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Clipboard Issue 46 & 47 Conclusion


So far we discussed communication in hospital management within the hospital. But hospital administrator has to maintain effective communication with external stakeholders like community/ church leaders, government agencies, patient relatives, suppliers of materials and service providers. Management takes decisions, deploys resources and gets the work done. In all these areas communication plays an important role. A good decision that is not communicated effectively cannot be implemented. Human resource deployment will be effective only when people who are deployed in various areas of the hospital communicate with each other effectively. etting the work done is predominantly communicating with subordinates continuously formally and informally so that people behave in a way that leads to the achievement of the hospital goals. The hospital administrator should know when to use the formal and informal communication with the staff. There is a definite work process in the hospital, which follows the formal communication channels. ikewise the informal communication too is vital to create a working environment, where the employee finds a sense of belonging and participates voluntarily in achieving the hospital goals.

Author CAK Yesudian, PhD, Dean, School of Health Systems Studiesm Tata Institute of Social Sciences Mumbai - 400088


Issue 46 & 47 April-September 2008

Laws on Hospital Administration

The book will prove to be useful to hospital administrators, doctors, lawyers, paramedical staff and students of medical sciences. The key author of this book is Mr Samuel Abraham


or queries please contact si ebaka Secy.,Administrators Section

Clipboard A CMAI publication focussing on issues related to hospital administration

Christian Medical Association of India

This book contains parts a Meial essial a is ses ei eileal ases b Cse a a is appli abili spials Ipa ab las ap pliable spial aiisa i The first part discusses various laws relating to Medical Professionals and an introduction to the udicial setup. It also elaborates on Environmental aws applicable to hospitals including biomedical waste. The second part deals with the aw of Torts, Medical Negligence and Ethics, Consent orms, Bolam test, the various Consumer Tribunals incorporated in the Consumer Protection Act 86. It also highlights important cases with landmark judgements. The book also features the various abour laws which are applicable to hospital administration including Industrial ispute Act 47. Important judgements in connection with labour jurisprudence are also dealt with. An added attraction is the exclusive chapter on AS requently Asked uestions.

blise b The eneral Secretary CMAI, Plot no. 2, A- ocal Shopping Centre, anakpuri New elhi 0 08 Tel 0 2 /2/ E-mail Website CMAI Baale ie HS Court, rd loor 2 Cunningham oad Bangalore 60 02 Tel 080 2220 464, 2220 87 E-mail iial Ciee r ijay Aruldas Mr eyakumar aniel Mr Innocent ess Sr ijaya Mr Samuel N avid Mr Edward avid r CA Yesudian Mr ohn Churchill i Mr ustin ebakumar iial Cia Ms Suba Priya abindran esi i ata Anthony ie Seema Printing Press

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

Dear Members Members,,


oday we live in a world of "Instant". Whether it is coffee, tea or even Biryani, it all comes in packages. Have you ever thought why these had ever come into existence? None of our grandparents or even parents dreamed of an "instant" world like this generation sees today. We live in a world that has made life easier and stress free, yet we hear the same old phrase "I have too much of work…I am stressed out”. Most institutions like Harvard, Mayo Clinic and Cleveland Hospital which are mighty pillars in healthcare are on the continuous process of conducting consultations on ways and means of improving productivity. Productivity has entrenched itself in most organizations as a key to the growth of the organization. It not only improves quality of operations, but also increases the revenue of the organization. Imagine if the purchase department has not ordered certain OT consumables that have been indented. This is because the finance department had not approved the purchase. If there are a few emergency surgeries that come, how would the surgeon be able to operate to save the patient? It can happen in any department. Even as we deal with the subject of productivity and how we can improve it, it is necessary that we be not just readers of the articles, but put into practice atleast a fraction of what we learn. This helps us improve our quality of life and that of others. You can be the catalyst by applying these principles in your work and personal life; you can influence your family and others around you. We are pleased to publish two very important articles in this issue. The first one is on time motion study and the second article is on communication in hosptals. I hope you apply someof these principles in your hospital services. Please send in your feedback/suggestions.

