The Global Healthcare Manager: Competencies, Concepts, and Skills

Contributors

INTRODUCTION

The main focus of this textbook is on the growing global importance of the healthcare manager role and the corresponding need for managers to develop the necessary skills to improve healthcare organizations. The book's content is guided first by the notion that, to be an effective change agent in a complex and dynamic global health context, healthcare managers must possess and develop a specific body of knowledge and competencies. The book's second guiding principle is that the aim of effective global healthcare managers is to improve and maintain the health of individuals and populations.

Global Healthcare Management

This book does not focus on global health, international health, or world health systems; instead, all of these concepts provide the frame of reference for global healthcare management. A framework for global healthcare management is shown in exhibit I.1 and described in the paragraphs that follow. Employing this framework, the competent global healthcare manager can lead health provider teams and shape the performance of healthcare organizations in achieving individual and population health outcomes.

Global Health

Global health represents the broadest influence of our framework of analysis, and it circumscribes the context of our area of study. The term global health has a variety of definitions, many of which have derived from adaptations of public health and international health or evolved from earlier notions of hygiene and tropical medicine. Koplan and colleagues (2009), working with the Consortium of Universities for Global Health Executive Board, crafted and adopted the following comprehensive definition:

Global health is an area for study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasizes transnational health issues, determinants and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population-based prevention with individual-level clinical care.

Other authors continue to discuss and define the elements of global health that remain essential and influence funding, education, leadership, governance, constituency behavior, international partnerships/cooperation, and policy. Health and sustainable development are inseparable. Meanwhile, interconnection and interdependence are fundamental to addressing the real challenges of global health that reside in what Frenk, Góméz-Dantes, and Moon (2014) call the triple burden of disease—the unfinished agenda related to communicable diseases; the growing worldwide importance of chronic diseases and longevity; and the health risks associated with globalization. As we shape the idea of a global society, we should shift our understanding of global health from the health of the poorest to the health of an interdependent global population.

As the nature of collaborative global health interventions evolves, the United Nations (UN) has requested that its members adopt the recommendations and strategies contained in a 2014 report from the director-general of the World Health Organization (WHO). The report calls for enhanced partnerships to advance the priorities of sustainable comprehensive healthcare systems; to achieve better health outcomes, shared responsibility, accountability, and inclusiveness; and to accelerate the transition to universal health coverage (UN 2014). It is worth noting that the coordination of multiple stakeholders presents significant challenges for global health governance.

World Health Systems

Most countries around the world have been experiencing a rapid evolution and transformation of their health systems. This trend was accelerated by the global health focus of the World Bank's 1993 World Development Report, titled Investing in Health. For the first time, the idea of investing in health moved beyond the health sector and into the realm of the ministries of finance, with significant attention to socioeconomic issues. Twenty years later, a Lancet Commission report set forth a framework for transforming global health within one generation, by the year 2035. The report highlighted four key premises (Jamison et al. 2013):

There is an enormous payoff from investing in health.

A ‘grand convergence’ in health is achievable within our lifetimes.

Fiscal policies are a powerful and underused lever for curbing of non-communicable diseases and injuries.

Progressive universalism, a pathway to universal health coverage, is an efficient way to achieve health and financial protection.

Starting in 2007, a series of UN-sponsored meetings began advancing the global health and foreign policy agenda. In December 2012, the UN member countries adopted a General Assembly resolution recognizing that governments have a responsibility to scale up efforts to accelerate the transition towards universal access to affordable and quality health-care services (UN 2012). Health systems around the word have already mobilized in pursuit of diverse strategies to achieve this goal within their very different and complex national settings.

Healthcare Organizational Performance

Every health system is dependent on first-contact hospitals that provide access to high-quality, appropriate care and use resources efficiently. Improving the performance of these first-contact hospitals is essential for strengthening any health system. A key objective of healthcare managers is to identify and suggest innovative, scalable solutions and conduct basic operations research using a practical, small-area demonstration strategy. Healthcare managers should use performance improvement techniques to measure output, improve processes, and develop managerial procedures.

Resource management involves the efficient and effective use of an organization's human, financial, and information resources. In healthcare settings, resources vary by country, region, geography, and locality, and many facilities and systems must operate under critical low-resource conditions. Effective healthcare managers possess appropriate skills for low-resource management and can obtain the best possible results under the circumstances. The combination of creativity, perseverance, and hard work can help overcome such issues as reduced access to medications, limited availability of equipment or supplies, and partial or restricted capability for advanced technological procedures.

Many organizations and authors have classified countries, or regions within countries, based on the level of socioeconomic and other types of resources available. This approach has led to such classifications as least developed countries, low-income countries, and lower middle-income countries, which many times reflect the priorities or interests of a particular development program. The challenge remains to apply management strategies that truly promote global health development. As Filerman (2013) suggests, some classification systems and nomenclatures can stand in the way of a unifying approach for global health development that addresses quality of life and health status across all populations without boundaries.

A number of frameworks have been set forth for the improvement of organizational performance in healthcare. For example, the WHO's framework, titled Everybody's Business: Strengthening Health Systems to Improve Health Outcomes, proposes six building blocks (WHO 2007):

Good health services delivery performance

A health workforce that achieves the best possible health outcomes

Reliable and timely health information

Equitable and cost-effective access to medical products, vaccines, and technologies

A health financing system that ensures needed services with financial protection and incentives for efficient use of services

Effective leadership and governance that ensures the involvement of the constituency in all aspects of health services

The Role of the Global Healthcare Manager

The role of the global healthcare manager has changed dramatically as areas of management have developed, as healthcare organizations have evolved and transformed, and as health reforms have been implemented around the world. The growth and diffusion of managerial concepts, theories, and technologies present unique challenges, and the challenges faced by healthcare managers vary depending on organizational level, type of facility or organization, country or region, resource level, and other factors. To meet these challenges, healthcare managers must possess appropriate knowledge and competencies.

