Understanding hospital performance: an empirical study

Abstract

The different categories of hospitals in India (government, voluntary, for-profit), have different ideologies which have traditionally governed their ways of functioning. With the contexts they work in getting increasingly difficult, they are being forced to change without a clear understanding of how to achieve better performance, nor of what the role of their ideologies is. This research attempts to develop this understanding. The review of literature identified several aspects as being keys to better performance. The theoretical model ascribed hospital success to achieving a alignment of these aspects which was appropriate to the environmental imperative on the one hand and to the sectorial imperative (the demand arising from the nature of the hospital) on the other. Twenty hospitals in Tamil Nadu (10 missions and 10 governments) were studied. The doctors and nurses in these hospitals were surveyed with a questionnaire; top management, staff and patients were interviewed. From the performance data collected, four measures of performance were used: job satisfaction, perceived patient satisfaction, number of outpatients per doctor, and CEO rating of effectiveness of strategy implementation. After principal components analysis of the responses, the average component score of the respondents from a hospital were used as the hospital score for each factor. The principal findings relating to the question’ how to achieve better performance’ were as follows: 1) Better performance was achieved by adopting a strategic posture appropriate to the degree of uncertainty in the environment. High uncertainty in the environment demanded an entrepreneurial posture while low uncertainty was best handled by a conservative posture. 2) Better performance was achieved by also simultaneously nurturing a commitment climate appropriate to the needs of the organization. The bases of the attachment of individuals to three foci of commitment – the hospital, their profession (doctor/nursing) and the patient – constituted a composite commitment profile. There were two types of commitment profiles associated with better performance – facilitative commitment and non – facilitative commitment. A ‘Facilitative Commitment’ is one by which an individual will respond appropriately to different situations without the need for externally – imposed instructions or constraints. In a ‘Non-facilitative Commitment’ appropriate responses do result, but only when prodded by means external to the individual – rules, threats, etc. The need for the particular type of commitment (facilitative or non-facilitative) depended on the ‘organizational imperative’. This refers to the demands imposed by the organization’s own needs, and requires a specific response in terms of an appropriate commitment profile. A high organizational imperative would demand a facilitative commitment profile, and a low organizational imperative, a non-facilitative commitment profile. The configuration of the ‘facilitative’ and ‘non-facilitative’ profiles were different for government and mission hospitals because the contexts in which they operate are different. The profiles reflect ownership, patient expectations, environmental pressures, organizational constraints, and organizational objectives. 3) Fuzzy administrative structures and plural norms sustained both an entrepreneurial strategic posture and a facilitative commitment profile. Crisp administrative structures and singular norms sustained a conservative strategic posture and non-facilitative commitment profile. The hospital has two kinds of work and the indirect ‘administrative’ work. Because of the nature of the hospital each of these are important and can be expected to have independent bearing on organizational outcomes. In the hospitals studied, the structures in the administrative and patient care situations had similar dimensions but were often different within a hospital.

Four norms were identified in the hospitals studied: Excellence Norm, Efficiency Norm, External Image Norms, Commercial Norm. a Plural norm pattern means that two or more norms are being strongly emphasized. A singular norm pattern means that one norm is much more strongly held than others, and has the dominant influence on decision-making.

As with functional commitment profiles, the specifics of what constitutes a fuzzy or a crisp structure as also the nature of plurality differed from mission to government sector. As in the case of functional commitment profiles, these differences reflected ownership, patient expectations, environmental pressures, organizational constraints, and organizational objectives. 4) When there is a high uncertainty environment that in itself (apart from any other reason) necessitates the presence of a facilitative commitment. Thus, in conditions of high environmental uncertainty and strong need for facilitative commitment, better performance was achieved by developing fuzzy administrative structure and plural norms. 5) Among hospitals facing conditions of low uncertainty in the environment, there were some which had a strong need for a facilitative commitment, and other which did not.

a) When there was no need for a facilitative commitment, better performance was achieved by developing crisp administrative structures and singular norms. This also appropriately sustained the conservative strategic posture demanded by the environment. b) When there was a low environmental uncertainty but a strong need for facilitative commitment, better performance was achieved by keeping a conservative strategic posture as demanded by the environment, but by developing fuzzy administrative structures and plural norms so as to sustain the facilitative commitment. This is inspite of the evidence from the research suggesting that a conservative posture will not be efficiently sustained by a fuzzy structure-plural norm combination. 7) Better performance also included ensuring coherence between norms, workplace structures and commitment climate so as to create the appropriate atmosphere at the patient-provider interface. Hospitals in which these three aspects did not represent a coherent effort to create the right atmosphere were not better performers.