How poor people management is debilitating the hospital system

Overuse of control is disengaging staff and delaying improved standards of care

Some of the pressing issues facing Australian hospitals may be alleviated by empowering highly skilled hospital workers – including doctors and department heads – to make their own decisions.

Studies in 20 Australian hospitals by UNSW Business School researchers reveal human resources (HR) practices rely too much on control and are preventing medical staff from using their discretion to make autonomous decisions on some basic people management tasks, including hiring to replace a departing staff member.

The upshot of too much control is disengagement and burnout among healthcare professionals and a delay in the introduction of improved standards for patient care.

"We believe there's an overuse of control for management in hospitals," says Julie Cogin, a professor, deputy dean, and director of AGSM @ UNSW Business School.

"The primary human resources management (HRM) approach to people working in hospitals is about control, with prescribed procedures – for everything from hand-washing to hiring – and excessive bureaucracy," she reports.

While control in hospitals is indisputably vital for some routine tasks and responsibilities, in others it is counterproductive and impinges on the efficiency of the hospital system and the morale of staff.

Control issues are just part of a series of confounding dilemmas in the hospital system that also include tight budgets shifting the emphasis from patient care to financial outcomes, and a culture in which many external stakeholders set training requirements for hospital staff, suggests Cogin and her co-researchers.

On top of this is a delay to better patient outcomes due to an unrealistic approach to healthcare reform that has set the bar too high, giving unachievable goals to the complex hospital system. 

'They are committed to their jobs and patients, but not the hospitals they work in or their employers'


Patient-centred care

Healthcare is a thorn in the side of governments across the world with common outcries about rising costs, inequality of access and increasing demand for hospital services exacerbated in no small part by ageing populations.

In Australia, news stories capture tales of newborn babies accidentally gassed, babies born in hospital toilets, insufficient hospital beds, protracted waiting times in emergency departments, ongoing staphylococcus infections and patients inappropriately treated.

There's been a keen focus in advanced economies – across Europe, North America, Australia and New Zealand – on "patient-centred care", a central tenet of healthcare reform, which takes a holistic approach to the patient based on their needs.

It requires healthcare workers and hospital services to revolve around the needs of the patient rather than the needs of the hospital, and for the patient to be educated and informed, as an important stakeholder in their own treatment.

Uptake of patient-centred care has been slow, though "research has shown its benefits include improved efficiency, fewer delays, increased diagnostic referrals and reduced overall costs due to less waste of hospital resources", notes Cogin.

"Making patient-centred care happen takes teamwork, a collaborative environment and high levels of employee engagement among hospital workers, so everyone from housekeeping staff to the CEO is part of the patient's care experience."

Typically, recommendations have been that hospitals adopt a "high commitment" approach to HRM, much like the tried-and-tested best practice approaches of private sector employers that depend on trust, job security, empowerment, teamwork and involvement in decision-making.

However, there's a heft of data showing that's far from the status quo in hospitals where employees are disengaged.

"They are committed to their jobs and patients, but not the hospitals they work in or their employers," Cogin says. With a research team, she set about exploring the barriers to delivering best practice HRM in hospitals and, ultimately, to identify what's hindering the delivery of patient-centred care.

Breakdown in the line of sight

In their paper, Controlling healthcare professionals: how human resource management influences job attitudes and operational efficiency, the researchers note a multitude of issues at play when it comes to the tools for behavioural change. 

Training is a problem. For starters, hospitals don't have a lot of discretion in the management of staff. 

"Hospitals are constrained by many different external enterprises, including professional colleges, universities and medical associations which determine the training required for doctors, nurses and allied health workers," says Cogin. 

"HR practitioners are unable to [have] influence in this system, so their role becomes auditing and monitoring that the necessary training or performance review is undertaken, rather than formulating new strategies for professional development." 

Another impediment is the tenure of senior doctors stymying performance appraisal. As a senior physician told the research team: "We're not on fixed contracts so essentially although performance appraisals can be useful discussion points, they are irrelevant for senior physicians." 

According to Cogin, doctors aren't the only ones missing out: "We found much evidence that people don't have appraisals or performance reviews – and they don't get feedback unless something goes wrong or patients are not checked out quickly enough." 

Such constraints make it difficult to get a workforce to embrace a new strategy – such as patient-centred care – and to align their day-to-day tasks with healthcare reform or where the hospital wants to take them. 

"Strategies around patient-centred care are well known at executive level, but they aren't penetrating the layers. We found healthcare workers and unit managers didn't know a lot about what it meant or how it looked for the way they work each day," says Cogin. 

"There's a real breakdown in the line of sight from the executive level to unit managers to staff. So while healthcare workers' focus is on having the best possible outcome for the people they are taking care of, they don't necessarily see the alignment between what they do each day and how this contributes to the hospital's strategy and healthcare reform." 

'Executives may be measured by the number of patients checked out on time … but if they're being checked out too early, the metrics don't capture the revolving door for readmissions'


Disempowered yet accountable

On top of this is the demotivating, rule-bound, control-based hospital environment. 

In the paper, a nurse outlines how her bureaucratic workload – answering phones, working rosters, covering audit requirements – left her no time for patients. 

When hiring, the bureaucratic process was so lengthy, by the time a "successful" candidate had been selected and delivered the good news, the candidate had often moved elsewhere. Meanwhile, the rest of the unit continued to pick up the slack for the vacant position. 

In one case a physician who manages a unit lamented the lack of delegation to department heads: "At the moment, only risk is devolved to department heads so we carry the can for adverse outcomes, but we're not given any trust to hold the purse-strings to manage the department or motivate people." 

"People were disempowered from managerial decision-making yet held accountable for effective operation," says Cogin. 

A divide has also grown with HR divisions. "HR is perceived as being part of the problem," says co-researcher Ilro Lee. "In one of the hospitals we surveyed one HR department manages several hospitals so they're often waiting days or having to chase down multiple people for responses or approvals." 

Hospital HR practitioners interviewed for the research, however, were outspoken about their frustration. 

"They want to partner, be more strategic and provide support with operational tasks but are under-resourced," Lee says. 

Rethink of expectations

There's been widespread coverage of public hospitals' escalating costs and trepidation over government cost-cutting – with a restoration of $2.9 billion in federal funds in April 2016 dismissed by experts as a pre-election stop-gap measure. 

Financial constraints may also mask some hidden problems, claims Cogin. 

"Executives may be measured by the number of patients checked out on time … but if they're being checked out too early, the metrics don't capture the revolving door for readmissions." 

The researchers recommend that a major rethink of expectations is required. 

"Hospitals are subjected to rules of many external stakeholders who prescribe how a variety of HR practices are undertaken so it's overly optimistic to think that hospitals will be able to replicate best practice HR from the private sector," Cogin concludes. 

A full commitment-based approach may be a step too far. 

"We need more realistic incremental changes to people management to give department heads and managers the autonomy to make people decisions, and the skills and resources to give feedback, motivate and engage people with non-financial rewards." 


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