Body of Knowledge and Competencies

Members of the Association of University Programs in Health Administration (AUPHA) Global Healthcare Management Faculty Forum, under the leadership of Dr. Daniel Dominguez and with the collaboration of the editors of this textbook, developed a body of knowledge (BOK) for global healthcare management, and that BOK has been adapted for this book. As the authors of the various chapters developed their learning objectives and competencies (which are presented at the start of each chapter), we modified the BOK into the final version provided in the appendix.

The BOK facilitates the development of a variety of competencies, including cognitive abilities, behavioral skills, attitudes, and characteristics, that support effective and appropriate professional interactions across a variety of cultural contexts. Within the profession of healthcare administration, such competencies would include (1) current and relevant knowledge of global health issues; (2) attitudes and behaviors required for multicultural understanding and effective transcultural communication; (3) the conceptual and analytical skills required for identifying and effectively applying global managerial best practices; and (4) attitudes, behaviors, and skills necessary for developing international partnerships, networks, and other collaborative and professional relationships for research, global learning abroad, teaching/coaching, and service learning.

Readers of this book can use the BOK in the appendix to further develop their competencies across any training or educational curricula. The first column shows the key domains or topics, and the second column describes the areas of knowledge. Consistent with the principles of the Bloom taxonomy, the BOK focuses on the two basic levels—knowledge and comprehension—for undergraduate students, and it emphasizes the four top levels—application, analysis, synthesis, and evaluation—for graduate students. Finally, the third column in the appendix indicates some subdisciplines and areas of application that fit within each of the domains or topics.

The Goal and Organization of This Textbook

The goal of this textbook is to provide students and practitioners with an integrative framework of knowledge and policy that addresses the growing diffusion of diverse managerial concepts, theories, and technologies. The book analyzes key concepts from the perspectives of clinicians and administrators of various nations, recognizing opportunities for public and private differences. The focus of the book is not directed toward global health or macro-level policy concerns; instead, such concerns serve only as a contextual framework for the effective leadership and decision-making processes of healthcare managers in their organizations.

The authors of this book developed the chapter contents to assist students in developing leadership and managerial competencies to become effective healthcare managers. The competencies and learning objectives are listed at the start of each chapter. The learning objectives focus on concepts that the students are expected to master, and the attainment of competencies requires application and practice. The level of competency attained will grow through achievement of the learning objectives, as well as through work experience and opportunities provided through discussion questions, vignettes, cases, and other exercises.

The text takes into consideration several major cross-cutting themes affecting the globalization of healthcare management, stimulating the reader to think about the intersection and interrelation of the chapters’ content. The book also provides opportunities for application and reflection through case studies, vignettes, and practical recommendations, as well as such tools as checklists and guidelines.

Cross-Cutting Themes

Major cross-cutting themes throughout the book include the following:

Sociocultural factors. The book recognizes the unique qualities and characteristics of every country and its cultures. To work effectively, managers need to understand that organizations are social systems composed of individuals and groups. Culture helps shape values, behaviors, attitudes, and the nature of work.

Clinician–manager relationships and leadership. Positive outcomes in healthcare require the formation of clinical/management teams, with professionals and health workers from a variety of disciplines working together to address complex problems. Effective teams are typically supported by leaders who respect the team members and help develop, carry out, and evaluate processes that enhance quality of care, performance, and patient safety.

Performance improvement and value-based management. This theme focuses on mechanisms that improve health outcomes, support provider and patient satisfaction, and lower the cost of healthcare. These mechanisms include, but are not limited to, management and reimbursement models such as risk sharing and pay-for-performance, as well as innovative mobile/virtual technologies that focus on wellness and value.

Resource management. This theme considers how resources are distributed among organizations in the same country, within diverse types of healthcare systems (e.g., public, private, charitable), and within the same type of healthcare system but in different geographical/cultural/social/economic subregions. It particularly recognizes the management challenges associated with low availability of resources.

Decision making, data analytics, and evidence-based management. With advances in information technology, more effective collection and analysis of data become critically important for management decisions. Many countries have adopted electronic health record systems that allow for the collection of substantial amounts of data. Through data analytics, managers can become better informed about quality of care, the costs and benefits of various clinical procedures, and measures of organizational efficiency and effectiveness. The available evidence and analytical insights can facilitate the evaluation of managerial practices and support decision making to achieve organizational improvement.

Sections and Chapters of the Book

This book is organized into four sections, with the chapters of each section contributing to a common theme. Section I, Essential Health Services Management Concepts and Practices, focuses on organizational structure, financing and financial management, human resources, and information technology. Section II, Leadership, Organizational Design, and Change, addresses leadership principles, governance, strategic planning, marketing, ethics, and organizational change. Section III, Managing the Organization–Environment Interface, focuses on the impact of the external environment on organizational performance. The chapters of this section discuss health policy, demographic shifts, and the growing importance of population health management and long-term care. Section IV, Looking Ahead in Global Health Management, concludes the text with a look at future trends in global health.

Detailed summaries of the individual chapters are provided in the paragraphs that follow.

Section I—Essential Health Services Management Concepts and Practices

Chapter 1—Functions, Structure, and Physical Resources of Healthcare Organizations

The central idea of this chapter is that function defines structure. Healthcare organizations vary—not only from country to country but also within each country—as they address access, quality, and cost issues influenced by social, economic, and political factors. The principles described in this chapter can be applied to ambulatory, acute, chronic, and home care organizations with varying levels of resources and local organizational response capacity.

The first part of the chapter examines the key functions of healthcare organizations, with an emphasis on the need for a continuum of patient-centered care. The chapter reviews the main components of a healthcare organization and the ways those components interact to produce and measure outcomes and drive performance improvement. It then explores and contrasts ways of designing and structuring organizations to effectively and efficiently carry out the key functions. Finally, the chapter proposes a scheme for the analysis and design of physical resources and functions to support the successful operation of a healthcare organization. This chapter provides important context for the rest of the chapters in section I, as well as for the quality and process design discussions later in the book.

