Review Article - (2021) Volume 11, Issue 3
Before accreditation, hospitals in Lebanon adopted different clinical protocols, which have led to differences in medical treatment provided, and this is compounded by the lack of transparent policies and procedures at the administrative, financial and clinical levels. In May 2000 when accreditation began its work by putting standards that must be applied in each department to get better output, quality become more and more crucial. But still we have a scale and gap of quality gutted from different hospitals especially in each department. So, my topic focused on the importance of quality in healthcare sector and the crucial role of integration between different departments in hospital to ensure a better quality, safety, performance, efficiency, satisfaction (quality dimensions). Many issues such as staff shortage, inflation and service demand have intensified the call for more efficient and effective use of resources through integrated system. Integrated health systems are widely considered to provide superior performance in terms of quality and safety as a result of effective communication and standardized protocols, but these outcomes have not been fully demonstrated. Despite the growing enthusiasm, and the attractive outcome for integration, information related to implementing and evaluating integration-related initiatives is dispersed and not easily accessible. There is a need to seek out and apply current knowledge on health systems integration to advance effective service delivery and get more focus on all quality dimensions that lead to better outcome in healthcare sector. This is why every hospital should focus on Quality and its different dimensions such as communication, safety, organizational structure and must know the importance of integration between its departments.
Organizational structure • Effective communication • Quality management • Business operations
Quality systems are quality assurance and quality improvement efforts that are designed and organized . Quality systems are be designed means by the planning and the executing of quality improvements according to accepted methods. To be organized means that efforts are managed and that employees work together towards shared goals .
According to this definition, quality improvements need to be ongoing and not limited in time to be considered quality systems. Naturally, improvement projects or programs can be important parts of quality systems. However, they cannot by themselves without coordination and plans for long-run implementation constitute quality systems .
In practice, quality systems go by many different names. Quality improvement is a general term that can apply from everything from small locally developed systems to standardized systems such as Continuous Quality Improvement .
A more specific term is quality assurance where quality measures are compared with outcomes in a structured manner, for instance, Total Quality Management or Balanced Scorecard . Quality accreditation denotes the case when the system has been approved by an external accreditation agency that regularly checks if the department complies with certain standards .
The primary elements of total quality management
Total Quality Management (TQM) can be summarized as a management system for a customer-focused organization that involves all employees in continual improvement. It uses strategy, data, and effective communications to integrate the quality discipline into the culture and activities of the organization .
Regarding TQM in hospital, total quality management is based on the premise that the quality of care and interventions is the responsibility of everyone involved with the creation or consumption of the care or services which are offered by the hospital, requiring the involvement of management, workforce, suppliers, and patients, to meet or exceed patient expectations and to assess patient safety in a quality environment.
Customer-focused is an essential element of TQM. Organizations depend on their customers and therefore should understand current and future customer needs, should meet customer requirements and strive to exceed customer expectations. The level of quality is eventually determined by customers. No matter what an organization does to foster quality improvement through training employees, integrating quality into the design process, upgrading technologies such as computers or software, or buying new measuring tools that the customer determines whether the efforts were worthwhile.
Also, total employee involvement is an essential element of TQM. People at all levels are the essence of an organization and their full involvement enables their abilities to be used for the organization’s benefit. All employees participate in working toward common goals. Total employee commitment can only be obtained after fear has been driven from the workplace, when empowerment has occurred, and management has provided the proper environment. Highperformance work systems integrate continuous improvement efforts with normal business operations. Self-managed work teams are one form of empowerment.
A fundamental part of TQM is a focus on process thinking. A desired result is achieved more efficiently when activities and related resources are managed as a process. A process is a series of steps that take inputs from suppliers (internal or external) and transforms them into outputs that are delivered to customers (again, either internal or external). The steps required to carry out the process are defined, and performance measures are continuously monitored in order to detect unexpected variation.
Integrated system is an essential element of TQM. Identifying, understanding and managing interrelated processes as a system contributes to the organization’s effectiveness and efficiency in achieving its objectives. Although an organization may consist of many different functional specialties often organized into vertically structured departments, it is the horizontal processes interconnecting these functions that are the focus of TQM.
