Professional management for eye care
The global initiative VISION 2020: The Right to Sight, estimates that only 25 per cent of existing infrastructure is used for eye care, while the target utilisation is set at 90 per cent. This requires a complete reorganisation. Many providers have the potential to significantly enhance their service by adopting professional management practice and new technologies in clinical services. This article addresses this opportunity from a professional management perspective.
The responsibilities of a hospital administrator could be broadly classified as managing patient care, functional areas, support services, and developmental work. Eye care providers need to focus on four key areas. Strategic management to enhance the efficiency of their organisations requires: human resources management; quality management; marketing; and financial sustainability.
The strategic management process starts with a clear and transparent ‘vision’ followed by situational analysis. Annual objectives are agreed upon by studying the magnitude of blindness, unmet needs, and organisational capacity. Objectives are translated into ‘operational strategies’ in the areas of human resources, quality, marketing, and finance. Deviations of actual experience from objectives provide learning experiences which help to fine-tune the strategies. As part of the strategic planning, organisations should consider vertical integration which brings together the following facilities:
- optical shop
- clinical laboratory
Together, these components help towards self-sufficiency of the organisation, and convenience of the patients. In the absence of these facilities, business outlets often exploit patients.
Human resources management (HRM)
Today the success of any organisation is centred on its most powerful resource, its staff. We must invest in the workforce which is the real pillar of an organisation. Personnel policy, covering human resource planning to retirement benefits, needs to be redesigned to delight our own people. Only a delighted employee can delight a customer. HRM is the foundation for quality. Successful organisations honour their people by recognising them as ‘service partners’ or ‘internal customers’. Empowerment, continuous training and development are vital parts of HRM.
Consumerism has entered health care. Patients represent a group of consumers who ask relevant questions, and make their own decisions.1 They look for the right services for the right money, ask questions about treatment options, look for more information, demand convenience, ask for evidence of quality, expect continuity of care, and explore alternative therapies.2
Quality means delighting customers. Customer orientation is the underlying principle of quality. Dimensions of quality, like promptness, accuracy, accessibility, and continuity of care, are focal points. Health care quality is broadly classified as ‘clinical quality’ and ‘quality service’.
Controlling infection, monitoring complications, length of stay, visual acuity, follow-up rate, and safe medication are a few of the clinical quality measures that need continuous monitoring and improvement. Productivity governed by management systems and standard clinical protocols sharpen the clinical skills.
Maintenance needs to be carried out on a number of levels: routine maintenance, for example cleaning and dusting; preventive maintenance, for example the schedule of planned maintenance actions carried out by in-house maintenance staff to prevent breakdowns or the failure of equipment before it actually occurs; scheduled maintenance through contracts with outside specialist agencies; availability of spare parts for equipment.
Providing quality service means ensuring caring, friendly, customer service. Customers view quality through simple indicators such as smiling faces, the smell of fresh linen, general cleanliness and hygiene.
The common citizen does not know where reasonable quality care is available at a reasonable cost. As professionals are reluctant to use marketing as a powerful information tool, many people are misguided by vested interest groups. It is therefore important to understand how best to inform people about the services available, so that they can make sensible judgments when seeking care.
In long-term planning, the emphasis should be on detailed analysis of the environment, particularly consumer behaviour. Most organisations collect no information at all about their consumers. Whatever data they do collect tends to be demographic. Rarely does one see awareness, perception, preference, and usage information. Organisations need to understand how individual patients see, think, feel, and act.3
If a hospital is genuinely interested in the welfare of the patients, reliable information and referral facilities should be available. Continuing medical education for general practitioners, and quarterly newsletters, are some of the ways to strengthen the referral system. Referring doctors look for an immediate response, communication about the health condition of the referred patients.
Promotional tools are powerful communication tools; if used without violating advertising and medical ethics, they help to create awareness and demand for services. Providers need to address patients’ fear of pain, side-effects, lengthy recovery time, and confusion about the extent of recovery. From registration to follow-up, sales promotions could be widely practiced. Corporate hospitals engage marketing executives to strengthen referrals. Camp organisers should see themselves as sales personnel responsible for promoting camps and building relationships with sponsors.
In eye care it has been shown that outreach programmes and patient counselling are powerful marketing techniques to generate demand.