Chapter 2—Healthcare Systems, Financing, and Payments

The purpose of this chapter is to provide a general overview of global healthcare expenditures, to discuss the macroeconomic drivers of variation among countries, and to provide insight into the primary models that countries have used to finance and deliver healthcare. The chapter starts by defining healthcare financing and exploring its functions, from revenue collection to pooling to purchasing and setting the benefits package. It also provides an introduction to the mechanics of health insurance and a discussion of the natural incentives associated with the way clinical providers are paid. The chapter provides relevant groundwork for the more detailed financial, quality, and managerial content contained in later chapters.

Chapter 3—Financial Management of Healthcare Organizations

This chapter focuses on micro-level considerations unique to the types of financial decisions faced by healthcare managers in complex national and multinational environments. It begins with a discussion of the primary long-term financial planning process and the major financial decision-making tools used by healthcare managers. It then describes the long-term financial risks and implications that organizations must address when operating within existing markets, when expanding their scale or scope of operations within existing markets, or when entering new markets. The chapter also discusses the primary short-term financial planning methods and the short-term financial risks and implications that organizations face when financing day-to-day healthcare delivery in national and multinational settings.

Chapter 4—Human Resource Management in a Global Context

Within a global context, the healthcare sector is essentially a human enterprise, and the connections that exist between people engaging in health work has been of the utmost importance. This chapter, therefore, focuses on human resources (HR) principles and effective HR management practices. Best practices (based on evidence-based management), sociocultural perspectives, and the impact of culture are incorporated in the discussion, as are lessons from the global health workforce. Additional HR lessons deal with self-management and emotional intelligence in the context of being an effective manager and leader of others.

Chapter 5—Information Technology for Healthcare

This chapter seeks to provide a basic understanding of information technology in healthcare. It offers an introduction to electronic health records (EHRs), discussing the exchange of data between records and the ways EHR data can be used in clinical support systems to improve patient care. The chapter also addresses privacy, security, and the protection of patient information. The chapter concludes with a discussion of the steps involved in assessing, selecting, and implementing EHR systems.

Section II—Leadership, Organizational Design, and Change

Chapter 6—Principles of Effective Leadership

Efforts to improve healthcare outcomes and quality require competent and effective leaders. Global healthcare leaders must possess the knowledge, skills, and competencies to develop and modify systems of care, build effective interprofessional teams, and drive continuous change and improvement. This chapter examines leadership qualities, traits, and characteristics; the leader's responsibilities and professional identity; and contemporary leadership issues—all while allowing for country-specific and regional variation. Applied examples help underscore the importance of managing resources wisely, ensuring sustainable projects, and meeting the needs of vulnerable populations. Discussion questions, case studies, and vignettes provide opportunities for the application and integration of key concepts and ideas.

Chapter 7—Strategic Management and Marketing

This chapter introduces the basic process of strategic planning, and it connects that process with the strategic marketing efforts needed to help the organization meet its goals and objectives. Examples and short cases from various countries and from different sectors of the healthcare arena promote systems thinking from diverse perspectives. After completing this chapter, readers will be able to draft a strategic plan with the ability to communicate with desired audiences through targeted channels of communication.

Chapter 8—Process Design and Continuous Quality Improvement for Operational Change in Global Health

A variety of operations management principles, models, tools, techniques, and quality improvement (QI) methods are widely prevalent across global health settings, and this chapter provides an overview of several that are most relevant for global health students and managers. The tools described in this chapter, once mastered and applied, can help ensure process improvements that truly add value to clients, constituents, stakeholders, communities, and the health sector as a whole. A key point highlighted by the chapter is that health management professionals and policymakers must understand the level of operational change desired and choose QI instruments that are most appropriate for that change and for their organizations or systems.

Chapter 9—Managerial Ethics in Global Health

This chapter addresses managerial ethics in the global health context. It discusses the importance of ethics in managerial decisions, with attention to the additional sensitivity that is required in situations where two or more cultures come together. The chapter provides examples of the difficult ethical issues that may arise in global health contexts.

Chapter 10—Boards and Good Governance

An organization's governing body, often called the board of directors or board of trustees, is a group of community, business, and health sector leaders who make decisions about the organization's purpose, plans, and overall direction. One of the aims of this chapter is to show how health system leaders in low-resource countries can explore the power of the board to foster conditions in which the people who deliver and manage health services are more likely to succeed. The chapter lists 5 key practices and 11 essential elements of good infrastructure for effective board work.

Section III—Managing the Organization–Environment Interface

Chapter 11—Health Policy Design

This chapter aims to help readers develop the knowledge base necessary to understand, effectively influence, and adapt to global (national) health policies. It focuses on key concepts of policy design that are employed throughout the world and are of particular importance for health managers and organizational leaders.

Chapter 12—Global Demographics and the Management of Long-Term Services and Supports

Global healthcare delivery systems in the twenty-first century face numerous demographic challenges, many of which are associated with the aging of the population and the growing number of individuals with chronic and disabling conditions. The ways countries address these issues will depend heavily on their traditions and cultures, their healthcare systems’ plans and policies, and their access to resources and technology. This chapter provides an overview of the demographic, historical, and cultural forces affecting the demand for long-term care, and it discusses management issues such as the need for trained staff in the long-term care field and the use of technology in care management. In addition, the chapter highlights five countries at different stages of aging—Japan, Sweden, China, Turkey, and the United States—and examines their unique experiences and solutions.

Chapter 13—Managing the Health of Populations

This chapter helps readers develop the knowledge and skills necessary to understand, plan for, and manage the health of a constituent population. It focuses on key concepts in population health management strategies that are employed around the world and are of particular importance to health managers.

