Key Management Issues at Hopital Ste. Croix

With the hospital currently “closed,” it is an excellent opportunity to put proper management systems into place in the hospital so that it can be administered correctly. Various systems that need to be established include, but are not limited to: leadership, human resources management, patient flow and medical records management, nursing standards and practice, infection prevention policies, pharmacy inventory and supply chain management, cost-based budgeting and financial management. Also, there is a need to try and develop an information management system that links archival records that come from community health outreach with the hospital’s out- and in-patient records. It is necessary to prioritize the development of these management functions and make sure that they are implemented in a consistent and complementary way.

It is my understanding that there has been a revolving door of physician administrators at the hospital in the last decade or two. More recently, it was discovered that many paychecks were being distributed to non-existent personnel. Further, the hospital has had minimally trained administrators who apparently weren’t aware of how to implement proper management systems. Thus, the first priority of the hospital should be to hire an administrator. A job description for this position should include the usual requirements: experience, proper values, strategic planning, communication, empowerment and relationship building. However, there are other responsibilities for the position at Hopital Ste. Croix and these are described among the various management issues that are described below.

1. Human Resources Management. Human resources management is the key issue for Hopital Ste. Croix today. An administrator needs to be hired and an executive team needs to be put into place to implement the management systems which will keep the hospital operational in coming years. The administrator’s position needs to be spelled out in terms of responsibilities, authority and lines of communication. Also, health professional recruitment, performance management, and compensation and benefits systems and policies have to be established. Further, the hiring of health professionals needs to be linked with the hospital’s strategic plan about which services it will not offer or offer and develop in the future. Overall, key elements of HRM that need to be developed include job descriptions, an organization chart of authority and lines of communication, performance appraisal and management, employee motivation and job satisfaction, employee training and development, employment records, compensation and benefits, a scheduling system, and personnel policies.

2. Financial Management and Budgeting. The hospital relies almost exclusively on cashiering. What needs to be developed is a cost accounting system by department and functional area. Cost accounting will allow the hospital’s management team and advisory board to strategically manage the hospital and oversee and fix problems. For example, if the hospital is making higher profits in one service area than another, a decision might be made to further develop and expand the more profitable service at the hospital. Likewise, if is discovered that private pharmacies in Leogone have an unusually high amount of business, it might be necessary to talk with the hospital’s physicians about what drugs they are prescribing and why. It sounds as though the hospital was losing business as physicians only prescribed higher cost drugs through the hospital’s pharmacy.

3. Developing an Executive Team to Manage the Hospital. It will be quite a task to find a hospital administrator for Hopital Ste. Croix who can perform all the necessary functions of a hospital while starting up many hospital operations and working with a new hospital advisory board. As such, I strongly suggest that the administrator’s job description be focused on strategic planning, implementation of new management systems and facilities management , leaving other operational aspects of the hospital to a new executive team. As shown in Attachment 1, the executive team for Hopital Ste. Croix should probably include the following positions: community relations, medical staff director, nursing/pharmacy/lab director, budgeting/finance director, and human resources manage/IT director.

4. Public relations and Political Sensitivity – Community relations should range from working with community groups, partnering with the government, and developing a plan to bring about an image of the “new hospital” as a high quality institution and an employer of choice throughout the area. Further, there has to be a concerted effort to work with the Ministry on health planning for the area. For example, we have discovered that a Duke University team has gained support from religious groups and others in North Carolina and elsewhere to build a hospital in Leogone. The hospital is supposed to start as a maternity center, but they appear to be aiming for many if not all services in that they have or will soon break ground for a 100,000 square foot facility.

5. Development of the Hospital’s Community Health Outreach Program and Network. The nutrition and community health reach programs have continued in recent years and, to some extent, have held up the hospital’s positive image as a center of health in the area. I’m not sure what else needs to be done by the hospital to support these programs, however, such a conversation should take place. Further, efforts should begin to link community health outreach workers records from their catchment areas to the hospitals out- and in-patient records to ensure continuity of care and care coverage.

6. Recruiting Health Professionals. Having physicians brought in from Port au Prince to work from 10am to 4pm, as has been done in previous years, is a strategy that is geared more toward the physcians’ interests for extra income than the hospitals’ needs for patient care and clinical availability. Working with the local pediatrician (his name escapes me) to gain his loyalty toward the hospital is a good starting point toward gaining a locally-based physician workforce for the hospital. However, further efforts for health professional (physicians, nurses, lab tech, IT, etc.) recruitment and retention need to be made.