Outreach programmes are essential in developing countries, as people neither have access to care nor awareness of health problems. Screening camps, community-based rehabilitation, and school screening programmes are some of the common approaches used. Planning, community participation, involvement of ophthalmologists, standardised systems and procedures, patient counselling and review are crucial to outreach programmes. Monitoring and reviewing performance and outcomes is important. The number of camps, number of patients examined, patients advised for surgery and operations completed, should be monitored to know how to improve the service. Free care combined with food and transportation enhances the acceptance rate. Patients need to be transported to the base hospital for operations on the day of the camps. Publicity for the outreach programmes also attracts paying patients to the hospital directly.
In many organisations, counselling has been one of the key contributors to dramatic growth. Patient counselling is a simple process of educating beneficiaries about the need and importance of eye care. It builds confidence among potential patients. Counsellors assist patients in decision-making by giving detailed information about the operation, pre-operative care, post-operative care, discharge, and follow-up. Counselling enhances patient satisfaction, and those satisfied patients act as catalysts to bring more patients.
A person who has completed his schooling, and who has good communication skills, could be identified as a trainee. In-house training should cover basic anatomy and physiology of the eye, common eye diseases, general surgical procedures, communication, interpersonal skills, and answers to hypothetical questions commonly raised by the public.
Counselling needs to be supplemented by a model of an eye, IOL, and information materials printed in the local language. Counsellors should educate the patients on safe medication and personal hygiene. The outcome is better when the relatives of the patients participate. Patients are made to feel comfortable enough to share their problems, and counsellors are helped to understand the patients’ views, and other information about circumstances, which are vital for services planning.
Irrespective of the consumer’s ability to pay, health care organisations face ever-increasing costs due to rapid advancement in technology, increased expectations of staff, etc. Health care provision is labour-intensive and staff salaries alone constitute a major percentage of the running costs. Blind adoption of western standards increases expenditure but really does not ensure quality. Since the resources generated are fairly limited, emphasis is on control of expenditures so that financial commitments can be met. There are different creative ways to control costs; the exercise4 summarised in Table 1 shows how the cost of care is directly linked to the volume of work (see Table 1).
As the number of operations increases, the simple logic is that the more operations performed, the more the fixed cost is spread over and the more the cost per operation decreases. Pricing is influenced by location, competition, reputation, economic status, service differentiation, etc., and few hospitals are capable of attracting paying patients. The high cost is due to lighter workloads, or high direct expenses, such as attractive compensation to retain staff in remote areas. Hospitals that conduct camps at the base hospital could not attract paying patients, as people tend to wait for the day of the camp. Service differentiation helps in practicing multi-tier pricing to attract people of different economic backgrounds, and in this way services can be made available at affordable cost.
Table 1. Cost of care linked to the volume of operations
Assuming that 80 percent of the annual total fixed costs of US $40,000 and variable cost per operation of US $14 are incurred in providing cataract surgery, cost per operation for 500 / 1000 / 2000 operations will work out as follows:
|Cataract operations||Total fixed cost($)||Unit fixed cost($)||Unit variable cost (US $)||Total cost($)|
Of the total cost, materials amount to approximately 40 to 45 per cent of the operating budget. Cost containment in this area usually brings quick results that invariably are well accepted, unlike reduction of personnel costs. The purpose is to ensure control from acquisition to disposal of materials. Purchase policy, simple inventory techniques like safety stock and re-order level, standardisation of supplies and equipment, and consumption report correlating to the level of activity (e.g., number of lenses issued and number of IOL implants in a month) help control the cost. Providers are responsible for eliminating unnecessary investigations, drugs and therapies, and for ensuring savings in the use of supplies and facilities.
Professional management practices would enhance staff satisfaction, improve quality, patient satisfaction, and public perception of services. This in turn would generate demand which could be met by providing a low-cost service through optimal use of the available limited resources. Ultimately, eye care organisations will become part of VISION 2020 by ensuring long-term sustainability. Are eye care organisations ready to include professionals, formally trained in hospital management, to ensure that administrative functions are effective?
1 Kotler P and Clarke RN. Marketing for Health Care Organization, Prentice Hall Inc., New Jersey. 1987. p. 278.
2 Lumsdon K. Baby Boomers Grow Up, Cover Story, Hospital and Health Networks, American Hospital Association, Sharon Hill, Sep 20, 1993, pp. 24-34.
3 Kotler P. and Clarke RN. Marketing for Health Care Organization (Op. cit.) p. 258.
4 Thulasiraj RD and Sivakumar AK. Cost Containment in Eye Care, J Comm Eye Health 2001 14;37: 6-8.