Justin Jebakumar Secy.,Administrators Section

Biblespeaks The 21st Century Pilgrim and his progress -Luke 9:23 any Christians today interpret "cross" as some burden they must carry in their lives - a strained relationship, a thankless job, a physical illness. Agreed all these have great strain on our lives, but there is a deeper meaning to “carrying the cross.” When Jesus carried His cross up to Golgotha to be crucified, no one was thinking of the cross as symbolic of a burden to carry. To a person in the first century, the cross meant one thing and one thing only: Death! By the most painful and humiliating means. It could only mean being willing to die in order to follow Jesus. This is called “dying to self.” It’s a call to absolute surrender. Only if we willingly take up our cross, putting to death our hopes, dreams, possessions, even our very life maybe for the cause of Christ, may we be called His disciples (Luke 14:27). The reward is worth the price. For Jesus followed His call of death to self with a gift of life in Christ! (Matt 16:25-26). May the Lord enable us to grow and give us the endurance to continue in our progress to be like Jesus!


Dr Geom Abraham, CMAI

I would rather do and not promise, than promise and not to do. - Arthur Warwick

Clipboard Issue 46 & 47

Clipboard Issue 46 & 47

Improving Productivity – learn or be left out


ne of the emphases that is given today in any domain of any industry is Productivity. It is the priority of CEOs, directors and business people. Productivity is never an accident. It is always the result of a commitment to excellence, intelligent planning, and focused effort�, said Paul Meyers a Management uru. Productivity is directly proportional to profitability.

you intend it to be. ust speak clearly, concisely and check whether the person you are communicating with has understood what you have said. You can save precious time by getting what you need first time.


A decision is the selection of a course of action from two or more alternatives. Everything we do involves decisions, from deciding what to wear in the morning right up to deciding whether or not

2. Planning

The Web definition says, it is the amount of physical output for each unit of productive input. Productivity is usually measured by its increase in output or that which comes from a standard quantity of input factors. Productivity is therefore considered to be a component of growth.

This is one of the most essential tools of improving productivity. nplanned work reduces productivity. eep a weekly, monthly and yearly planner on your desk and you record the work that needs to be done. With larger tasks, plan the entire task at the beginning. Break it down into smaller steps and assign a date by which each step should be completed. elegate projects that can be done by someone else, but keep it closely supervised as to who is doing what and when you need it completed.

Why do we need to measure productivity?

3. Prioritizing

The productivity measure has several purposes. It is used principally to compare the performance of either produce or the people associated with the produce. It can also be used as an efficiency indicator, which can help identify the areas to improve growth. Measuring productivity is a concept that all businesses would have to familiarize themselves with. In the volatile world of business, we have to face the fact that all efforts exerted by everyone in the organization are directed towards gaining profit.

Moving from one task to the other without accomplishing anything each day, or constantly rushing to finish on deadlines is a sign that you need to reorganize your approach in terms of task scheduling and work prioritizing strategy.

What is productivity?

But when it comes to productivity, this measure would actually depend on just how productive the employees of your company are. And measuring this is a bit difficult, because its hard to quantify the performance of employees for the simple reason that these are people you are dealing with unless there are set goals and objectives.

What are the ways to improve productivity?

Productivity means working smarter, not harder,� says Michael Souza, an author of books on management.Every productivity cycle is related to value and time. If the value is increased and time is reduced it improves productivity.

1. Communication

One of the most important skills in any job is effective communication. When you are communicating with staff and clients, make sure that all your instructions and information is understood the way


Each morning go through your inbox and prioritize its contents. Once you know what is to be done, how urgently it is needed, and how long it is likely to take to complete, put the tasks in order of importance to your work schedule for the day. When the mail comes in, prioritize any items that need attention and then add these to your work schedule. At the end of each day, take a look at the work that has been accomplished. All unfinished tasks need to be scheduled for the next day or with extra hours the same day.

4. Procrastination For many this is the biggest time thief of all! The most important issue is that you need to acknowledge that you are guilty of procrastination, and then identify the tasks you tend to put off as long as possible. Once you know which things you are likely to procrastinate, consider why is it that you dont want to do them. Perhaps they are too big, too boring, or just appear to be a waste of time. By identifying the reasoning behind your procrastination of issues, you can find solutions, such as breaking larger tasks into smaller pieces see planning above, scheduling the boring tasks for first thing in the morning so that they are done, and del-

nication, normally the reception of the message is acknowledged. eception can be delayed or may fail due to the failure of the delivery mechanism. It can be postal delay or delivery to the wrong person or even failure of technology like internet failures. Hospitals rely heavily on individual messengers to deliver messages within the hospital, which is faster and reliable. ecoding and understanding are the two steps that determine the success or failure of the communication process. ecoding is the interpretation of the message and assimilation is the understanding of the message. The first two steps of organization of thoughts and encoding should match with the decoding and understanding. If that is so, the sender and the receiver are in the same plane and the message is conveyed successfully. Any gap between the two would mean communication gap. eedback is the process where the receiver conveys his/her understanding of the message. eedback may be in the form of reply or it may be the action taken based on the message received. This will reveal whether the receiver has understood the message the way it was conveyed by the sender.

