A Report in Organization and Management Structure and Design

Norman Rey G. Reyes

SETTING OBJECTIVES IN THE HEALTHCARE INDUSTRY

It is noted that in different types of health care organizations each of which have different fundamental goals or objectives, and these differing objectives can strongly affect the managerial activities of the organization. In order to put these objectives into the perspective of the health system, it is necessary to establish a definition of system. Several historical ones are quite useful. For example, a system has variously been defined as: an organization of interrelated or interdependent parts that form a unity, a set of parts coordinated to accomplish set of goals, and an organized or complex whole: an assemblage or combination of things or parts forming a complex or unitary whole.

Goals
Goals are specific statements of outcomes that are to be achieved. They provide direction and vision for actions as well as a timeline in which activities will be accomplished. Defining goals and time frames helps reduce stress by preventing the panic people often feel when confronted with multiple demands. Although time frames may not be as fast as the nurse manager would like (the tendency is to expect change yesterday), necessary action have been identified.

Real and Stated Goals

What is the objective of the health system and its organizational components such as hospitals, ambulatory care centers, and even physicians offices? Is its objective to raise the health status of an individual or a community, or simply to deal with symptomatic problems? An answer to that question must begin with the realization that can be both real and stated. For example, oftentimes one can hear administrators of healthcare facilities and programs say that they have three goals: teaching, research, and service. But what are the real goals? What do they actually when they say teaching, research and service? What is behind such a goal?

OBJECTIVES The Department of Pediatrics has been committed to the goal of providing complete undergraduate and postgraduate education in Pediatric Medicine. Hopefully, this goal will be in congruence with the national goal of providing for the health care of Filipino children and with the college goal of producing a well-rounded medical practitioner and pediatric specialist, as the case may be. 1. Education and Training a. To provide academic courses for the undergraduate medical student that will enable him to acquire knowledge, skills, and attitudes which would contribute to his development as a basic physician. b. To provide formal courses and clinical programs for the resident physician-in-training to acquire knowledge, skills, and attitudes that will contribute to his development as a general pediatrician. c. To provide post-residency training opportunities for the pediatrician to acquire knowledge, skills, and attitudes in relevant Pediatric subspecialties. d. To provide continuing medical education courses in pediatrics for general practitioner, general pediatrician, residents, and other health sciences personnel. e. To provide opportunities for graduate studies through masterate/diploma courses in Clinical Medicine (Child Health) and two-track residency and fellowship programs. f. To provide resources and opportunities for faculty development. 2. Research a. To promote an atmosphere that will encourage and facilitate research. b. To provide resources and opportunities for faculty, fellows, residents, and undergraduate students to do investigative work in pediatric areas of interest (basic, clinical including delivery of health care, pediatric education). 3. Service a. To provide resources for quality comprehensive pediatric care in both the in-patient and out-patient areas. b. To participate in local / national health care delivery and referral system. To be able to work as a member of a team in whatever situation, be it community or hospital-based. c. To be teachers and leaders both in the academe and in the community. d. To pioneer/get involved in community development/outreach programs that redound to better pediatric care, both for the healthy and sick newborn infant, child and adolescent.

A controversy about poor quality obstetrical care and the use of midwives raged in the United States and Great Britain in the late 1800s and early 1900s. What was behind the stated goals of the physician leaders of this profession? The solution developed in Great Britain was to educate, license, and upgrade midwives so that they had the role and responsibility in the medical system of providing normal obstetrical car. On the other hand, the controversy over responsibility and authority for delivering normal obstetrical care continued in the United States for decades.