Micro-processes add up to larger processes, and all processes aggregate into the business processes required for defining and implementing strategy. Everyone must understand the vision, mission, and guiding principles as well as the quality policies, objectives, and critical processes of the organization. Business performance must be monitored and communicated continuously.
An integrated business system may be modeled after the Baldrige National Quality Program criteria and/or incorporate the ISO 9000 standards. Every organization has a unique work culture, and it is virtually impossible to achieve excellence in its products and services unless a good quality culture has been fostered. Thus, an integrated system connects business improvement elements in an attempt to continually improve and exceed the expectations of customers, employees, and other stakeholders .
A critical part of the management of quality is the strategic and systematic approach to achieving an organization’s vision, mission, and goals. This process, called strategic planning or strategic management, includes the formulation of a strategic plan that integrates quality as a core component. Identifying, understanding and managing interrelated processes as a system contributes to the organization’s effectiveness and efficiency in achieving its objectives .
A major thrust of TQM is continual process improvement. Continual improvement of the organization’s overall performance should be a permanent objective of the organization. A continual improvement drives an organization to be both analytical and creative in finding ways to become more competitive and more effective at meeting stakeholder expectations .
Effective decisions are based on the analysis of data and information. In order to evaluate the organization performance, data on performance measures are necessary. TQM requires that an organization continually collect and analyze data in order to improve decision making accuracy, achieve consensus, and allow prediction based on past history.
Communications involve strategies, method, and timeliness. During times of organizational change, as well as part of day-to-day operation, effective communications plays a large part in maintaining morale and in motivating employees at all levels.
These elements are considered so essential to TQM that many organizations define them, in some format, as a set of core values and principles on which the organization is to operate.
Important and influential examples of the organizational approach to quality are the Total Quality Management and the Continuous Quality Improvement movements. They were based on the principles of the continuous search for improvement, the alignment between provided services and patient needs, and managers that involve the entire organization in striving for quality.
The Total Quality Management method requires a detailed description of all processes of the organization as a starting point. An important feature is the forming of teams that are called quality circles. A team should consist of all employees that are connected to the specific process in question. Such teams could thereby be interdisciplinary or interdepartmental. The task of the team is to analyze and improve the processes by using the tools provided by the method. The process should be carried out in a positive spirit where difficulties and mistakes should be seen as opportunities for improvement-not as problems to be punished.
Numerous hospitals have implemented Total Quality Management or Continuous Quality Improvement programs but few implementations have been evaluated by scientific standards.
There are many different ways of applying these quality management principles. The nature of the organization and the specific challenges it faces will determine how to implement them. Many organizations will find it beneficial to set up quality management systems based on these principles. Some of these programs have also developed into straightforward accreditation systems to further reinforce their impact on the health care system.
The organizational approach to quality is rather different from the professional bureaucracy approach. In the organizational approach, physicians are still considered to play an important role for quality improvement, but their role is downplayed compared to their paramount role in the professional bureaucracy approach.
Importance of understanding organizational structure of hospital
Understanding organizational structure of hospital facilitates the understanding of the hospital’s chain of command. It shows which individual or department is accountable for each area of the hospital. In this way the hospital can be seen as departments and individuals who interact together as a whole body. The structure will show the path of orders among the departments and which department coordinates with the other.
The Complexity of Organizational Structure Depends on Size of Healthcare Facility; large acute care hospitals have complicated structures, whereas, the smaller institutions have a simpler organizational structure. In other words, the bigger the organizational chart is the more sophisticated the hierarchy will be. More departments bring more complexity whereas simpler and smaller organizational structure has smaller departments and less complexity structure. Grouping of hospital departments within the organizational structure. Although each hospital department performs specific functions, departments are generally grouped according to similarity of duties. Departments are also grouped together in order to promote efficiency of the healthcare facility. Individuals work and understand each other since they have a common task to accomplish. They cooperate within the department to achieve a specific activity.
