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Clipboard 2013 Issue 67 Issue 67 July - September

Clipboard A Quarterly Update on Management Issues from the Administrators Section of the Christian Medical Association of India Dear Members, Greetings from the Administrators Section of CMAI!


take this opportunity to invite you for the Biennial Conference which is to be held at Karunya University campus from 6th to 9th November 2013. Kindly make yourself available to attend this historic meet as we celebrate 100 years of nursing education in the country. To register, please download the form from www. and send it to me along with the applicable payment. A commemorative Souvenir will be released during the Conference. Incase you would like to advertise or sponsor, please contact me. Organizational structure refers to the way that an organization arranges people and jobs so that its work can be performed and its goals can be met. When a work group is very small and face-to-face communication is frequent, formal structure may be unnecessary, but in a larger organization decisions have to be made about the delegation of various tasks. Thus, procedures are established that assign responsibilities for various functions. It is these decisions that determine the organizational structure. A hospital management structure is indeed a challenge for any administration. The traditional method of hierarchy will not be applicable. For example a nurse has to take instruction from the Nursing Superintendent but at the same time she needs to follow and abide by the instructions issued by the duty doctor. This leads to complexity. Every time the doctor issues an instruction she cannot say “Contact the Nursing Superintendent”. In this issue we explore this challenge and examine the applicability of Matrix Management structure in hospitals. Please send in your comments and suggestions. Stephen Victor Secretary, Administrators' Section

Biblespeak Brokenness: Integral to Corporate Transformation 2 Timothy 3: 1-5 There is a long list of signs that St. Paul mentions as that of “terrible times in the last days” (vs1). Not much has changed in our present context as well, as many of these relate to our times. In one phrase, these are characteristics of godlessness, which can easily deter us from engaging in God’s purposes and plans. These have a definite impact within an institutional set up as well, where we relate to others. When one becomes “lovers of themselves, lovers of money, boastful, proud, abusive…” human relationships go through a redefinition, making us more isolated and a natural consequence towards a “do not disturb me” mindset. Our relationship with God is also redefined in the process, where it “has a form of godliness but denies its power” (vs5). We get into an act of ritualism, subconsciously perhaps, rationalizing and more importantly trying to prove ourselves before others of a practice of faith, which lacks the power of God. The power of God is foolishness to this world, will necessarily challenge our egos and put us in the context of brokenness. When was the last time we went through this essential phase of transformation in Christ!!! Regards, Fr. Thomas Ninan Acting Head, Department of Communications, CMAI

While a poor structure makes a high performance impossible, the best structure in the world will not ensure good performance

- Peter F. Drucker


Clipboard Issue 67

Organization Structure in Hospitals – Stephen Victor Why need an organizational structure


esus sent the disciples two by two into the villages with empowerment to heal the sick (Matt 10). They came back very excited and shared their experiences. Why didn’t Jesus send them in groups of three? There could be several answers for this question. From a management perspective we can infer that when three people go on a mission there needs to be an organizational structure which poses challenges to the operations. One of them has to be designated as the leader. This complication was evident when Paul and Barnabas traveled in missionary trips. The major dispute arose regarding inclusion of the third person (John Mark)! When an organization grows in number, the type of structure needed to successfully accomplish the purposes of the organization varies. This article explores these needs and an attempt is made to explain their applicability.

Limitations of traditional organizational structure

In the traditional methods of organizational structure the organization was doctor centric. The Chief Doctor was the head of the institution and everyone in the organization took direct instructions from him / her. However when the number of employees kept increasing, the “one man” organization became ineffective because of several limitations. The number of employees a supervisor can efficiently and effectively direct is 5 – 30 people. This


is clearly demonstrated in the life of Moses. Let me quote this instance from the Bible. “The next day Moses took his place to judge the people. People were standing before him all day long, from morning to night. When Moses’ father-in-law saw all that he was doing for the people, he said, “What’s going on here? Why are you doing all this, and all by yourself, letting everybody line up before you from morning to night?” Exodus 18: 13-26 Moses said to his father-in-law, “Because the people come to me with questions about God. When something comes up, they come to me. I judge between a man and his neighbor and teach them God’s laws and instructions.” Moses’ father-in-law said, “This is no way to go about it. You’ll burn out, and the people right along with you. Now listen to me. Let me tell you how to do this so that God will be in this with you. Be there for the people before God, but let the matters of concern be presented to God. Your job is to teach them the rules and instructions, to show them how to live, what to do. And then you need to keep a sharp eye out for competent men — men who fear God, men of integrity, men who are incorruptible — and appoint them as leaders over groups organized by the thousand, by the hundred, by fifty, and by ten. They’ll bring the hard cases to you, but in the routine cases they’ll be the judges. If you handle the work this way, you’ll have the strength to carry out whatever God commands you, and the people in their settings will flourish also.”