Section IV—Looking Ahead in Global Health Management

Chapter 14—Future Trends in Global Health

This chapter describes current and future global health trends that are affecting healthcare managers and health system design. Areas of focus include health policy, technology, public health, human rights, workforce planning, changes in health sectors, catastrophic events, and trends in consumer behavior. The chapter takes a forward-looking approach to critical issues that have an impact on global health status.

Epilogue

The epilogue concludes the book with an overview and summary of the key elements of global healthcare management, with an emphasis on the interrelations between global health, global health systems, and the performance and leadership of healthcare managers. It synthesizes the book's content into a set of building blocks to support future healthcare managers and foster effective healthcare management across the globe.

Instructor Resources

This book's Instructor Resources include an instructor's manual, PowerPoint slides, and a test bank.

For the most up-to-date information about this book and its Instructor Resources, go to ache.org/HAP and browse for the book's title or author names.

This book's Instructor Resources are available to instructors who adopt this book for use in their course. For access information, please email [email protected].

References

Filerman, G. L. 2013. The Role of Health Services Administration Education in Global Health Development: A New Perspective. Journal of Health Administration Education 30 (4): 241–50.

Frenk, J., O. Góméz-Dantes, and S. Moon. 2014. From Sovereignty to Solidarity: A Renewed Concept of Global Health for an Era of Complex Interdependence. Lancet. Published January 4. www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(13)62561-1.pdf.

Jamison, D. T., L. H. Summers, G. Alleyne, K. J. Arrow, S. Berkley, A. Binagwaho, F. Bustreo, D. Evans, R. G. A. Feachem, J. Frenk, G. Ghosh, S. J. Goldie, Y. Guo, S. Gupta, R. Horton, M. E. Kruk, A. Mahmoud, L. K. Mohohlo, M. Ncube, A. Pablos-Mendez, K. S. Reddy, H. Saxenian, A. Soucat, K. H. Ultveit-Moe, and G. Yamey. 2013. Global Health 2035: A World Converging Within a Generation. Lancet. Published December 3. www.globalhealth2035.org/sites/default/files/report/global-health-2035.pdf.

Koplan, J. P., T. C. Bond, M. H. Merson, K. S. Reddy, M. H. Rodriguez, N. K. Sewankambo, and J. N. Wasserheit. 2009. Towards a Common Definition of Global Health. Lancet. Published June 2. www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60332-9/.

United Nations (UN). 2014. Report of the Director-General of the World Health Organization on Partnerships for Global Health. Published September 26. https://documents-dds-ny.un.org/doc/UNDOC/GEN/N14/549/23/PDF/N1454923.pdf?OpenElement.

———. 2012. Global Health and Foreign Policy. General Assembly Resolution A/67/L.36. Published December 6. www.un.org/ga/search/view_doc.asp?symbol=A/67/L.36.

World Health Organization (WHO). 2007. Everybody's Business: Strengthening Health Systems to Improve Health Outcomes: WHO's Framework for Action. Accessed March 23, 2018. www.who.int/healthsystems/strategy/everybodys_business.pdf.

SECTION

I

ESSENTIAL HEALTH SERVICES MANAGEMENT CONCEPTS AND PRACTICES

CHAPTER

1

FUNCTIONS, STRUCTURE, AND PHYSICAL RESOURCES OF HEALTHCARE ORGANIZATIONS

Bernardo Ramirez, MD, Antonio Hurtado, MD, Gary L. Filerman, PhD, and Cherie L. Ramirez, PhD

Chapter Focus

The key idea of this chapter is that form follows function, and function defines structure. Healthcare organizations vary—not only from country to country, but also within each country—as they address issues of access, quality, and cost that are influenced by social, economic, and political factors. The principles described in this chapter can be applied to ambulatory, acute, chronic, and home care organizations with varying levels of resources and local organizational response capacity. The first section of this chapter examines the key functions of healthcare organizations, with an emphasis on the need for a continuum of patient-centered care. Later sections review the main components of healthcare organizations and the ways they interact to achieve desired outcomes and performance improvement. The chapter explores ways of designing, structuring, and analyzing organizations to effectively and efficiently manage physical resources and carry out key functions.

Learning Objectives

Upon completion of this chapter, you should be able to

distinguish the key functions of healthcare organizations and relate them to the priorities of access, cost, and quality;

develop mechanisms to assess the performance of healthcare organizations;

design a structure for an organization that takes into consideration the resources available in a given community to achieve the best possible health outcomes;

plan and prioritize the physical resources needed to effectively accomplish the organization's key functions, taking into account the available resources in that particular system; and

integrate physical, human, and technological resources to provide appropriate clinical, support, managerial, and supply chain services in a healthcare organization, taking into consideration all legal, accreditation, and regulatory mandates.

Competencies

Demonstrate an understanding of system structure, funding mechanisms, and the way healthcare services are organized.

Balance the interrelationships among access, quality, safety, cost, resource allocation, accountability, care setting, community need, and professional roles.

Assess the performance of the organization as a part of the health system.

Use monitoring systems to ensure that corporate and administrative functions meet all legal, ethical, and quality/safety standards.

Effectively apply knowledge of organizational systems, theories, and behaviors.

Demonstrate knowledge of governmental, regulatory, professional, and accreditation agencies.

Interpret public policy, and assess legislative and advocacy processes within the organization.

Effectively manage the supply chain to achieve timeliness and efficiency of inputs, materials, warehousing, and distribution, so that supplies reach the end user in a cost-effective manner.

Adhere to procurement regulations in terms of contract management and tendering.

Effectively manage the interdependency and logistics of supply chain services within the organization.

