate goal of some hospitals or means

to achieve an ultimate goal, for example, a mission hospital may be ultimately committed to healing; a corporate hospital for profitability and a steel plant ultimately concerned with production of steel. However, the health workers in an institution are committed to providing best health care. The following are the organizational and management factors and the factors from patients perspective which contribute to patient satisfaction.

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2.12.1. Organization factors

and

management

Philosophy and value systems of the Hospital/Management

Congenial atmosphere and importance for patient care Infrastructure for health care Quick and efficient handling procedure Being treated as a human being Efficient staff Periodic communication about illness and recovery, participation in decision making Information about cost-benefit Efficient and appropriate billing systems Warm feeling of send-off Get well and Thank You Notes Accessibility, transport, accommodation for relatives.

2.12.2. Key to patient satisfaction

Criticalness of the disease Caring waiting ,attending Concern for welfare-Empathy-Love Communication to patient and relatives Comfort cheerful atmosphere Closeness-Distance Cost of care

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 Competency of the doctors-nurses Cooperation from staff and relatives Cleanliness of the hospital.

2.13.

DOCTOR-PATIENT

RELATIONSHIP

TOWARDS PATIENT SATISFACTION

The central element in medical practice is the interaction between the health care providers in the hospital which consists of the physician, nurse, patient relatives and the patient which leads to effectiveness of the medical care and satisfaction of the patient. The following are the factors influencing the interaction, the role of physician, and opinions of the patients regarding the effectiveness of the patient physicians and nurses.

2.14.

FACTORS INFLUENCING THE PHYSICIAN-

PATIENT RELATIONSHIPS
In a doctor patient relationship, the patient is emotionally dependent upon the doctor. In a state of illness the patient cannot behave logically and the doctor must take this into account. The physicians are supposed to treat patient alike, equal in matters of health illness. The physicians has the privilege to examine patients physically and to question the about intimate details of their private lives.

32

The doctor is expected to be neutral in judgment and to exercise emotional control. The doctor is supposed to treat the patient according to the patients needs and the health standards of the community. The physician is expected to maintain a dynamic balance, between attitudes of the detachment and concern. According to Dr. G.S. Ambedkar, a Senior Anesthesiologist of India, the doctor by the unique nature of his profession, can cultivate lifelong friendship; soft words of reassurance, gentle stroking of the hands of a frightened patient, are enough to mitigate fears, especially when the patient is to undergo surgery. The effectiveness of the professional dependents primarily on the knowledge, sincerity of purpose and capacity to develop patients faith. Mutual understanding goes a long way in doctor-patient relationship.

2.15.

EXPECTATIONS OF THE PATIENT FROM THE

PHYSICIAN AND THE HOSPITAL

The patient and the relatives expect the physician or the hospital to play the role of an enabler to enable the patient to move from:

State of sickness to health State of pain/aches to no pain State of dependence to autonomy or independence State of passivity to activity State of hope to hope

33

 State of anxiety and worry to no anxiety/no worry State of submissiveness to assertiveness State of cheerfulness to smiling and cheerfulness From a feeling of not being alive to being alive State of no energy to being energetic. The degree to which the physician/nurse/or the hospital can play this enabling role would influence effectiveness of the institution.

2.16.

TRAITS OF GOOD PHYSICIANS/NURSES

Series of survey studies conducted by many organizations with

outpatients and inpatients of over 50 hospitals in different parts of the country indicate that the traits of good physicians/nurses are: Doctor/Nurse take interest in the patient and in the welfare of the patient Gives implications of test results Explains about the seriousness of the disease Information given is truthful ,honest, and sincere Is available and accessible Is listening and sympathetic Is kind and sympathetic Gives hopes and encouragement Is intelligent, has knowledge, skills and training Inspires confidence Has human nature and treats others as a human being Is kind hearted

34

In doctor patient relationship, there is a need for mature interdependency. The physician or the nurse must be compassionate. According to the Block of Mathews (1, 4-14), Jesus went forth, and saw a great multitude, and was moved with compassion towards them, and he healed all the sick. According to His Holiness, Dalai Lama, the power of compassion is the healing factor. According to Dr. N.H. Anitha, if the doctor has compassion, even with modest and poor facilities, he can do a lot towards healing and health. Mutual understanding goes a long way in doctor patient relationship. The patients own courage faith and psychological status also play an important role in the management of a disease and in the healing process.