Moses listened to the counsel of his father-in-law and did everything he said. Moses picked competent men from all Israel and set them as leaders over the people who were organized by the thousand, by the hundred, by fifty, and by ten. They took over the everyday work of judging among the people. They brought the hard cases to Moses, but in the routine cases they were the judges.” As a result of this new organizational structure not only was Moses relieved but the whole nation was a satisfied lot. Justice was meted out earlier than having to wait for an appointment with Moses for long duration. A glimpse at the Structure i.e. 1050-100-1000 gives us a picture of the levels. Moses was placed at the fifth level. The Chain of Command was clear. Chain of Command is defined as “The continuous line of authority that extends from upper organizational levels to the lowest levels and clarifies who reports to whom” and Chain of Command Principle says “Subordinate should have one and only one supervisor to whom he/ she is directly responsible.”

Line and Staff functions in an organizational structure

A continuous line authority is easy to follow and there is no scope for confusion. However this model is applicable only for small organizations. For larger organizations another feature needs to be added to ensure its effectiveness. This is called Staff Authority which supports line authority by advising, servicing and assisting, but they needn’t be obeyed by the subordinate.

Clipboard Issue 67 This is explained by the following simple diagram.

work team, which brings together individuals who report to different parts of the company in order to complete a particular project or task. The term "matrix" is derived from the representative diagram of a matrix management system, which resembles a rectangular array or grid of functions and product/ project groups.

In the diagram the roles of the Medical, General and Nursing Superintendents are line functions because they directly report to the






Director. However the roles of the HR and Finance Managers are staff functions. The HR Manager will recruit, train and develop the staff of all the departments but they will not have a controlling role. The organization will run smoothly when these functions i.e. Line and Staff are clearly defined and demarcated. Line and Staff functions also have their limitations when the organization grows into a very large establishment. In such cases a structure called Matrix Management is required.

The origins of Matrix Management structure dates back to the early 1960s when a forNURSING SUPT malized matrix method called "unit management" was implemented by a large number of U.S. hospitals. Not until 1965, however, was matrix management formally recognized. The first organization to design and implement a formal matrix structure was the National Aeronautics and Space Administration (NASA). NASA developed a matrix management system for its space program because it needed to simultaneously emphasize several different func-

Matrix Management Matrix management is a technique of managing very large organizations (or, more commonly, part of an organization) through a series of dual-reporting relationships instead of a more traditional linear management structure. In contrast to most other organizational structures, which arrange managers and employees by function or product, matrix management combines functional and product departments in a dual authority system. In its simplest form, a matrix configuration may be known as a cross-functional

tions and projects, none of which could be stressed at the expense of another. It found that traditional

management structures were too bureaucratic, hierarchical, slowmoving, and inflexible. Likewise, basic organic structures were too departmentalized (i.e. myopic), thus failing to productively use the far-reaching expertise NASA had at its disposal. NASA's matrix solution overcame those problems by synthesizing projects, such as designing a rocket booster, with organizational functions, such as staffing and finance. Despite doubts about its effectiveness in many applications, matrix management gained broad acceptance in the corporate world during the 1970s, eventually achieving fad status. Its popularity continued during the 1980s as a result of economic changes in the United States, which included slowing domestic market growth and increasing foreign competition. Those changes forced many companies to seek the benefits offered by the matrix model. The below diagram shows a very simple matrix structure as applicable for hospitals. In a large hospital all the doctors report to the Medical Director and the nurses report to the Nursing Director. However when they go to the Inpatient Department or the Outpatient Department they need to work under the instructions of the persons managing that Department. Since their roles are defined and demarcated, there is very less scope for confusion.