Key Terms

Facility design

Healthcare system

Health technology assessment (HTA)

Prearchitectural medical functional program

Regionalization

Sustainability

Key Concepts

Facility design

Facility management

Low-resource management

Medical equipment

Operations management

Organizational design

Performance improvement

Physical resources managementFacility design

Introduction

We can define the most important functions of healthcare organizations using a systemic analysis inspired by Avedis Donabedian's (1988) original conception of structure, process, and outcomes. Exhibit 1.1 shows how, as the population and the healthcare organization interact, the system aligns the available or required resources to produce the key notions of utilization, access, productivity, efficiency, and effectiveness, which interact to shape the organization's performance. Performance, meanwhile, depends on the competent actions of healthcare managers and other human resources in the organization.

Since the mid-1900s, the functions, responsibilities, and competencies of healthcare managers have developed in different ways around the world. In the United States and Canada, the role primarily developed as a postgraduate specialty supported by the W. K. Kellogg Foundation under the umbrella of the Association of University Programs in Health Administration (AUPHA). A handful of university programs were established in 1948. As demand grew and the healthcare field expanded, new graduate and undergraduate university programs developed in a number of schools related to health or management disciplines (Counte, Ramirez, and Aaronson 2011).

Around the world, a number of countries—and a number of locations inside countries—have developed a strong alignment of professional healthcare managers across healthcare organizations; other locations, however, have almost no notion of healthcare management as a profession. In some countries, clinicians are promoted to serve in managerial roles at healthcare organizations without first having had the opportunity to acquire management competencies (West et al. 2012). The International Hospital Federation (IHF) has created a special interest group in health management to promote the professionalization of the discipline and the use of a leadership competency framework to improve the impact of managers at all levels of organizations and health systems (IHF 2015).

The main functions of healthcare systems and organizations in the continuum of care are financing, provision of health services, stewardship, and resource development (Frenk, Góméz-Dantes, and Moon 2014). Of these functions, provision of health services and resource development are key, and they are the ones further explored in this chapter. Provision of health services starts with sound planning and effective/efficient organization. Financing is addressed in chapters 2 and 3, and stewardship is discussed in chapters 6 and 11.

The Performance of Health Systems: Six Core Domains

Healthcare organizational performance around the world was the focus of an extensive study sponsored by the World Bank, in which investigators conducted a thorough literature review and developed a guide to concepts, determinants, measurement, and intervention design (Bradley et al. 2010). The World Bank report examined six core performance domains:

Access

Utilization

Efficiency

Quality

Sustainability

Learning

The first four domains are related to the iron triangle of healthcare, a concept that was introduced by Kissick (1994) and later provided the basis for the triple aim initiative developed by the Institute for Healthcare Improvement (IHI). Kissick's iron triangle consists of access, quality, and cost containment, whereas the IHI's triple aim adds the dynamics of population health (IHI 2012).

Access incorporates several dimensions—physical access, financial access, linguistic access, and information access—that are supplemented by service availability and the provision of nondiscriminatory services. Equitable treatment should be provided regardless of gender, race, ethnicity, religion, age, or any other physical or socioeconomic condition. Utilization includes dimensions of patient or procedure volume relative to capacity or population health characteristics. Efficiency is determined by cost- or staff-to-service ratios and by patient or procedure volume. Quality includes clinical and management quality, as well as patient experience.

The last two domains—sustainability and learning—are key to ensuring constant, self-propelled growth in an ever-changing, complex environment such as healthcare. Sustainability in healthcare can be defined as the capacity of health services to function with efficiency, including the financial, environment and social interaction that guaranties an effective service now and in the future, with a minimum of external intervention and without limiting the capacity of future generations to fulfill their needs (Ramirez, Oetjen, and Malvey 2011, 134). Sustainability can be considered from two distinct perspectives or dimensions. The first perspective focuses on the sustainability of processes that create a basic functional network throughout the organization, allowing for flexibility and quality improvement—both of which are necessary for the dynamic change environment of healthcare. The second perspective deals with organizational sustainability, and it includes five multidimensional pillars:

The environmental pillar represents the initial point of focus for sustainability, and it includes—but is not limited to—the use of clean and renewable energy and the conservation of the natural environment. This pillar incorporates recycling techniques to preserve the quality of the atmosphere, to reuse solid and liquid waste, and to safely dispose of contaminants.

The sociocultural pillar strengthens community support and promotes the identification of key cultural, ethnic, and other values among the community of staff, patients, and users. It incorporates population health and social marketing strategies.

The institutional capacity development pillar promotes the strategic management of the organization. It aims to strengthen competencies at all levels and instill an empowering knowledge management culture, facilitating coordinated efforts of governance, leadership, and personnel integration and participation.

The financial pillar ensures the delivery of healthcare programs and activities that are cost effective and efficient in the use of resources. It is indispensable for achieving the organization's goals and objectives.

The political pillar involves staff, patient, and community advocacy to advance the interests of the organization.

Finally, the learning domain empowers the organization to adapt to change and to explore and adopt innovations. It incorporates efforts to use data audit and feedback processes, to distribute relevant information and provide patient education through partnerships with the constituency, and to implement training and continuing education initiatives for the healthcare workforce.

The Challenge of Organizing Health Services Resources to Achieve Optimum Performance

The provision of universal access to optimal prevention, care, cure, and rehabilitation can be considered an ultimate goal of healthcare. Most governments, either directly or indirectly, subscribe to this goal; the challenge is—given the limitations of resources and entrenched infrastructure—achieving the greatest possible return on the investment toward reaching it. All countries, regardless of their level of wealth or industrialization, are limited in their ability to achieve this goal, often because of political philosophies expressed as public policy. Even those nations in the most favorable positions often lack the will or capacity to translate their knowledge of what is possible into practice for the benefit of all people.

Over many years of technological development and interaction among professional, political, and economic forces, three enduring organizational foci have emerged for achieving the optimum health status for a population. They are (1) hospitals, (2) primary care provision, and (3) regionalization.