Quality and communication
Hospitals are increasingly showing interest in internal and external corporate communication: corporate magazines, leaflets, and social networks. In recent years, internal communication has become important due to the types of services that hospitals offer patients, the increasing importance of doctor-patient communication, and the organizational performance of the hospital (collaboration between departments to provide comprehensive services) . The framework aims to assess the way of operating internal communication in a hospital, the approach of analyzing interpersonal and corporate communication in a hospital, the way of investigating internal communication in a hospital, and the manner of proposing a model of professional management of internal hospital communication.
Also, internal communication is responsible for disseminating intangibles (brand architecture and communication principles) that positively affect patient perception and the corporate reputation of a hospital. Furthermore, internal communication should improve organizational performance by promoting internal dialogue and teamwork.
Communication has become a strategic element capable of positively influencing the medical services provided to patients. Internal communication should be the most important communication initiative for a hospital and doesn’t fluctuate in function of the types of medical services provided to patients and the high number of workers employed by these organizations, who have direct contact with patients. The objectives of internal communication are based on a respect for ethics and aim to the usage multiple tools, and also reflect different strategies.
From interpersonal communication to corporate communication Health is a basic human need a right recognized by international organizations, and a source of concern for many people. Although the promotion of health issues and healthy habits begins in the home environment, five organizations responsible for promoting health can be identified: hospitals, health authorities, pharmaceutical companies, insurance companies, and patient associations . A notable example is the hospital, whose primary functions include patient care, teaching, also it includes research, collaboration with other hospitals, job creation, and social functions.
The management of these organizations is challenging because they are composed of various interrelated departments that coordinate to achieve their primary organizational mission: improving patient health. As a result, a hospital considers several aspects, such as the design of hospital facilities, the influence of this design on doctor-patient communication, and the communication skills of hospital employees .
The main players in interpersonal communication in a hospital consist of medical staff, nursing staff patients, the families of patients, health executives, and employees who perform various administrative or maintenance duties . From a communicative standpoint, the medical staff assumes significant responsibilities because they must use interpersonal communication to understand the pathology, needs, and expectations of patients and assist patients with reducing stress, improving adherence to treatment, and exercising self-control. Nursing staff are critical to hospital communication because the patient frequently expresses a greater trust in nurses than in other medical staff. As the recipient of the majority of communicative acts, the patient is the main player in hospital communication. Because a patient’s family can influence their decisions about treatment, excellent communication between families of patients and the medical and nursing staff is crucial. Health executives assume transverse responsibilities in areas such as coordination, employee motivation, and distribution of information within the organization. Administrative and maintenance employees also influence hospital communication, especially employees who are involved in the final contact with the patient, which is common in this type of organization. Of all the groups cited, the medical staff and the patient are significant. Their relationship is determined by their communication skills. Verbal and nonverbal communication skills facilitate the medical staff in successfully managing the conditions of their patients.
According to, the medical staff interacts with seven types of patients: the elderly, children and their parents, adolescents, patients from cultures that differ from the cultures of the medical staff, patients who have difficulty reading and writing, timid patients, and aggressive patients . With each of these types of patients, the medical staff must adapt their communication approach: spend more time with the elderly, enhance the value of “normal” when speaking with young patients, reassure adolescents, consider the cultures of patients from other countries, provide repetitive information until patients with reading or writing problems understand their medical conditions, encourage shy patients to communicate, and rapidly identify and calm aggressive patients. The family of the patient can be added to these groups because they help the patient to understand medical information and influence their motivation to continue treatment. The medical staff conveys necessary information and provides emotional support to patients and their families. Doctor patient communication is determined by three aspects: information asymmetry and a lack of specific informative elements; social and familial support for the patient, and cultural adaptation of the physician to each patient. If the interaction between the patient and the doctor is acceptable, the patient can more adequately control their medical situation, is more involved in consultation, and is more accepting of the support of the medical staff. Therefore, the doctor should ask questions and encourage the patient to adhere to treatment.