Clipboard Issue 67

Doctorines in Jurisprudence Relating to Medical Profession

A few doctrines in jurisprudence relating to medical profession are discussed below

Vicarious liability


he dictionary meaning of vicarious is “something felt or experienced by watching or reading about somebody else doing something rather than by doing it yourself.” (Page 1442 Oxford Advanced Learner’s Dictionary) E.g. He got a vicarious thrill out of watching his son score the winning goal. Liability means “the state of being legally responsible for something.” It is usually declared in terms of money. E.g. The company is reported to have liabilities of nearly one crore. Therefore, vicarious liability means, in legal parlance, one person being liable for the negligent actions of another person, even though the first person is not directly responsible for the injury. For example, ‘A’ is a driver appointed by ‘B’ to drive the car from Coimbatore to Chennai. Due to his rashness and negligence, he causes an accident and a person ‘C’ dies due to that. Now, for rash and negligent driving, ‘A’ is booked under Section 304A of the IPC. In order to establish a charge of negligence under Section 304A of the IPC, it must be established that the death of ‘C’ was the direct result of negligence or rashness of the accused person ’A’.

half of their respective employers. Therefore, for the negligence committed by the employees, the employer is vicariously held responsible. Under the law of Torts, the Government alone is vicariously responsible for the negligence committed by its employees, especially by the doctors in government owned hospitals, while treating the public (State of Haryana vs. Smt. Santra, AIR 2000 SC 1888).

Eggshell skull rule The eggshell skull rule is a legal doctrine used in both tort law and criminal law. When a patient suffers from an inherent physical or psychological predisposition to a particular illness or injury, which has been activated by the damage inflicted by the medical practitioner, the patient is entitled to damages to the full extent of the injury, though it is exacerbated by the predisposition and thus sustains a much greater injury/damage than an ordinary individual would have experienced.

At the same time, ‘A’ was employed by ‘B’. ‘A’ was engaged for a specific wage. He was involved in an accident during the course of employment. ‘A’ would not have been involved in this accident had he not been employed by ‘B’. Therefore, the compensation should be paid to the legal heirs of ‘C’ (Victim) not by ‘A’ but by ‘B’ who employed him and for whom ‘A’ was discharging specific tasks.

The term implies that if a person had a skull as a delicate as the eggshell, and a tort-feasor or assailant who did not know of that condition were to tap the person on the head, causing the skull to break, the person responsible would be held liable for all damages despite the fact being unforeseeable. A medical practitioner (a tort-feasor) meets his patient as he finds him. If the patient (complainant) suffers personal injury from the wrongful act of the medical practitioner and the patient’s claim for damages cannot be argued that the patient would have suffered less injury, if he had not had an unusually thin skull or an unusually weak heart.

Likewise, the medical practitioners, nurses, paramedical staff are discharging their duties for and on be-

At the same time, the medical practitioner has every right to refuse treatment in certain conditions, e.g. if he


feels incompetent to treat a case, if patient does not adhere to his instructions which may lead to contributory negligence. But once the procedure/ treatment is started, the doctor has to take full responsibility for his patient’s condition. (An extract from Laws on Hospital Administration by Mr Samuel Abraham)


A CMAI publication focussing on issues related to hospital administration

Christian Medical Association of India Published by The General Secretary CMAI, Plot no. 2, A-3 Local Shopping Centre, Janakpuri New Delhi 110 058 Tel: (011) 2559 9991/2/3 E-mail: Website: CMAI Bangalore Office HVS Court, 3rd Floor 21 Cunningham Road Bangalore 560 052 Tel: (080) 2220 5464, 2220 5837 E-mail: Editorial Committee Dr Bimal Charles Dr Jeyakumar Daniel Mr Innocent Xess Sr Vijaya Mr Samuel NJ David Mr Edward David Dr CAK Yesudian Editor Mr Stephen Victor Design & Production Susamma Mathew Printer: Impulsive Creations

Clipboard July - September 2013  

Quarterly Update on Management Issues from the Administrators Section of the Christian Medical Association of India

Clipboard July - September 2013  

Quarterly Update on Management Issues from the Administrators Section of the Christian Medical Association of India