Hospitals

In every country, hospitals are the most visible symbol of healthcare development and care for the sick. They represent public assurance that there is a place for people to go for care when needed. Hospitals are also important economic engines, generating employment and anchoring the economies of communities. They consume a large portion of the health sector resources in many countries.

The hospital is arguably the most complex contemporary organization to manage. Hospitals, particularly in developing countries, struggle internally with inadequate management and governance; limited sources of income; insufficient human resources; poorly planned, financed, and maintained physical plants; and rudimentary quality controls. At the same time, they are often buffeted by such external forces as regulations, competition, inadequate payment systems, and conflicting service demands.

Experts from a number of countries, the World Health Organization (WHO), and the international development agencies of industrialized nations came together in an extraordinary meeting to address the challenges facing hospitals today and going forward (German Federal Ministry for Economic Cooperation and Development [BMZ] / German Corporation for International Cooperation [GTZ] and WHO 2010). The meeting was based on the premise that the role of hospitals should change within the upcoming decade, and it sought to clarify the critical issues concerning hospital reform. It also sought to formulate a plan to address those issues. There was no official follow-up to the meeting, but the consensus sent a powerful message to the policy community. The key issues identified by the meeting are as follows (BMZ/GTZ and WHO 2010):

Clarifying the role and function of hospitals in the health system

Political dimensions and expectations of hospitals

Hospital isolation in the face of blurring demarcations

Linkages between hospitals and other levels of the health system

Cost and benefit of technological progress

Data to measure hospital performance in relation to population outcomes

Universal coverage and accessibility

Hospital financing within overall health spending

Hospital governance and autonomy

The legal framework within which hospitals operate

Human resources

Involvement of private hospital actors

Hospitals in a global health marketplace

Hospitals and the wider economy

There is no better summary of the challenges facing hospital and health system administrators and planners.

Primary Care Provision

The development of primary care has emerged as the central strategy to achieve universal access, comprehensive care, and cost containment, not only in developing countries but also in industrialized countries. The goal for low-resource societies is to provide essential services that are realistically within their reach, with community participation. WHO (1978) has promoted primary care development since the Alma-Ata Declaration of 1978. The declaration was formulated by public health leaders who were largely committed to the position that healthcare is a right and that the state has the responsibility to provide it.

Alma-Ata created an enduring tension between two ideal models—a hospital-centric ideal model of health system development, with overtones of private practice and specialization, and an ideal model based on publicly supported community-based primary care providers, with the hospital in a supporting role. The conflict between the two ideal models was summarized by Frenk, Ruelas, and Donabedian (1989, 1):

In most developing countries the concern is that…[hospitals] already absorb such a high proportion of resources that they seriously threaten any effort to achieve full coverage of the population. Furthermore, it is widely believed that a health care system centered around hospitals is intrinsically incompatible with the geographic, economic, and cultural attributes of many populations. In addition, the mix of services offered by hospitals…is believed to poorly match the prevailing epidemiologic profile and the population needs for preventive and continuous care.

Gillam (2008, 537) assessed the practical impact of the Alma-Ata Declaration on governments’ policies and actions, noting that early efforts at expanding primary care in the late 1970's and early 1980's were overtaken in many parts of the developing world by economic crisis, sharp reductions in public spending, political instability, and emerging disease. The social and political goals of Alma Ata provoked early ideological opposition and were never fully embraced in market oriented, capitalistic countries. Hospitals retained their disproportionate share of local health economies.

In setting out a model of a preferred future, the WHO (2008, 55) states: Primary-care teams cannot ensure comprehensive responsibility for their populations without support from specialized services, organizations and institutions that are based outside the community served…[and] typically concentrated in a ‘first referral level district hospital.’ Assuming that, in many countries, most of the existent service deliverers are controlled by the system designers, the model calls for coordination of all resources to be vested in the primary health team, presumably mandated by law in most cases. Under that premise, The primary-care team becomes the mediator between the community and the other levels(WHO 2008, 55).

It is important to emphasize that primary care systems are ultimately dependent on hospitals. To be comprehensive, a system must have a hospital available to treat complicated, often life-threatening cases. The system also must be able to receive trauma cases from rural employment and transportation situations that far exceed the competencies and resources of primary care. Patients who are unable to access community and primary care services have been known to travel great distances to reach the nearest hospital in case of emergency.

Regionalization

Regionalization is the third enduring organizational focus, but a specific definition of the term is evasive. The term has as many definitions as it has plans and applications. Roemer (1965) stated that regionalization cannot be defined on the basis of experience but that agreement can be reached with regard to its objectives. The following general objectives have emerged, with a degree of agreement across applications, as central to the regionalization process:

The efficient utilization of limited health resources

The efficient utilization of expensive health resources

The provision of adequate, appropriate, and accessible health services to a population

The improvement and maintenance of standards of health services provision

The application of the concept of regionalization to healthcare provision can be traced back more than a hundred years. The event that had the broadest global impact was the United Kingdom's 1920 Interim Report on the Future of Medical and Allied Services, commonly known as the Dawson report, after Sir Bertrand Dawson, a physician to the British royal family. The report proposed a comprehensive national organization of health services that was organized around base hospitals and integrated most services in defined regions of the country (Consultative Council on Medical and Allied Services, Great Britain 1920). The United Kingdom implemented the report's basic principles in the country's National Health Service over the course of 28 years. The Dawson report has influenced health systems in a variety of countries, particularly in Europe.

Dawson proposed dividing the country into regions that would (eventually) meet most of the preventive and curative health needs of the population. Specialized, scarce, and expensive services for a wider area (or country) would be available on referral but not duplicated at the regional level. The services of hospitals would be defined according to a classification system, thereby ensuring access to basic services while avoiding competition and underuse. The influence of Dawson's emphasis on the integration of preventive and curative resources to achieve a more effective investment balance cannot be overstated.