The development of a corporate communication culture should be based on the strategic use of internal and interpersonal communication. This action requires that the hospital have a communications department that is primarily responsible for defining the brand architecture of the hospital, i.e., identity, values, mission, vision, culture, and image . An organization should outsource its identity to generate cohesion between the employees and the organization and must measure three variables: organizational performance, communication actions, and symbols. In addition to identity, the hospital defines its corporate values. Organizations should create, disseminate, and maintain these values to unite their corporate communicative actions.
The mission Organizations are developed to achieve economic, social, or community objectives, which comprise their mission in society. By defining its mission, the hospital can improve three aspects of corporate communication
- Knowledge of the target audience
- Priorities of the organization
- Definition of the communicative tone
Targeted vision represents a more profound level of motivation than the mission because it describes long-term goals of the organization. Vision determines the communicative actions by an institution and guides the work of their employees, especially their directors. Also, institutional culture refers to the set of values, attitudes, behaviors and personality of an organization. As a result, it is essential that an organization implement corporate communicative actions
Hospital image reflects the opinions of the population toward an organization and its activities; the image of a hospital is built on trust, which patients manifest toward the institution. Brand image fulfills the following functions: highlighting identity, defining culture, building personality, reinforcing teamwork, attracting workers, encouraging investors, preventing crises, encouraging new products, generating favorable public opinion, reducing involuntary messages, optimizing investments in communication, building reputation, attracting clients, and inventing the future .
Hospitals define their policy of corporate communication by brand architecture. The set of activities involved in managing and orchestrating all internal and external communications aimed at creating favorable starting points with stakeholders on which the company depends.
The implementation of a corporate communication policy is a priority for every hospital. Communication exerts its greatest impact when it is based on a previous strategy and is managed from an integrated perspective or from a circular perspective that considers multiple interactions of internal and external participants. Professional management of corporate communication helps employees establish social bonds internal conflicts. Communication surpasses the simple dissemination of information and influences the performance of an organization .
For example, the type of interpersonal communication established between the medical staff and the patients in hospitals can influence physical and psychological outcomes of the patients and prevent medical errors and professional malpractice. Professional management of corporate communication can help a hospital improve its corporate reputation, which is evaluated by interest groups .
Inter-departmental relationships and safety
A research was performed by was the operating department of a large teaching hospital in the North-West of England through the interviewing of 80 members of hospital staff. It aims to study the causal relationship between the work environment and the delivery of clinical care. This research draws on the theory of normal accidents to extend this analysis and better understand the "organizational factors" that threaten safety. The results show that the work of the operating department was determined by inter-dependent, "tightly coupled" organizational relationships between hospital departments based upon the timely exchange of information, services and resources required for the delivery of care. Failures within these processes manifest as "breakdowns" within inter-departmental relationships lead to situations of constraint, rapid change and uncertainty in the work of the operating department that require staff to break with established routines and work with increased time and emotional pressures. This means that staff-focus on working quickly, as opposed to working safely. The authors concluded that the analysis of safety needs to move beyond a focus on the immediate work environment and individual practice, to consider the more complex and deeply structured organizational systems of hospital activity. Furthermore, by departmental managers the scope for service planning to control for safety may be limited as the structured "real world" situation of service delivery is shaped by interdepartment and organizational factors that are perhaps beyond the scope of departmental management .
Inter-departmental Communication is critical to many different functions including raising awareness both within and outside the organization on its strategies and objectives, plans, performance and challenges for patient safety. Also it helps to engage and create dialogue between staff, also to engage and motivate employees and others to support to assess patient safety. Therefore, to assess Interdepartmental Communication, the information should be complete, understandable with regard for the knowledge, responsive, accurate, balanced, timely Out of date where the information describes activities during a specific period of time, and accessible on specific issues.
Internal communication and relation between departments
Regardless of internal communication objectives, this activity must be consistent with external communication initiatives to facilitate the corporate strategic process. Although many people do not understand the need for internal communication in a hospital, it is crucial that these organizations have specialized communication departments. The members of this department should possess the skills of a scientific journalist: scientific outreach capability and the ability to understand health issues from different points of views.
