Quality Management in Health Care System in Nigeria: A Case Study of Isalu Hospitals Limited, Ogba, Lagos
INTRODUCTION In this age, hospital services have gone beyond the conventional way of doctors sitting in their clinics, reading newspapers or engaging in other vain discussions hoping that patients would patronise their healthcare services. Various private hospitals have carved out a niche for themselves using relationship management, customer relations and hospital marketing techniques to expand their business. Although the prime aim of hospital/healthcare establishments is to save lives, the truth is that private healthcare services are profit-driven as owners have to cater for various expenses and overheads to keep the business moving.
Those who run healthcare business grapple with regular payment of staff salary, procurement of new medical equipment, maintenance of computers and buildings, payment of electricity bills, procurement and fuelling of power generators, maintenance of official vehicles, communication expenses, staff seminars and printing of receipts, appointment cards and medical report sheets. Just like a good product, a good hospital service sells itself. This comes mostly through testimonials from people who have practically experienced the service(s).
But a good product or service cannot, by itself, propagate its services to the users. Certain machinery should be put in place to achieve this end. Although medical bodies such as Nigeria Medical Association strictly prohibits hospital advertising, the dynamic nature of medical business, not only in Nigeria but globally, has made it mandatory for Health Maintenance Organisations (HMOs) to place their advertisements on the pages of newspapers, over the radio/television and on the Internet under the guise of health insurance, since insurance does not forbid advertising its services to various target groups.
Good customer care/ relationship management matters in healthcare business because keeping the existing clients—that is, the patients—seems easier than getting the new ones, as satisfied clients will do a lot of our testimonial appeals for us to the new prospects. Some people will use our service on the recommendation of a friend or sibling. This is because patient who feels good experiencing our medical service is most likely to stay with the healthcare and make recommendations to others about us.
In these days of sophisticated and well educated customers, patients look beyond coming to the hospital and being attended to in the “usual manner”. They want to experience an informal contact (tactile communication); they want the doctor to tell them what they don’t know in medicine because many of them have already googled their internet to know about their ailments before consultation; they want to feel like they are in their homes; they want to feel that they are in safe hands and they want to be healed by the words of mouth of the doctors in charge, nurses on duty as well as all other contact points— i. . the staff—in the hospital. Hospitals therefore establish mutual relationship with several HMOs as well as corporate companies (on retainership) and families or private patients to garner more companies on their clientele. STAGES OF COMPANY DEVELOPMENT Various business organisations launch their products/services into the market to claim some market share. Right from the time a product or service is newly introduced, there is always scramble among companies that offer similar services or produce parity products to have some comfortable share of the market to their advantage.
In order to achieve this, most producers or service companies have good positioning of their USP. Some hospitals have ATM where patients can easily withdraw money to settle their medical bills without any stress of going to the bank. Some have supermarkets where people on appointment can take some bread with drink before taking their drugs or injections. Others have immaculate environment befitting of a healthcare. Each of these is a strength, a unique selling point (USP) for their medical business. (a)Pioneering stage— This refers to when services are new to the prospective clients. They are only being introduced.
Concepts are created. Proposals are developed and companies, HMOs as well as individuals are being convinced to use such medical services. Many companies die at this stage and never make it to the competitive stage. (b)Competitive stage— Most service companies or products remain at this stage throughout their life cycle. Here market acceptance has been met by a service company as certain percentage of the market share has been claimed. Many hospitals especially private ones can be categorised under this stage. The more quality medical service they provide, the more competitive and recommendable they become. c)Retentive Stage—This is the highest point a product or service company can achieve. Although not all products or service companies get to this stage, it is not impossible for any healthcare establishment to get there in Lagos State for instance. It is not always easy to get to the top and retaining it is more tasking. At this stage, the superiority of a company service over all service providers will be established, making it command more clients and greater market share . DEFINITION OF TERMS For the purpose of exposition, I will like to define the following words—quality, management and healthcare respectively.
Quality In the estimation of Longman Dictionary of Contemporary English, 2005 edition, the word quality is defined as how good or bad something is. It goes further…something that is typical of one thing and makes it different from other things, for example size, colour etc this may be a unique way of doing things. We may settle for this last definition of the word quality by the same lexicon: a high standard. Management Management can be defined as the activity of controlling and organising the work being carried out in an oganisation. The word ‘management’ also means the people who are in charge of a company.
According to Kreitner (1980), management is a “problem-solving process of effectively achieving organisational objectives through the efficient use of scarce resources in a changing environment”. The universally accepted functions of management are planning, organising, staffing, directing and controlling, according to Onifade (1999). Healthcare Simply put, healthcare refers to the service of providing medical care to different categories of people. By classification, there are primary and secondary healthcare systems. Primary healthcare refers to the patient’s first contact for health care.
