"Balancing Act: The Interplay Between Outcomes and Perceptions in Hospital Success"

In my capacity and years as Hospital Administrator I have often pondered on this question and tried to answer it as best as I can. A hospital is today expected to fulfill its basic function of providing healthcare outcomes to all its stakeholders. These include three main groups. 

• The first are service users or patients who seek a cure for their ailments and who seek information about their health in the form of medical education, preventive medical advise support services of rehabilitation. 
• The second are the service providers who include doctors, nurses and paramedical staff. 
• The last are the employees of the hospital who provide support service front office, security and safety, facility management and IT support. 

A smooth Hospital like an organization has many more hidden layers supporting it like nutritional support, transportation services, counseling and much more. 

Any organization especially one with a very old legacy and lineage carries a perception in the minds of its stakeholders which has both positive and negative connotations. Is it important to keep this in mind while becoming part of desirable change. 

Introduction: 

Traditionally the Indian Healthcare and hospitals in particular were slow to adopt management principles. A feeling pervaded the healthcare industry that medicine being a noble profession it was considered bad to think in terms of making profit from human suffering which the hospitals were pledged to alleviate. The business of making Universal Healthcare a right was considered the job of the public sector hospitals and it was thought that the non profit sector would supplement this effort by running charitable hospitals. 

Hospital Administration always seemed to be projected as an easy job and clinicians with no administrative experience were given the job to run hospitals. When I was a visiting consultant I instinctively thought that we as clinicians knew everything and administrators needed to just give in to our demands as we brought the patients and knew what is best for them at all times. Later there was a trend to appoint doctors from the army as administrators, because it was assumed that armed forces personnel had the ability to manage non-medical manpower and infrastructure better. However, there is no data or evidence to suggest that armed forces imported administrators fared any better than civilian doctors. Professionally trained administrators are now much more common in India.

Medical practice Art or Science:

 Over the years there have been major changes in healthcare and the methods of providing the same and this has resulted in hospitals becoming different too. The old traditional clinical medicine based on intuitive judgement and sound clinical examination which is helped and confirmed by a few relevant investigations has been replaced. Medicine was practiced as an art and observation and intuition played a big role in the decision making process. Today, the doctors rely on history and a few examination findings before using sophisticated and precise imaging and diagnostic tests which leads to what is called evidence based medical practice. 

Quality and Standards: 

The changing scenario has led to an ever increasing emphasis on modernization, investment in equipment and improvement in infrastructure making hospitals safer and better. The resultant changes have led to a greater emphasis on standardization of care and maintenance of quality standards. NABH, JCI, ISO are the bodies which have created regulations and standards which are recommended to help improve the quality of care and clinical outcomes. 

Processes vs Perceptions 

 

The above diagram from my favourite book on Hospital Administration summarises the problem clearly. 

Process improvements require rigour training and development and are time consuming and tedious to implement especially in old traditional hospitals with manpower used to functioning in a certain way. Bringing about changes which are driven by compulsion and compliance leads to depersonalization of the practice of medicine. Nurses, doctors and all support staff get caught in documentation and implementation of processes at the cost of relegating the patients care to a lower priority. The technology and Electronic Medical Records and system driven methods of practicing medicines are no doubt important but do land up depersonalizing medicine. Defensive medicine and now AI driven ensure that physicians become slaves of algorithms and standard treatment guidelines. This may reduce errors and medicine may become 6 Sigma compliant but this will not result in making an organisation any different from others. 

Perceptions are made by a culture change and delivered by motivated individuals in organizations especially hospitals with a caring legacy. While hospitals are considered places of suffering every individual in a hospital which has a culture based on the following  principles they create memorable experiences for the patient. 

• Initiative shown as anticipating the needs of the patients before they are expressed. 
• Teamwork shown as in individuals taking responsibility to solve patients problems and working as a team for each other. 
• Empathy shown by acknowledging patients feeling and sharing them as their own.
• Respect for the dignity and privacy of the patients.
• Communication to ensure the patient is explained everything and is told about delays or changes in plans at all times.

This comes from having every employee understanding that it is perception that creates patient loyalty as against patient satisfaction which comes process driven outcomes. 

Improving Outcomes and Perceptions

To Improve

Outcomes	Perceptions
Focus on team responsibility	Focus on personal responsibility
Map and study processes	Take action on information—just do it
Understand process variation	Understand patient perceptions
Improve staff competence & skills	Improve staff behaviors & attitudes
Stress what people should be doing.	Stress what people should be saying
Seek measurable results	Seek to impact impressions
“Zero defects” thinking	“Best possible” thinking
Eliminate carelessness	Eliminate avoidance

            

Conclusion: 

I have come to believe that there has to be a balancing act between Outcome driven quality and Perception driven quality both of which are of immense importance. It is almost like Right and Left Brain with a preponderance of emotional thinking as against analytic thinking. While both are important in my humble opinion the Right brain is right for the hospital, but the left brain cannot and should not be left behind. For me right brain has an edge in the winning stakes as it promotes and creates loyal customers who ensure that they drive by word of mouth publicity other patients to the Hospital.

Vispi Jokhi