2.17.

CONCLUSION
Whatever be the reasons every hospital has to continuously plan,

asses, monitor, director and control related activities so as to ensure full satisfaction of the patients. The best judge is the client himself and the best advertisement is mouth to mouth advertisement. Hence analysis of patient satisfaction is essential to make the services effective and efficient.

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CHAPTER 3 RESEARCH METHODOLOGY

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3. RESEARCH METHODOLOGY

3.1.

TITLE A study on organization climate in Samaritan Hospital, Pazhaganad.

3.2. 3.2.1.

OBJECTIVES GENERAL OBJECTIVE To study about organization climate in Samaritan Hospital, Pazhaganad.

3.2.2.

SPECIFIC OBJECTIVES

To assess the present satisfaction level of the in-patients of Samaritan Hospital, Pazhaganad. To analyze the activities of the in-patient departments. To suggest improvement, if any, for the betterment of the inpatients departments. 3.3. STUDY DESIGN It is a descriptive study as it is concerned with estimation of the satisfaction of in-patients in Samaritan Hospital, Pazhaganad. The investigator is trying to obtain data by means of survey of in-patients.

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3.4.

DEFINITIONS

3.4.1.

THEORETICAL DEFINITIONS

3.4.1.1. In-Patient In-patient is a person who is admitted in the hospital for the care and cure of an ailment through the diagnostic, therapeutic or preventive services of the hospital. 3.4.1.2. Satisfaction According to Revised and Updated Illustrated Oxford Dictionary satisfaction means the state of being pleased or contended. It refers to the positive emotional response that individuals and groups have about the fulfillment of a need or desire.

3.4.2.

OPERATIONAL DEFINITIONS

3.4.2.1. In-patient In-patient means a person who is admitted in the hospital for the care and cure of an ailment through the diagnostic, therapeutic or preventive services of Samaritan Hospital, Pazhanganad. 3.4.2.2. High Satisfaction A score between 4.2 and 5 in the survey result towards a particular variable, question or statement is indicative of being highly satisfied with that variable, question, or statement. 3.4.2.3. Satisfaction

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A score between 3.4 and 4.2 in the survey result towards a particular variable, question or statement is indicative of being satisfied with that variable, question, or statement. 3.4.2.4. Moderate Satisfaction A score between 2.6 and 3.4 in the survey result towards a particular variable, question or statement is indicative of being moderately satisfied with that variable, question, or statement. 3.4.2.5. Dissatisfaction A score between 1.8 and 2.6 in the survey result towards a particular variable, question or statement is indicative of being dissatisfied with that variable, question, or statement. 3.4.2.6. High Dissatisfaction A score between1 and 1.8 in the survey result towards a particular variable, question or statement is indicative of being highly dissatisfied with that variable, question, or statement.

3.5.

UNIVERSE The In-patients of Samaritan Hospital, Pazhanganad for the period from

the 13th to 27th Sep. 2010 is the universe of the study.

3.6.

SOURCE OF THE DATA

Source of Primary Data

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Nurses of Samaritan Hospital and In-patients of Samaritan Hospital from the period of 13th to 27th Sep. 2010. Source of Secondary Data Internal records, registers and journals are available in the hospital.

3.7.

SAMPLE DESIGN In this study multi-phase sampling was used.

3.7.1.

Stratified Sampling As far as the in-patients are concerned stratified sampling is the most

appropriate method to get response for every department. Since data for each department is to be got, stratification according to department was essential. There are 13 departments in the hospital [except Casualty, Psychiatry and Aneasthesiology]. Therefore, stratified sampling was used. 3.7.2. Systematic Sampling After the stratification of inpatient department, systematic sampling was used. Every 3rd patient in the daily schedule of the mid night census book of each ward chosen as the sample till the representative sample of that department was got.

3.8.