7. Gaining the Loyalty of Health Professionals. A key problem that needs to be addressed is the need for physician loyalty to the hospital. There are a variety of strategies that could be used to gain and maintain the loyalty of health professionals. For example, the hospital should implement an incentive system that augments physicians’ monthly salaries. For example, if physicians are going to get paid the equivalent of $1,000US/month, it would be helpful to lower this (e.g., $900US/month) allowing for a monthly bonus based on productivity and quality management. Productivity could be measured in terms of patients seen, willingness to work off hours (on call in the evenings and weekends, etc.). Another strategy to consider implementing is to put physicians, and possibly other health personnel, on annual, renewable contracts. This will minimize the costs of unproductive physicians as well as severance arrangements that are built into employment policy in Haiti. Having the above performance and quality management systems in place will go a long way toward administrative oversight and developing needed loyalties from the health professionals on staff.

8. Developing Current and Additional Revenue Sources. The hospital is torn between cutting costs and increasing productivity while providing a variety of care services. Instead of seeing the budget as a given, the hospital needs to consider new sources of revenue which will allow the hospital to grow in capacity and its ability to serve all populations, including the poorest of the poor. One strategy to gain revenues, while increasing physician loyalty, is to open up a private wing in the hospital. For example, the 2nd floor of the pediatric ward provides an excellent opportunity for this. It is a large space that won’t get wet (during floods), it has a reception area, is generally private and away from most other hospital operations, and it could be spruced up to meet the higher expectations of private-care seeking patients.

9. The Development of the Hospital as a Training Facility. To enhance its reputation as a referral hospital, Hopital Ste. Croix needs to build physician and nurse training into its operations. The hospital should serve as a training ground for the new nursing school in Leogone and it should begin to welcome physician residents for training. To enhance a continual learning environment, all health professionals should be required to participate in a “grand rounds” meeting a couple days per week at the hospital. Grand Rounds is the place to discuss unique cases and learn about new procedures and techniques. It also indirectly serves to develop a colleagial among staff and between staff and administration at the hospital.

10. Putting Management Monitoring and Evaluation Systems into Place. The hospital needs to put management systems into place to track patient flows/registrations, quality management, cost centers and expenses, employee productivity, compensation and benefits, etcetera. For example, quality management can be measured in terms of patient care (infection rates, re-admissions, patient satisfaction). Key to putting a quality management and other systems into place is getting a good computer system and network and maybe even a computer server. This will also require a dedicated IT person for installation and maintenance of the system.

11. Inspiring Employees to Work Harder and Smarter. Communication is key to excellent hospital administration. Administrators need to gather information about the hospitals operations and they need to communicate the results of this information to key staff (physicians) and their advisory board. However, communication should not just be limited to operational support. Administrators also need to develop supportive, collegial and personal relations with all employees and staff. Administrators that get to know their employees and staff on a more personal level have a much higher probability of job success than administrators who are merely operationally focused.

12. Working with an Advisory Board. Although it is good to hear that an excellent board has been developed in the U.S. for Hopital Ste. Croix, the new board’s capacity to govern will be very limited if it has to rely on anecdotal evidence of hospital operations. What is needed to move the hospital forward in terms of governance and administration at the hospital is the development of management systems which provide weekly, monthly and quarterly reports which can monitored and evaluated for good and bed trends.

13. Facilities Development and Management. Admittedly, I do not know much about facilities management, but it is clear that there is a need to get a hospital architect to consider how the hospital should be renovated to make it a quality environment. For example, the ventilation and fan system in the out-patient ward is situated in such a way that the tuberculosis consulting room will put physicians, patients and others at risk of catching this deadly air borne disease. This system needs to be restructured and consideration should be made to putting TB consults in an isolated area of the hospital. Also, the hospital sites in a low lying area and flood waters drain onto the land. What can be done to lessen standing water around the hospital (mosquito breeding grounds) and lessening the likelihood of flooding of the first floor of the hospital during the rainy season? Is there away to divert rain waters away from the hospital and toward a less-used area of the community? Further, consideration should be given to developing the second floor of the large peditrics unit. This space is likely to be under-utilized even if the hospital were full services operational today. As described above, the second floor of the pediatrics unit could be used for revenue generation through the care of private patients.