CHAPTER TWO
2.6 Importance of organisational performance in health sector
It is apparent that no single principle can encompass all relevant values for the achievement of an equitable allocation of health resources. The general consensus among researchers is that a combination of various methods is necessary to attain an „acceptable‟ level of equity in resource distribution. The onus is on health policy makers to ensure that the public understands the basis on which the allocation of health resources is made through the formulation of transparent allocation measures.
This study highlights the need for policy makers and managers to understand the importance of issues of equity in relation to health employees. There is also a need to ensure that health resource allocation systems equitably consider the welfare of patients or consumers in terms of access to health services since health systems are mainly about the recipients of health services. Health policy makers and managers have to appreciate that processes aimed at improving individual or group conditions of service for employees and introducing equity mechanisms for the welfare of patients may actually generate more problems for health organisations than they attempted to fix because organisations are systems whose different components interact for the good of the whole.
On being asked about the constraints that they experience in the attainment of organisational objectives, most managers tend to mention the lack of resources of a financial, material and human nature. Kanani et al (1988) suggest a departure from this commonly held position by noting that several constraint analysis exercises show that, to a large extent, constraints have a non-resource aspect. This is an important revelation since even where resources are in short supply, other deficiencies are often present at the same time, for example, complex administrative procedures, inappropriate staff attitudes, and lack of management capacity to implement performance improvement initiatives. A valid argument exists for assuming that organisational performance improvement does not depend on pouring resources into programmes since there may be need to address other equally crucial areas such as strengthening the managerial capacity of relevant organisational staff. A publication by the Population Information Program (2002:1) states that: „Performance Improvement is useful in resource-poor settings because it focuses attention on often-neglected causes of performance problems, such as unclear expectations or infrequent feedback, that need not be costly to correct.‟ The publication also noted that performance improvement techniques are necessary for solving problems and helping staff members to undertake new tasks or adjust to new standards of work.
Alavi and Yasin (2008) states that the apparent reluctance of service organizations to utilize quality improvement based strategies and practices is difficult to understand, especially in the context of the increased significance of the demands of customers. The researchers encouraged decision makers, based on the findings of a study that they had conducted, to commit organisational resources toward the effective implementation of quality improvement initiatives. They concluded that investing in quality improvement was not only justified, but also necessary in a changing competitive environment. The health sector needs to articulate a clear vision for quality and develop frameworks for quality improvement. The overall health sector goal should be to have continuous evaluation of health practices, programmes and policies that attain desired results while also concentrating on areas that need improvement.
Generally, a focus on performance improvement initiatives facilitates the use by the organization of systematic, evidence-based or best practices for resolving workplace problems rather than resorting to trial and error methods that may prove to be costly and ineffective. The value of systematic methods of tackling work performance problems is that the institutional context of the performance problem is identified and the requisite stakeholder consensus for problem solving achieved. The organisational members have the opportunity to reflect on the mission, goals, strategies, and culture of the organization which add up to increase the preparedness of the organisation to better attain its mandate. Effectively run
performance improvement programmes empower staff to develop the culture of identifying problems and seeking solutions either as individuals or as teams. Staff have clarity as to what their job is and are motivated by the awareness of how they contribute to the attainment of the overall institutional goals.
The communication process between supervisors and their subordinates is enhanced through agreement of performance targets and the means by which they should be achieved. With periodic performance reviews, weaknesses in the performance process can be identified timeously and corrective measures taken to close any performance gaps. This introduces an element of objectivity and reduces the chances of employees feeling that their supervisors victimise them, in instances of poor performance, based on the supervisors‟ whims. Health care institutions can, through the application of performance improvement measures, be better placed to respond to clients‟ demands for quality services.
Health managers need to concern themselves with issues of improving the performance of their organisations so that they can achieve their mandate, which is to deliver efficient and effective health services to their target populations. Health service managers need to enhance the knowledge and skills of their staff for them to do a good job. They also have the obligation to coach them on what is expected of them so that they meet organisational expectations. Health managements, however, need to be critical in analysing the causes of inefficient or ineffective institutional performance since poor performance is rarely ever solely attributed to the employee‟s shortcomings in skills and knowledge but to other factors as well in the health system. The other factors that have a bearing on performance are the internal and external determinants such as motivation, incentives, environmental factors, resources, and leadership amongst others. Training, which was traditionally assumed to be the solution to organisational performance problems, is, by itself, inadequate. The analysis of performance issues by health managers should yield information that sheds light on how to bridge the gap between the current organisational performance and the desired level of performance. Bridging the performance gap requires that the management takes an active role in managing the institutional performance improvement systems.