It deals with general health problems which are mostly handled by GPs. They are hospitals dealing with health problems such as malaria and other basic illnesses and accidents while secondary healthcare system is a branch of healthcare that deals with specialised and more technical areas such as paediatrics, surgery, gynaecology, ophthalmology and many others. A healthcare provider can therefore be defined as a hospital where medical care is provided in various forms: laboratory investigation/diagnosis, clinical analysis, medical check-up, edical advice, surgery, blood transfusion, admission and so forth. Quality management in healthcare should be seen as a problem-solving process. How qualitative are the processes in our hospitals today? Are they of high standard or otherwise? The problem-solving process in any hospital environment cuts across all the contact points of the system—right from the gatemen through the customer service executives, the nurses, the laboratory scientists, the pharmacists to the consulting room.
This chain does not exclude the maintenance officers, the cleaners, administrative staff, the kitchen executives, the security men and all others that have one role or the other to play in the process of caring and live-saving. Quality management in healthcare will be examined in the following key areas viz: ? Information management ?Patient management ?Staff management ?Relationship management ?Human Resource Management. ?Corporate Social Responsibility Information management: This bothers on how organisational messages are communicated in our hospitals, vertically or horizontally?
Are messages well relayed to their proper destinations? How do heads of departments in the healthcare system manage hospital information at their disposal? Do we maintain the professional secrecy in the job? Many of us are aware of doctor-patient confidentiality for instance. The laboratory scientist has a lot of information at his disposal. Does he shield the information from the third party? Does he label accurately his specimen to avoid mix-up of laboratory results to the patients? Are our nurses used to discussing such information casually?
Do people divulge the hospital’s classified information to the outsiders? These are heart-throbbing questions practitioners in healthcare should examine deeply from time to time. Telephone reception in hospital environment is another vital area where many hospital owners do not take seriously. Many nurses and other administrative healthcare workers lack telephone etiquette. In hospital environment, telephone reception should exceptionally be handled with courtesies and empathy because all patients calling the hospital lines, whether through the ntercom or hotlines, day or night are not doing so in vain or for pleasure. Many patients on admission are distressed and need urgent attention. The ringing of an emergency bell should serve as a saving grace to the in-patients. Some patient is in pains and wants to know if he should continue his dosage or come over to the clinic—this has to be confirmed from the doctor almost immediately because the patient is waiting on the phone. Some patient will call to know when doctor A, B or C will be on duty because she has confidence in their treatment and prescriptions.
An enrollee will want to know if he has been delisted by his HMO or whether his brother-in-law can come with his card and be treated on fee for service. We must not wait for the third ring before springing into action. This will prove us as real life-savers. The manner and approach by which a hospital staff attends to any of these patients in terms of the information they need will, to a large extent, depict the quality of service available in such a healthcare. Patient management: How do we manage our patients? Do we value one patient over another because of their differing backgrounds?
Do we give them the required attention needed at all times? For how long do we delay them especially when they are distressed or in pains? As healthcare practitioners, do we give them due recognition as soon as they enter our facility? Whether an HMO, retainership or private patient, all patients must be accorded courtesies, recognition, sympathy and attention. Are the nurses giving them the total nursing care most hospitals/HMOs promised on the pages of their profiles, tracts or website? Do hospitals design and administer questionnaires on patients’ satisfaction/dissatisfaction of their medical services so as to improve on various areas?
Areas such as drug efficacy, hospital hygiene, doctor’s competence, nurses’ attitude and laboratory test results should be appraised by healthcare management as feedbacks from the patients. However, the best way to get feedback from patients is through interpersonal discussions and interview. By this, the healthcare practitioner can read beyond verbal discussions. This will help them improve on areas of deficiencies and at the same time know their strength. At times, in some hospitals, nurses are fond of passing the buck as to who will take the vital signs for a patient who is in pains or who will clean the medical pack.
This attitude gives a negative impression of our ladies(men too work as nurses! ) clad in immaculate white to save lives. A patient is ethically and professionally protected on any medical information relating to them. Healthcare professionals especially doctors should protect their patients in this relationship because it is the right of the latter. Common observations have revealed that hospital practitioners like nurses and laboratory scientists in some instances are fond of discussing the confidential document or medical status of patients openly with colleagues to the hearing of other patients or even outsiders.
Apart from the fact that this practice is unethical, it shows a betrayal of trust on the part of these supposed ‘professionals’ who are expected to be guardians of patients’ confidential information. Patients with some pain should not be further unleashed with psychological pains through careless gist by healthcare staff during/after working hours. Some health workers would gossip in their OPD that so-so patient is XYZ, whereas a large percentage of people who visit hospitals these days are well aware that a patient whose card is marked XYZ is HIV positive.