Channels of Communication There are three channels of communication. They are downward communication, upward communication and horizontal communication, which are self explanatory. a a Ciai Here the communication flows from superior to subordinates. Normally downward communication is sent to subordinates in the form of orders to get the work done. They are in the form of written orders or orally asked to perform some tasks. But an intelligent hospital administrator will use the downward channel to share information with subordinates and also motivate them with encouraging words. This way the downward communication channel is used to create a congenial working environment in the hospital. b pa Ciai Here the communication flows from subordinate to the superior. This channel is mostly used to report performance to the superiors. Sometimes there are formal reporting formats to report the performance to the superiors. However, a good hospital administrator will use this channel to consult the subordinates and get ideas from them to improve the working process in the hospital. Encouraging upward communication in this manner will result in innovation in the hospital. pward communication also creates a sense of belongingness among the subordinates and they actively participate in hospital affairs. pward

communication is vital for creating team work in the hospital. ial Ciai This is communication across departments and individuals at the same level in different departments of the hospital. Horizontal communication is vital for coordination and is the most important channel of communication in the hospital. Individual departments may be very efficient but lack of horizontal communication can lead to poor coordination and the patient fails to receive the benefit of all the expertise available in the hospital. It is a challenge for the hospital administrator to establish horizontal communication. Often professionals are individualistic and may not like to communicate with fellow professionals in other departments leading to poor coordination and poor delivery of hospital services. Therefore, it is important for the hospital administrator to improve horizontal communication, so that individual professionals understand their fellow professionals better and collaborate with each other to provide effective services to the patients.

Communication Barriers People working in organizations have their personal needs and goals, which may contradict with each other. This may come in the way of effective communication in the hospital. People compete with each other for positions in any organization and hospital is no exception to this. Thus rivalry and jealousy may impede effective communication in the hospital. Especially in hospital, one often finds professional rivalry and empire building process - a senior specialist may keep on focusing on his/her narrow field of specialization and build it for personal goal rather than the hospital goal. pward communication is often blocked because subordinates are suspicious or scared to convey their opinion to the superiors fearing reprisal. It is the task of the hospital administrator to remove these fears and encourage upward communication. Otherwise ideas do not flow and innovations cannot be carried out in the hospital. In addition to the above mentioned human barriers to communication, technological and physical barriers can affect effective communication in the hospital. Hospitals need fool-proof internal and external communication system. acilities like intercom and public address system should be well maintained in the hospital. urther, ambulance services with wireless communication are vital for any hospital for dealing with emergencies. All these physical facilities should be maintained well to ensure uninterrupted communication in the hospital.


Clipboard Issue 46 & 47

Clipboard Issue 46 & 47

Communication in Hospital Management Importance of Communication Communication assumes importance in any organization, where human efforts are more involved in achieving the goals. Today most of the manufacturing organizations managed to reduce the human resource by introducing high technology that could replace the human efforts. This has happened either due to shortage of skilled workforce or due to the complexity of dealing with human beings in the workplace. However, hospital is an exception to this. While hospital too has undergone tremendous change in the recent times in terms of acquiring new technologies, it has not in anyway reduced the workforce in the hospital. On the contrary, new technologies have brought in new group of workforce such as bio-medical engineers, technologists and a variety of technicians. In short, hospital is a labour intensive organization. Hospital is not only labour intensive but also its labour is complex. Its labour force ranges from school level educated ward attendant to highly educated super specialist doctors. To manage such a large and complex workforce of a hospital, communication is the main tool to ensure individual performance and to coordinate the human efforts to achieve the hospital goals. While hospital requires predictable behaviour, human behaviour is not predictable. Human personality and the work environment affect the human behaviour to a great extent. Here communication plays a major role to ensure that human efforts are well coordinated and people respond spontaneously to work situation to fulfill the task, thereby achieving the goals. Cooperation and collaboration are key to the success of any hospital, for which communication is vital. Hospital is an organization that deals with the life and health of individuals, where errors and omissions have no place. It is not a manufacturing organization, where the defective products can be rejected or sold at a rebate. Errors and omissions are often due to communication failures. Therefore, hospital needs a fool-proof communication system to ensure that medical errors and negligence do not occur. inally, hospital work involves high degree of coordination, team work and information sharing. Every stage of treating a patient needs coordination of different sections and individual staff of the hospital. or example, to run an efficient out patient service, high degree of coordination is required among the patient registration section, clinical departments, diagnostic departments, nursing department and pharmacy.