Hospital-centered regionalization has become a widely discussed approach to health system organization in a number of countries, particularly in Europe but also elsewhere. For instance, the Chilean National Health Service reorganization program, which started in the 1960s, created hospital areas with the understanding that a hospital would have full responsibility for the health of the population within its service area. With all health activities linked to the hospital, clinical physicians would have to be directly involved in the field programs, potentially leading to the effective integration of preventive and curative medicine. At the time of the program's implementation, private hospitals were not included; the director of the area was to be the director of the largest (frequently, the only) hospital in the area.

The rationalization of health-provision resources to serve a defined population—be it a country, region, district, or community—is a very appealing idea. In theory, it is most likely to succeed in a central command-and-control political system, wherein one owner has control over all the components. However, that theory assumes that the full range of essential services exists or is accessible in each region. Application becomes more complicated—and potentially unrealistic—when applied to pluralistic environments with diverse financing schemes, multiple ownerships, local governments, advocacy organizations, and competing demands. Also, of course, additional complications follow from the differing political philosophies about the role of the state.

One key organizational issue focuses on how to integrate new knowledge into the capital planning process. Another issue deals with reducing the duplication of diagnostic services that can be provided electronically to many hospitals. An additional question is how to create incentives in the capital management process that will modify internal organization and facility design to support such changes (Edwards, Wyatt, and McKee 2004).

Kenya's pluralistic environment provides an example of how the role of the private sector can be constrained by the lack of access to capital. A substantial portion of care is provided by private for-profit and faith-based hospitals that have difficulty obtaining loans. As a result, funds are not available to start new hospitals, or to improve or replace existing facilities (Barnes et al. 2010). In Benin, banks generally loan only to large, well-established hospitals that are managed or owned by well-known doctors, and smaller enterprises are rarely considered. Capital funding limitations can also result from poor management skills, difficulties with property titles, and lack of collateral (Strengthening Health Outcomes Through the Private Sector [SHOPS] Project 2013).

Addressing these issues will require an understanding of global experience and an emphasis on the development of leadership and management competencies. The professionalization of healthcare managers will be indispensable in advancing the effective and efficient use of organizations’ resources.

Organizational Planning and Design

Organizational planning and design enable managers to align the healthcare organization's functions and resources with its mission, vision, values, goals, and objectives. The planning process incorporates a variety of tools to facilitate work relations and interactions, efficient resource allocation, and effective decision making.

The challenges facing healthcare managers can be either internal or external to the organization. One of the most important internal challenges involves the increasing technical complexity of the services being provided, which stems from continually changing medical technologies and the diversity and professional autonomy of the health professionals who interact in the delivery of services. Other internal and external challenges are associated with healthcare managers’ need to balance the components of the iron triangle. Balancing access and equity with efficient, cost-effective services and quality outcomes requires robust organizational design and planning, as well as flexibility to confront the dynamic conditions of the healthcare environment.

Organizational designs take as many forms as needed to address the uniqueness of a dynamic organization. The designs are usually reflected in an organizational chart that describes the relations, authority, responsibilities, and interactions of the different units and individuals. Other documents and tools—such as organizational manuals, job descriptions, policies, regulations, and legal or administrative documents—also describe the various functions, resources, and responsibilities in more detail. A number of these tools are described throughout this book. Some tools commonly used in the planning process are flowcharts, affinity diagrams, Gantt charts, and balanced scorecards. In large and complex organizations, and across countries and healthcare systems, increasingly comprehensive information systems and the application of informatics are now indispensable.

Several questions need to be answered before an appropriate organizational design can be determined. For example, how can we design an organization that responds to the pace of change and complexity of the external environment? How can we create a simple enough organization that presents clear responsibilities for all areas of the organization while responding to complex interrelations and problems that need to be solved? How can we incorporate clinicians and managers in the decision-making process? How do we create strong supporting guidelines throughout the organization while at the same time allowing some level of autonomy and empowerment for the providers and units (Baker, Narine, and Leatt 1994)?

An organizational chart can be presented in a variety of ways, and there is no clear best organizational design. Most organizations will use combinations of design types, most of which derive from three basic formats—functional design, divisional design, and matrix design. Functional design is the most traditional of the formats, and it is well suited to organizations that offer well-defined services or products, respond to slower environmental changes, and have clearly defined stakeholders. Divisional design works better in larger organizations with multiple product or service lines that can be grouped into larger divisions. Finally, matrix design is most appropriate for organizations that must respond to rapid changes in technology or highly dynamic or competitive environments. A variation of the matrix design is the program design, which combines substantive areas and strong, well-differentiated programs with complex and unique requirements for performance. These design formats have been used in all types of healthcare organizations, and each includes elements that can effectively contribute to organizational success. It is relatively common for organizations to adopt hybrid models or change their organizational designs to respond to specific circumstances.

Management of Physical Resources

How do organizational processes determine the physical design and structure of healthcare organizations? This discussion will focus on two main elements. The first element involves the planning processes of healthcare units, of which a critical component is the development of a prearchitectural medical functional program that defines the services to be offered and the resources required. The second element involves the supplies and utilities needed by healthcare units (e.g., electric power, water, fuels, medicinal gases, telephones, internet), which can be provided by either public services or private companies. The processing and distribution of these supplies take place in the house of machines, which serves as the nuclear resource for the units’ function and connects the operation of all systems (e.g., electric, hydrosanitary, air conditioning, telecommunications, information technology). These activities enliven the elements and allow the optimal operation of functional units or facilities, administrative services, and support services as an integrated, efficient, and effective operation.

Clinical units, administrative units, and the resources of general support services that were defined in the corresponding prearchitectural medical program are distributed among the hospital buildings. Each functional unit has its own structure with respect to physical, human, material, and technological resources. The units carry out processes that transform the resources into services, the results of which are generally evaluated with indicators of quantitative and qualitative performance. Each unit receives general support services, including maintenance of architectural finishes, furniture, facilities, and equipment; cleaning and disinfection; disposal of waste; and the supply of inputs required for operation. These elements and their interrelations are illustrated in exhibit 1.2.