The controversy pitted those physicians trained in the new specialty of obstetrics against the rather disorganized group of traditional providers, that is midwives. Even the American Medical Association had a surprising position on this issue. In 1912, its president, Dr. Abraham Jacobi (for whom a major teaching hospital in the Bronx is named), pointed out in his inaugural address that the current view of midwives as dirty and sloppy women was based not on fact but rather conjecture and that, if clinical facts surrounding obstetrical care were examined, physicians, not midwives, would be eliminated. What, then, motivated distinguished professors (primarily from Johns Hopkins University) to work so assiduously to eliminate midwives? Was it simply that the midwife provided poorer quality medical care? According to some sources, the goal was to eliminate midwives in order to provide the appropriate volume of patients for fledging physicians to practice their new skills. Further, once these skills were learned, midwives have to be eliminated if physicians were to build practices to support themselves. Others, however, have argued that midwifery died because of the new immigrant considered seeing a physician to be the modern way, while midwifery was considered old-fashioned.

Regardless of the reason, it is obvious that midwifery essentially passed the scene for decades, even though there was no clearly defined medical care objective in its elimination. More recently, other public and private policy, the house has been eliminated. Was this a deliberate objective of the health system? Indeed, was it in the best interests of the health status of the individual and community, or rather in the best interests of the providers and/or the organized arrangements for delivering the services?

Another issue or example is the concept of prisons for determining real versus stated goals. Many wardens, sheriffs, or court officers state that prison is a place of rehabilitation; other say that it is the place where offenders go to pay their debt to the society or, to put it another way, that it is a place for punishment. Essential to all of these stated goals is the real goal; a prison is an institution organized by society to segregate people from free society for some period of time. Although never overtly stated, one of the clearest goals of any prison or jail is that of keeping certain people locked up.

Goal Setting
Individual or organizational goals encourage thinking about the future and what might happen, what one wants to have happen, and what is likely to happen. Goal Setting helps to relate current behavior, activities, or operations to the organizations or individuals long-range goals. Without this future orientation, activities may not lead to the outcomes that will help achieve the goals and meet the ideals of the individual or organization. The focus should be to develop measurable, realistic, and achievable goals.

It is useful to remember that goals are set in a variety of ways and that organizations often have multiple and sometimes conflicting goals. Indeed, the manager is frequently charged with resolving the most serious of these conflicts. In general, goals are set as a result of four major factors: (1) politics, (2) economics, (3) constituencies, and (4) organizational personalities.

Politics
Politics are local, national, regional, and environmental or internal. For example, the sheriff and the mayor of a southern city realized that the health and medical conditions of a prison, which had already resulted in a federal lawsuit, would prove an embarrassing political issue during a forthcoming election unless the situation were cleaned up . Further, they envisioned the possibility of amassing some political capital from developing a model health system. Internally that is, within the prison the feeling was that the system was simply out of control and the warden and sheriff were being used for the political purposes of the medical department. Thus, to some extent, a desire for change was dictated as a convergence of local political needs.

Economics
Always an important factor, economics is becoming an even stronger in the setting of organizational goals. The conventional wisdom in health care is that the demand for services comes from outside. The patient walks in, states a complaint and symptoms, and goes through the usual examination. Despite what the consumer may think or feel, it is the health professional who turns on the effective demand of the system.

Constituencies
Community groups have grown more vocal about their desires and sometimes these desires, which are wrapped in the mantle of medical care, are masking something else. For example, are the goals of the neighborhood health centers to provide medical care or to provide jobs?

Organizational Personalities
It is imperative to recognize the importance of the individual in setting organizational goals. At the national level, a president can restate and reorganize national priorities. One leadership position can have power and choose to exercise it. For example, a new director of a medical center was able to shift the goal of that seemingly highly controlled organization from that of being a self-sufficient non communityoriented organization into that of being an organization that is an integral part of the economic and professional life of a community. Examples abound in the managerial literature about the role the individuals can and do play in the leadership and management of organizations.

A new chief financial officer (CFO) decided to do a careful audit and learned, amongst other things, that the financial health of the organization was dramatically worse than the board president was presenting to board and the public. The CFO documented his findings and offered a belttightening and revenue generating solution for the future. By acknowledging the accuracy of the CFOs analysis, however, the president would be admitting that he had for years been steering the organization off course. So, instead of making the called-for changes, he simply fired the CFO and installed a yes man as the top finance person. The organization eventually went into financial extremis.