SAMPLE SIZE

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The rule of the thumb sample size is 10% of the population. The hospital has got a yearly in- patient of around 15100. During the period of study 15 days there can be 620 patients getting admission in the hospital. Since the rule of the thumb sample size works out to be 62 in-patients as far as the 15 days of the study is concerned. Yearly IP = 15100 IP for 15 days = (15100*15)/365 = 620.55 10% of IP = 62 Accordingly it was calculated for each department. Table no.1 showing the process of determination of representative sample Sl. No. 1. 2. 3. 4. 5. Cardiology Dental Dermatology ENT Gen. Medicine I Department IP 2009 2509 7 6 194 2643 IP For 15 Days 103.11 0.28 0.26 7.97 108.62 10.311 0.028 0.026 0.797 10.862 10% Representative sample 10 3 3 3 11

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6. 7. 8. 9. 10. 11. 12. 13.

Gen. Medicine II Gen. Medicine III Gynaecology Ophthalmology Orthopaedics Paediatrics Gen. Surgery Urology Total

3091 105 1695 75 840 2601 928 391 1508 5

127.02 4.31 69.6 3.08 34.5 106.8 38.1 16.06

12.702 0.431 6.96 0.308 3.45 10.68 3.81 1.606

13 3 7 3 4 11 4 3 78

3.9.

SAMPLE SELECTION Sample is chosen on department wise. Every 3rd patient in the daily

schedule of the mid night census book of each ward chosen as the sample till the representative sample of that department was got.

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3.10. TIME BUDGET Table no.2 showing the preparation of time budget

Particulars Topic Selection Tool Preparation Pilot Study Data Collection Processing of Data Report Writing

No. of days 3 10 1 14 15 15

3.11. PILOT STUDY A pilot study was conducted on the first day of the study. Five patients were administered with the interview schedule. The method of sample selection before pilot study was to select every 3rd patient admitted on the day of study in each department. While interviewing the patient two of them opined that they had been admitted in the hospital for the first time and they did not have much experience about the hospital. So the methodology was changed and every 3rd patient in the schedule of the mid night census was taken. Questionnaire was found to be appropriate.

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3.12. METHOD OF DATA COLLECTION 3.12.1. INTERVIEW SCHEDULE An interview schedule is prepared to evaluate the opinion of In-Patients. The interview schedule has questions on demographic factors, common services provided in the hospital, nursing services, medical services, dietary services, housekeeping services, accommodation facilities and other services. There are 41 questions divided into five parts. The first part consists of 11 questions on demographic factors and the second part consists of 7 questions on the common service provided. The third part shows four subdivisions on nursing services, medical services, dietary services, housekeeping services, accommodation facilities and other services and 23 questions on the subdivisions. The fourth part deals with the causes of selecting the hospital for treatment and the fifth part is regarding recommendations of improvement.

3.13. PROCESSING AND ANALYSIS OF DATA 3.13.1. EDITING

No editing was needed as it was a fully structured interview schedule. 3.13.2. CODING

The responses of the interview schedule were five types namely very good, good, average, bad, very bad which were marked as A, B, C, D & E respectively in the interview schedule. These responses were assigned the numeral of 5, 4, 3, 2 & 1 for A, B, C, D & E respectively. 3.13.3. CLASSIFICATION

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The questions were already classified into group as discussed in methods of data collection. So the response is also classified in the same manner.

3.14. TABULATION It is the process of summarizing raw data and displaying the same in the form of statistical table for further analysis. In this study the researcher must find. Total average score Variable wise average score Question wise average score Department wise average score Demographic factors wise average score.

3.15. CALCULATION OF RESPONSES A score between 1&1.8 - High Dissatisfaction

A score between 1.8&2.6 - Dissatisfaction A score between 2.6&3.4 - Moderate Satisfaction A score between 3.4&4.2 - Satisfaction A score between 4.2&5 - High Satisfaction

3.16. INTERPRETATION & REPORT WRITING

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3.16.1.

Interpretation

The data as per the above tables were interpreted by the investigator and report is prepared. 3.16.2. Report Writing

The report is divided into five chapters. The first chapter deals with general introduction. Second chapter is on Literature Review. The third chapter deals with methodology and fourth chapter deals with analysis of the in-patient satisfaction survey. The fifth chapter deals findings and suggestions.

3.17. LIMITATIONS In the departments like ENT, Gen. Medicine III and Ophthalmology every patient admitted in the hospital was chosen as the number of admissions during the period of study was less than the representative sample of the study. Departments of Dental, Dermatology and Urology did not have any admission during the period of study.

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