Internal communication has several implications for employees, managers, patients, and the entire hospital institution . Employees are a key group of any organization: their knowledge of the brand and organization determines the performance of the organization. It is important that employees are aware of the strategies of an organization so that these strategies can be performed. They should also acquire the required information to effectively perform their work and achieve their professional goals. One of the objectives of internal communication is helping people to adequately perform their job, which includes training them in different fields, such as fields related to the economic management of an organization in Figure 1 .
Training employees positively influences the productivity of an organization. In addition to training, internal communication is also important for removing existing antagonisms between employees. The employee must be provided honest, necessary, and sufficient information that is based on transparency. A satisfactory work environment positively influences the motivation of workers. Internal communication enables employees to adequately adapt to constant change in the organization .
Internal communication positively affects employees because it helps them to integrate into the organization, which is especially important for contact personnel whose behavior determines perceptions by patients about the hospital and its employees. Internal communication assists hospital managers in four different ways:
- To build satisfying relationships with employees
- As a source of daily information about the organization
- To promote a culture of responsibility, which is essential in any hospital?
- To achieve organizational objectives through various initiatives, such as rigorously defining the objectives of each department or contributing knowledge about the reality experienced by an employee
Internal communication is a strategic activity for managers that allow them to inform employees about the purpose of the organization, coordinate various departments, and increase employee commitment to achieving the objectives of the organization. In addition to employees and management, internal communication has several implications for patients . The main implication is that it comprises part of the medical services provided to the patient; patient-physician communication influences satisfaction of the physician, helps build trust in the patient, and helps improve the efficiency of the functions performed by the medical staff.
Internal communication also has several implications for the hospital. It enables a hospital to better understand the expectations, clinical needs, and personal needs of its patients, which prevents medical errors and patient safety. Although the medical staffs are more comfortable with treating a patient from a clinical perspective, they should adopt a holistic approach that ranges from treating the patient to satisfying their needs. After interacting with the patient, the medical staff can identify a patient’s needs and explain the reasons for their decisions.
In addition to providing information about the patient, internal communication helps an organization satisfy its organizational objectives by facilitating the conversion of strategies to specific actions for employees .
Corporate communication that is based on a previous strategic approach can achieve a high level of performance. Authentic internal communication is accurate, honest, understandable, timely, and strategic. However, it encounters various problems of downstream communication information saturation, contradictory information, lack of clarity, lack of communicative returns; upstream communication excessive control by management, hostile management due to offensive messages, lack of responsiveness by managers, and channel failure, and horizontal communication rivalry and distrust, functional specialization of departments, and lack of motivation.
A primary problem of internal communication involves rumors in climates of uncertainty, in which the lack of information, the lack of motivation, insecurity in the workplace, or the existence of conflicts between departments are manifested. Internal communication professionals in hospitals attempt to solve these problems due to a scrupulous respect of ethics, which exists in all forms of health communication.
study was conducted through a survey among 250 hospital CSuite Executives and 100 Risk Managers in hospitals across the US . The study was comprised of core questions measuring attitudes and behaviors related to patient safety and hospital risk. It aims to study the barriers of the healthcare system that must overcome to improve patient safety and the action taken to keep patients safer in hospitals. Regarding communication, whether it’s in the operating room, the emergency room or the board room, communication can sometimes be less than ideal, despite the best of intentions. The results show that most respondents (59-69%) agree that the quality of coordination and communication between departments at their hospitals presents a challenge for maximizing patient safety. Both CSuite Executives (56%) and Risk Managers (61%) believe that an increase in the number of clinical staff who touch a patient, i.e. the number of handoffs, makes communication more difficult and potentially compromises patient safety. As one risk manager put it, “The barriers are the communication with the healthcare team. The handoff from one unit to another and from one physician to another physician or nurse is a hard transition for the patient.” Furthermore, the results show that the number one barrier to ensuring a safe environment for patients was the lack of teamwork, negative culture and poor communication. Also, when asked to describe in their own words the barriers to patient safety, a plurality of executives give answers related to a lack of teamwork and a negative culture. The results showed that communication was seen as a problem on several levels, from nurses fearing retribution for speaking up about patient safety issues to documentation burdens to the number of patient “handoffs” among hospital staff inhibiting effective communication.