Some of the services like emergency services need high level of coordination with all other sections of the hospital to deal with emergencies. Certain other services like surgery need high level of team work. Though the patient and the relatives may think that the surgeon is conducting the surgery, it is a major team effort to conduct a major surgery. Information sharing, especially between the diagnostic departments like radiology and the laboratory and the clinical departments, are vital for treating the patient.

Communication Process Any hospital needs good formal and informal communication systems. A good formal communication system is required to ensure fool-proof work system, where as a good informal communication process is needed to maintain a congenial working environment, wherein individuals voluntarily deliver their best to the hospital. Communication process involves seven steps. They are organization of thoughts, encoding, transmission, reception, decoding, understanding and feedback. The sender should be very clear in his/her mind what he/she wants to convey to the receiver. Once the thought process is clear, the sender should be able to translate the thought process into a format that will be sent to the receiver. In formal communication, specific communication formats are developed, so that there is uniformity and clarity in communication. The laboratory has very clear formats to send the laboratory results to clinical departments. Transmission is important to the communication process. Transmission should be timely and accurate and should reach the right person. Often communication failures take place in this stage. arious media and communication technologies are used to transmit the message. ormal communication normally follows written media such as a letter, circular on the notice board and so on, where as informal communication uses verbal media like direct contact, telephonic conversation and so on. Today, electronic technology is used to make the communication faster and almost instant. Hospital administrator has to choose the right medium and technology to transmit the message, so that it makes the desired impact on the receiver. Selection of medium and technology should be cost effective also. eception of communication should also be efficient and effective. irst one has to ensure that the receiver has received the message. In formal commu-

egate see delegation below any tasks that are so routine.

5. Delegation If you have staff employed to help you, delegate some of your routine tasks which you can quickly instruct someone else to take responsibility. emember to communicate the instructions clearly and ensure that they are understood before leaving the task in the employees care. Once you delegate something, just do a quick review to ensure its done correctly and on time. elegating a few tasks to team members will free up your time for more specialized work.

How does it impact Healthcare Industry? ife is precious and delays can cause death. Speed is the essence in healthcare. If there is to be speed in the system then planning, communication, delegation and prioritization are the keys to improved productivity. Some of the keys to improve productivity in hospitals and institutions are listed below

ð ei als You need to set goals for the organization to improve productivity. oals are set to be achievable, attainable and practical - goals for individuals, departments and for the organization. The productivity of a work group seems to depend on how the group members see their own goals in relation to the goals of the organization”, says en Blanchard. You need to have measurable goals and need to continuously monitor them. ð ali In one organization, I saw mirrors in almost every corner. Below it was the question, who is responsible for quality? If convinced, look into the mirror. Each of us contribute to the quality of the task that is assigned to us individually and collectively. uality can be assigned to both man and machine. Many hospitals feel cheap is best. When you invest in equipment and manpower, look at long term and not short term gain. One such productivity improved process is Six Sigma. ð aie Cae The patient is the reason that you and I are in the healthcare industry. Mahatma andhi said "The customer is the most important person in business." ikewise in our sector the patient is the most important person. In todays context hospital and hospitality should go hand in hand. Hence more initiatives are introduced to improve the productivity of patient care in hospitals.

ð plee Cae

To bring the best in a person is to have the right people for the right job. Talent is hard to come by and sometimes hospitals may have difficulty in managing the income versus expenditure. They need to look at ways and means of manpower retention. At a recent consultation at Mayo Clinic for improving healthcare, ohn other, AAP said, "rom my perspective, there are three change drivers information, measurement and money. To move the system in the right direction, you have to get those three elements working together." Appraisal systems, incentive schemes, employee survey and continuous group meetings help keep the management and the employees in constant touch and communication to feel the pulse of each other. This helps to arrive at strategies for improvement of the organization.