Casto (2009) writes that in today's competitive health care market, customers have high expectations of quality health services. Health care organisations are expected to have ongoing performance improvement programmes since these are critical to the sustainability of their institutions. Cherian (2010:1), writing about customer care in a business environment states that: „A repeat customer is the result of a relationship you have built up through excellent customer service.‟ This statement is, to a large extent, equally true for health institutions in the health sector with exceptions where the patients really have no choice but to go back to the same health facility. Since health facilities have the aim of improving the quality of life of their clients, managers have to ensure that this is made possible by
offering the best possible service which will make the clients happy to make repeat visits should there be need.
Wadhwa (2002) made observations with regard to the Australian health care system, which can be applied to other countries‟ health systems, that as the health care industry strains national financial resources, it has increasingly come under pressure to provide evidence of quality service and quality improvements.
Wadhwa (2002:1) noted that: „the current health care consumer is better educated and the best informed it has ever been.‟ The health care consumer is thus in a position to make more informed demands on the health system which has to respond to client requests for access to care, information regarding treatment options and participation in their own health care and treatment decision making process. Health care managers need to break with past traditions whereby health care system management was seen as supply driven and inefficient because it kept clients away from the product design, development and the delivery process. In the present era of health services management, where the customer may play a more pronounced role in influencing health care decisions, managers should adapt and be proactive in shaping the health system to meet the new quality focus through performance improvement initiatives.
Performance improvement principles are important for health managers as they emphasise the importance of teamwork, systems and processes, customer focus and measurement of work performance. The advocacy for teamwork takes into cognisance that organisational members have individual contributions to make to the overall success of their institutions and are inclined to participate more in the implementation of plans that they have assisted in developing. The emphasis on systems and processes is important for managers as it alerts management to the need for taking the lead in coordinating organisational efforts so that the various elements in the organisation understand how they interrelate with each other for the achievement of a common goal which is to meet the clients‟ expectations. The need for measurement in the management of performance is important from a managerial point of view as it brings to the fore the value of having reliable information which is evidence-based to facilitate the analysis of processes, identify problems, develop strategies and implement them and conduct evaluations in order to close the gap between the current performance and the ideal performance level.
Massoud (2001) points out that experience with implementing improvement initiatives in different settings, such as engineering and manufacturing, has contributed to a better understanding of how initiatives can be applied to the healthcare field. Health managers can take advantage of advances made in the development of the performance improvement methodology and its further application to a wide range of circumstances as well as the integration of evidence-based medicine in clinical quality
improvement activities to make adaptations for improving health management in general. The context of health services management is ever changing and this requires managers to keep pace with the new development in their management styles. The need to update performance improvement methods was aptly captured in the words of Berwick, (cited in Massoud 2001:13) when he stated that: „Every system is perfectly designed to achieve exactly the results that it achieves.‟ This means that if the performance management system is flawed then the results of the performance will not be satisfactory since the system will not have evolved in line with environmental conditions. Health managers need to satisfy themselves that their performance management systems match the requirements of the work environment by identifying outdated processes for the achievement of optimum performance levels. Heiby (2001) states that it is generally accepted that the performance of health workers can, in addition to other factors like training, be influenced by the nature of the health system in which they find themselves. Health managers need to change the health system so that it supports improved compliance with evidence-based guidelines.
Coe (2004), in a review of a book by Kristin Baird, observes that health care has become big business, hence the need for improved performance in dealing with health care clients. Coe quoted statistics that indicated that: it is six times more costly to attract a new customer than it is to retain an existing one; a satisfied customer only tells five other people; an unhappy customer tells approximately twenty other people; and it only takes thirty seconds for a customer to form an opinion. In the light of such information, health managers have an obligation to ensure that the performance of their organisations is of a standard that adequately satisfies the recipients of health care. Coe (2004:1) states that: „It is a fact-- customer service expectations in health care are high, which creates a huge challenge for health care workers. We must make an exceptional impression on every customer, every time.‟ If health managers are to meet the high expectations of their customers, then they need to rise to the occasion and create an enabling environment for their staff to perform their customer-focused duties with the diligence required.