The authors recommended that patient safety and financial sustainability should be complementary goals, not competing objectives. Hospitals should seek to define and establish clear responsibility for patient safety. To have positive outcomes, patient safety must be a multi-disciplinary goal. Also, executives need to walk the talk and set the tone for a consistent culture of patient safety where open communication is not only valued but expected. Everyone, from doctors to nurses, needs to “own” patient safety.
They also recommended that everyone, not just patient safety departments and the C-Suite, needs to be able to influence the culture, as well as the deployment of safe patient care. Everyone who touches a patient is equally responsible for patient safety. Anyone who identifies an issue with patient safety must feel free to discuss that issue for the benefit of patient safety without fear of retribution. All stakeholders/disciplines need to engage in a thoughtful, collaborative and strategic approach to creating effective tools and processes for improving patient safety and reducing the potential for adverse outcomes.
Patients' perception of care and measures of hospital quality and safety
A study done in 927 hospitals using the data from the Hospital Quality Alliance to assess technical performance in medical and surgical processes of care and calculated Patient Safety Indicators in order to measure medical and surgical complication rates. The study aims to study the relationship between patients' perception of care and measures of hospital quality and safety. The authors did the study based on the hypothesis of the unknown relation between the extent to which patient experiences with hospital care and the measures of hospital quality and safety. The result show that the overall rating of the hospital and willingness to recommend the hospital had strong relationships with technical performance in all medical conditions and surgical care (p<0.05). Also the results show that better patient experiences for each measure domain were associated with lower decubitus ulcer rates (p<0.05), and for at least some domains with each of the other assessed complications, such as infections due to medical care. The authors concluded that patient experiences of care were related to measures of technical quality of care, supporting their validity as summary measures of hospital quality. Further study may elucidate implications of these relationships for improving hospital care [22-26].
Finally, the quality indicators developed and maintained by the agency for healthcare research and quality are one response to the need for multidimensional, accessible quality measures that can be used to gage performance in health care. The Quality Indicators are evidence based and can be used to identify variations in the quality of care provided on both an inpatient and outpatient basis. Regardless of how quality is defined, the only way to know whether the quality of health care is improving is to measure the performance of those that deliver it. Performance measures and performance measurement systems provide a tool to determine if quality exists. Currently there is a proliferation of performance measures, and development of these measures shows no sign of failing. In addition to few recommendations in order to improve the Quality system and practical approach that are suggested and highly recommended to be applied.
• Support the internal communication: The employees should feel free to question the decisions or actions of those with more authority; also they should be asked their opinions about ways to improve the quality and the patient safety.
• Have a great teamwork: The employees should work together as a team to get the work done. Furthermore, the hospitals units are asked to work together to provide the best care for patients (integration). All the employees should have a good knowledge regarding the strategic planning and the targeted goals of the organization.
• The actions of hospital management should always target the patient safety as a top priority.
• All the employees should be aware regarding the updated policies and the procedures in the organization. The policies and procedures should be reviewed to see if they contribute to errors.
• The organization should create a non-punitive environment.
• The employees should be informed about errors that happen in the work department. Once a mistake occurred, it should be reported and the employee be treated fairly when making errors. The errors lead to improvements in patient safety in a specific unit where it is imported to implement a non-punitive environment and the employee should freely speak up if he see something that may negatively affect the patient care.
• Have a clear Vision: Having a crystal clear vision of what you want to achieve which is communicated clearly to all involved will ensure the commitment and motivation are present to achieve the goal.
• Have a Workflow System: A workflow system will allow the employee to work effectively and creatively by freeing up time to do the work the matters. Understanding the most effective flow of work will ensure that work is not duplicated or distractions don’t interfere with the work that matters.
• Take Responsibility: Take responsibility for all of employees’ actions and behaviors. Eliminate any victim behavior.