Conclusion If an organization has to improve its productivity, the onus is on the leader to drive it down to the employees to make them a part of the vision of making this happen. Peter ruker, a famous Management uru says, The productivity of work is not the responsibility of the worker but of the manager.” We need to develop visionaries and leaders that will drive the productivity improvement processes and plans individually and collectively through the organization. "When everyone is hooked on to the vision and the goal, productivity is like being able to do things that you were never able to do before.", said ranz afka in one of his lectures. Change needs to take place to improve productivity and it starts with an individual and has to be contagious throughout the organization.

About the author Paul Samuel has spent over 20 years of his career in the healthcare industry and has held various responsibilities in organizations and institutions. He consults for companies to introduce product and solutions that make the world greener. He also consults for hospitals in various areas including improving productivity and profitability.

or any queries, please contact the author at

Clipboard Issue 46 & 47

Clipboard Issue 46 & 47 e iis a elle ae ie i e ie bel

Time-motion Study: A Simple Effective Management Tool For Mission Hospitals Introduction Most of the mission hospitals are situated in rural areas and serve the poor. Efficient management of the people and resources are the key to cutting down costs and making the hospitals affordable to the poor. The time motion study is a simple one that would help the hospitals to plan and make the work very efficient. In simple terms it means following the various persons without their knowledge and finding out what they do at any given time and then plan the work, so that there is efficient output. We describe how the time-motion study helped us modify and improve the performance at the Burrows Memorial Christian Hospital in rural Northeast India.


ie Mi

Waiting to pay the registration charge


Waiting to see the doctors


Time spent at the octors



Time spent for billing



Time spent at the Cashiers



Methods arious visitors to the hospital, both medical and non medical persons were used for carrying out the study. They followed various groups of staff and patients without their knowledge, recording what they were doing at the hospital, obtaining information once every minutes. They followed patients, their relatives, administrative and nursing staff. A detailed study of how the nurses spent their time was carried out by Mr inay ohn at Christian Medical College and Hospital, ellore, at the Pediatric Intensive Care unit for a week.

Findings The table on the right shows how the patients spent their time during an average working day from the time they registered. It was observed that the overall time spent by the nursing staff was on nursing activities, on charting and time on non-nursing activities.

The following changes were made .The first change was that the registration fee was collected at the registration counter rather than the cash counter to save time for the patients 2. A preliminary examination room was added where the nurses checked and entered the preliminary history guided by the computer. They also checked and entered the vital signs of the patients.


Time spent at the Pharmacy 6


Time spent inquiring



Time spent outside the hospital premises



Time waiting for procedures and results

a.Broadcasting the surgical procedures and scopies live.This was coupled with health education and evangelical broadcast.





b.Making the relatives act out small health education and other skits and filming them with video camera and editing and selling it back to them.


. An interim deposit was collected at the cash counter and this was used at various places to deduct money that was needed for the various investigations like the laboratory, ultrasound, -ray, surgical procedures etc. This way the patients need not stand in the line at the billing and cash counters repeatedly and also the cashiers spent less time and effort in giving back the change. The patients settled the account finally when they were leaving the hospital. 4.or helping the patients understand the concept of interim deposit and for explaining why various investigations are carried out and to provide instructions on how to take the medicines, the print-station counter was opened. .To keep the patients and their relatives occupied while they were waiting for the investigations and procedures, the following were tried

c.eeping reading materials and having the nursing students give health education talks. 6.To have the nursing students do research projects that involved patient care, anxiety etc. that would keep the patients and relatives occupied. 7.Having a library, reading room, counseling and prayer room etc. near the outpatient department to keep the patients and relatives occupied.

Discussion The time-motion study is a simple tool and could be carried out easily. The person who is being observed should not know about it to avoid what is called the Hawthorne effect�, which is a bias that occurs because the person knows that he/she is being observed. In the original study at the Hawthorne Bulb Company the production went up whenever the study was carried out.

A great number of changes were made and new protocols were made just based on the observation of 0 patients. The results were seen almost immediately with the patient satisfaction going up greatly. Several changes in the nursing care and protocols are planned based on the findings of the survey done at Christian Medical College, ellore and at Burrows Memorial Christian Hospital. Several changes were made in the job description of the other staff that was studied but the details are beyond the scope of this article. It is sufficient to say that it is a very useful administrative tool.

Authors .r nanaraj MS en, MCh rology, Burrows Memorial Christian Hospital, Alipur, Banskandi Post, Cachar istrict, Assam, India 7880. Mobile 472628 2. Mr inay ohn MSc Nursing, Christian Medical College and Hospital, ellore.


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

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