At a 2010 Beryl Institute Conference in Dallas with the theme „Power of Impressions‟ one of the major conclusions was that as health services clients are required to spend more of their own money on health care, they will consider the entire spectrum of value, from access and expertise to service, convenience, and price. The Conference discussed research findings by management consultants, Katzenbach Partners, based on a survey of 1,003 Americans, that indicated that more than half of the participants said that they chose health facilities based on whether they believe employees understand their needs. The authors argued that improved customer service can lead to major improvements in the health care system because it had the potential to contain cost by limiting no-show appointments, the inefficiencies caused by switching providers, such as duplicated tests, and the inconveniences of malpractice suits. They further
noted that better customer service increased the satisfaction not only of patients but also of health care providers, contributing to the retention of key personnel. The conference recommended that health care providers should transform their organisations to focus on patient problems, provide innovative solutions and make the health system more efficient and effective. Health managers were encouraged to manage health care organisations in a way that made them responsive to clients‟ needs. The health facilities that failed to address patients concerns through customer focused initiatives risked losing business through their customers switching to providers that were more accommodating of customer needs.
According to Scientific Research Publishing (2010) knowledge gathered through satisfaction surveys is necessary for, amongst other uses, addressing the problems of patient access to health services and defining measures of performance. The health sector needs information on its customers‟ perceptions regarding the services received so as to constantly deliver higher levels of patients‟ satisfaction. Leaders of organisations in the health sector have an obligation to be concerned about the quality of service that they provide because of the special circumstance of their customers, that is, in the absence of medical training, the customers are less qualified than their providers to make decisions about the technical competence of health professional. Health staff, therefore, need to safeguard the interests of the patients so that they receive the best care possible. The requirement for management to prioritise the needs of clients is important since at times patients and managers have different perceptions of what constitute quality services, mainly because managers tend to be too optimistic about the service that they provide.
The gap in the perceptions between the providers of services and the clients can be closed by a process whereby the former systematically determine patients‟ needs and prioritise activities to attain higher levels of performance.
Lande (2002), commenting on the importance of performance improvement initiatives, stated that health programmes that enable and inspire staff to do their best have the effect of also improving the quality of care provided. The importance of this observation for managers is that they need to realise that their staff need to understand what is required of them at the workplace as well as whether they are actually meeting organisational expectations.
Lande (2002:3) further states that „Performance Improvement encourages use of evidence-based „best practices.‟ In place of trial and error, it offers a systematic approach.‟ An important requirement for the success of performance improvement initiatives is the aspect of their inclusiveness through the empowerment of organizational members to work together to assess their work circumstances and look for opportunities of improving service provision to their customers. This means that health managers, by
prioritising performance improvement, can be more analytical in addressing the problems that affect the efficiency and effectiveness of their operations.
Evidence indicates that despite the Abuja Declaration of 2001 where African countries pledged to allocate at least 15% of their national budgets to the health sector, in most of them the allocation to the health sector is still far below that target. Kabeera (2010) quotes an Africa Public Health Alliance report that revealed that thirty-two out of fifty-three African Union member states invested below $20 per capita in the health sector which is less than half the World Health Organisation recommended minimum. The report showed that some countries performed well with Rwanda having a health sector budgetary allocation of 18.8% followed by Botswana with 17.8%. On the lower side, Burundi was second from last with 2.4% and Somalia had the lowest percentage of a negative zero. According to the Africa Health Dialogue, Kenya allocated about 5.5% of total Government expenditure to the health sector in the 2010- 2011 financial year. Through performance improvement initiatives, resource-poor environments, such as those commonly found in African health sectors, can benefit by focusing on priority activities in order to provide services that need not be costly to implement.
Health managers need to take seriously the implications of poor service delivery by their institutions.
Institutions that are primarily profit driven and those that are guided by motives other than profit are faced with the same challenge of having to provide quality services to their clients to guarantee their sustainability. Ignoring the quality dimension in health service provision can only be done at the risk of health institutions losing clients.