A chief executive officer (CEO) or board president who has clear organizational goals but whose goals are rarely articulated to the organization as a whole. Whether it is the leaders brilliance, insight, or luck the organization becomes successful for number of reasons.

IDENTIFICATION OF ORGANIZATIONAL GOALS

Identifying organizational goals gives the new manager the necessary bearings to chart a suitable personal course in the organization. The identification of goals has value to the organization in three major ways: orientation, legitimization, and measurement.

Orientation
Goal identification provides an organization with a certain direction, or orientation, that can and does help in the shaping of planning and policy directions. In practice, however, most organizations, particularly health care ones, it sometimes seems, have such general goals that they can and do fit into their plans whatever makes sense at a given time. To be less charitable, it could be said that most of these organizations are simply responding as typical economic opportunists. Orientation has an important influence on the resources that are attracted to an organization. Managers who seek positions are or should be interested in the goals of the organization with which they are likely to be associated.

Legitimization
Goals, both stated and unstated, have a way of providing their own legitimacy for an organizations or individuals activity. If a voluntary organization has a goal of providing health services to homebound individuals, it can, with great ease, legitimately extend its boundaries of operation to include a gamut of activities that are not thought of as traditional health services.

The most dramatic example of this, which has already passed into the folklore of American medical care, is the work of Dr. Jack Geiger at the Delta Health Care Center in Mound Bayou, Mississippi. When he and his team arrived in that depressed area to set up a health center funded by Office of Economic Opportunity, they found the social and economic problems to be considerably more pressing than the health problems. Their solution was not simply to prescribe drugs but to prescribe other necessities most notably, food. Within the context of the general goals of those programs, what Geiger and his group did was unique, but it was also within the legitimate goals of the program. With no goals or only the vaguest , it is difficult to win support for virtually anything and even more difficult to sustain support.

Measurement
Most people have been socialized from early childhood to achieve in one way or another. Growth charts, scales, reports, and myriad another types of documentation make it clear that some predetermined goals should be met. The underlying problem in all of this is that most people also have a natural tendency to set goals that can be measured, even though those measurable goals may have little to do with what is to be achieved. It is difficult to measure progress toward a goal when that goal is unclear, unidentified or controversial.

CONSTRAINTS ON HEALTH SYSTEM GOALS

A consideration of the stated and real goals of the health system is important to management, since so much of managerial behavior is related to an organizations goal. It must be recognized that the health system has significant constraints on its goals.

Legal Constraints
Court-rendered health definitions of health have profound operational implications; a courts interpretation of health can grant or deny jurisdiction to a health department or agency, deny or award claims for insurance and injuries, close down businesses, and enforce warranty provisions.

Political Constraints
The political process can and does shape or even distort goals. One example is, legislators in Louisiana about the significance of various health status indicators on their budgetary decisions. In general, the indicators that were important to these politicians were those that are most commonly heard, although not necessarily understood, such as infant mortality rates.

Professional Constraints
The role of professionals in setting goals for healthcare organizations cannot be minimized. To conceptualize this point, it is necessary to understand something about the ritual that physicians, the group that whom most managers have to work most closely, have passed though en route to their medical degree. This ritual of an extended educational experience, the acquisition of social and technical skills, and a value system that is the exclusive property of the professions results in a professional philosophy that holds as almost sacrosanct the idea of autonomy. Only the members of the profession are qualified to evaluate or discipline other members. The loyalty of most professionals is to their profession, not to the organization for which they work. Their goal orientation, then, is toward professional goals; in medicine, for example, these goals might be technical excellence rather than an organizational goal. Conflict comes when the professions goals diverge form that of the organization.

Kiong Hee Huat Tsai!