The construction and operation of healthcare units are strongly regulated by laws, rules, and norms of compulsory observance, typically to ensure quality, preservation of the environment, and health and safety in the workplace. The operation of the units generates liquid, solid, and gaseous waste, the management of which must be in accordance with legal provisions intended to control the pollution of air, land, and water mantles and to avoid risks to the health of patients, users, service providers, vendors, and visitors to the units. Because of safety concerns, particular interest exists with regard to proper management of equipment and substances that emit radiation and biological products capable of generating infections.

Current trends support the efficient use of energy and the use of renewable energy to promote a less costly and more environmentally friendly operation. Such trends can be seen in the use of solar panels for the heating of water and photovoltaic cells for the generation of electric power, as well as intelligent systems that control lighting and air conditioning.

Water management seeks to ensure water availability, storage, and potability, to maintain both a continuous supply and a critical reserve in case water availability is suspended, which may happen during natural disasters. Potable water is critical both for ingestion and for use in processes of care that require efficient washing of hands, surfaces, and equipment. Wastewater treatment plants can be used to recycle water and reduce consumption, leveraging water to recharge the subsoil, to water gardened areas, and to use in health services.

Solid waste management is of the utmost importance. Classifications for solid waste management include organic and inorganic waste, potentially contaminated waste, and waste that requires special management because of strict regulations regarding its collection, storage, transportation, and disposal.

Health units’ internal and external communication requires a complex telecommunication infrastructure, internet connectivity, and systems that allow the efficient management of voice messages and data. Such systems are particularly important for the electronic registration of various transactions and interactions necessary for the operation of the unit.

The Planning Process

During the planning process for the construction of healthcare units, a number of elements are taken into consideration: location and geographical area of influence; the target population, with its demographic and epidemiologic profile; the types of services to be offered; and market analysis with respect to offer and demand of services both public and private.

Based on the preliminary information, a prearchitectural medical functional program is developed. This program defines the services that will be offered and any required physical spaces in accordance with the applicable regulations. A key challenge is to articulate the requirements to create functional units equipped with all the necessary resources to ensure their correct operation. At the same time, additional challenges involve making sure that the interrelations between the clinical units and the support services establish a pattern of consistent functionality and maximize efficiency to users, staff, and suppliers of goods and services. The dimensions and orientation of the land to be used for the construction will affect the number and configuration of the levels to be built, as well as the distribution of services to be provided.

The functional medical program provides the basis for the development of the architectural project, which in turn will produce functional units with appropriate furniture and equipment. Given the highly specialized and constantly evolving nature of hospital services and medical technology, this plan needs to be developed by a group of experts in hospital design, with participation of both architects and the operators of health units.

The architectural project must comply with the established framework of laws, regulations, and standards. It should keep in mind the following considerations:

Installed capacity that responds to the needs of the target population, as well as the provision of personal clinical services

Sufficiency of resources to achieve the goals and objectives (productivity) outlined in the business plan

Functionality (efficiency and effectiveness) in compliance with current regulations, to ensure regular and emergency access to clinical healthcare services with comfort and security for staff, third-party suppliers, patients, and their families

Once the clinical and support units (e.g., outpatient care, emergency care, hospitalization wards, diagnostic support units, general and administrative services) and their specific capacities (e.g., numbers of offices, cubicles, operating rooms, warehouses, waiting rooms) have been defined, the final considerations for the functional plan involve determining the medical and instrumental equipment required for the operation of the various units. Decisions made at this point will depend on the financial resources available and the level of complexity expected for a particular medical facility.

Once the prearchitectural functional program has been developed and adjusted, the executive project defines all systems, facilities, and equipment that will require supplies and utilities such as water, drainage, electric power, hydrosanitary services, air conditioning, medical gases, fuel, and telecommunications. These needs are reflected in a program with a phase-in plan that considers the stages required for construction, facilities, equipment, preoperation, and commissioning of the units in question.

The next step involves carrying out the executive project, which requires the development of the operating systems necessary for the installation and provision of the projected utilities and supplies. Project leaders should consider environmental and safety implications and ensure full compliance with regulations and standards for construction and facilities. They should also take into account the requirements that may need to be met in the future to achieve certification from accreditation agencies, such as The Joint Commission in the United States.

Execution of the project requires a project management program that elaborates required tasks, equipment and other resources, and the responsible parties. The project management program takes into consideration the span of time required for various activities and tasks, sets targets for their conclusion, and facilitates coordination between components. A variety of project management software programs are available to assist with this step. Depending on the unit's magnitude and complexity, the management of the project or supervision of work can also be contracted to a third-party company that has experience with similar units.

Of particular importance is the definition of the management model to be used to operate the healthcare unit. Selection of this model considers the strategic framework (i.e., mission, vision, values, goals, and objectives); the organizational model; the desired measures of effectiveness; the distribution of resources and workforce; internal operation manuals; work regulations; rules, both internal and external; and market and/or operational plans and programs. Specific calculations need to be made for the supply and consumption of various materials, including items needed for office operations; food and medical supplies; emergency and regular maintenance materials; and tools and equipment.

Health need assessments and the steps outlined in this section can determine the amount of investment required, as well as the cost of the operation, for a unit. This information, in turn, can inform the development of a business plan to identify the feasibility and sustainability of the proposed facility or unit.

Functional Unit Requirements

The requirements for the operation of a health unit should be assessed using the management model, with attention to organizational design, the staff or personnel necessary to meet the established work shifts, job positions and descriptions, organizational procedures and manuals, rules and regulations, and necessary inputs. Planning for the design, operation, and use of resources is influenced by such factors