Although dynamic hospitals are finding alternative terms as tags on their patients’ files, doctor’s reports or medical examination forms, all allied workers to the doctors in the healthcare should be well sensitised on the trauma such patients go through when their ailment is divulged to strangers without their consent. Another area of patient management in the healthcare is prescription and administration of drugs. This area largely constitutes the output of doctors’ diagnosis/treatment. Patients will always accuse the providers of prescribing or dishing out ineffective drugs.
The doctors on their part blame this on the economic system/proliferation of fake drugs since they are not the manufacturers of these drugs. Healthcare practitioners such as doctors and pharmacists should collaborate with NHIS, NMA and Pharmacists Association to tackle the problem of drug fakery in the country while each healthcare establishment should source their drugs from registered pharmaceutical companies such as Fidson, Evans, Reals, Emzor, Beecham or Pfizer for instance. This will make them achieve desired results in treatment of their patients.
Oftentimes, patients never complete their drug dosage as prescribed by doctors. Sadly, they expect good result. But what we are told in medicine is that if a patient fails to complete the last two of a 4-4-2 anti-malarial drug at a specified time, for instance, such patient has to start all over again or take a complete dosage of another anti-malarial on doctor’s prescription. Patients should be oriented, by doctors, on dangers of not completing their drugs. Staff management: If you smile at a mirror, amazingly, it smiles back at you.
This basically concerns the management of a healthcare whether government-owned or private. How do we manage our staff? Do we pay them as at when due? Do we express that a staff is more important than the other? Do we value viable ideas/proposals from members of staff or jettison them into the trash bin? An organised healthcare should realize that a tree does not make a forest. It should make all its members of staff work as team. For example, players in a football team cannot afford to play in disarray and achieve fruitful result.
So is the practice in the theatre, in the labour and even during emergency. The combination of the efforts of the nurses, domestic staff, doctors and the laboratory scientist yield the desired result of life-saving. Members of staff in the healthcare should be team-players to achieve the high professional standard in our society. A hungry man, they say, is an angry man. Since the living of healthcare workers too largely depends on their salary, all stake-holders in the health sector should realize that prompt payment of workers’ salaries amounts to saving their (workers’)own lives too.
Since they are the engine room of an organisation, they must be considered by the management of individual organisation as most important. Their sweat, their energy, their ideas and commitment to various responsibilities assigned to them will—in the long run—make the organisation achieve its objectives. The good treatment of the internal publics by the management always reflects on the output of the business. Private hospitals should encourage research, paper presentations among staff and sponsor them for seminars so that they impact this for more efficiency in their healthcare establishments.
Relationship management: Good interpersonal relationship in any organisation is the key to achieving success and growth. If certain colleagues are not in good talking terms, there can never be a quality management—problem solving process—in that organisation, especially in the healthcare where workers’ primary business is to save lives. Therefore, there should be good relationship between the staff and the top management; between the customer service and the nursing departments; between the domestic and the administrative department and so forth.
All the departments of our hospitals or other healthcares like HMOs should be able to work as a team. As a former relationship manager in the healthcare, I had always got back to various departments/units on feedbacks from our clients to achieve this purpose. All forms of biases should be cancelled and a third party should always mediate between two conflicting groups or individuals. Quality management in our hospitals requires the concerted efforts of all people involved.
Below is a sample questionnaire of Isalu Hospitals Limited, Ogba, Lagos on service evaluation: ————————————————————————————- Hospital Service Evaluation fig 1. Poor Satisfactory Good Excellent Caring attitude of doctors Nurses’ competence Neatness of our hospital environment Communication/listening skills Infrastructure: A/C, TV, Computers Performance of housekeepers Can you recommend our hospital to your family member/friend? Yes No Other comments…………………………………………………………………………………………………………………………….. ————————————————————————————————————— The above questionnaire was administered on 100 patients using Isalu Hospitals, Lagos in June 2009 and the following were the responses received. In all, 82 of the respondents said they could recommend the hospital(in terms of its services) to their family and friends while 18 were indifferent. 70 of them rated doctors’ performance as good, 21 as satisfactory and 9 as excellent. 65 of the respondents said the nurses’ performance was satisfactory, 25 said it was good and 10 said it was excellent.
Under communication skills, 30 of the respondents ticked satisfactory, 33 ticked good and 37 excellent respectively. Also, 25% of the respondents ticked satisfactory, 35% ticked good while 40% ticked excellent under hygiene. On other comments,65 of the patient respondents said the hospital’s bill was high, 20% said the hospital needed a bigger space while 15% were indifferent. The data can be vividly represented in fig. 1A, fig. 1B and fig. 1C respectively: fig. 1A fig 1B Fig 1C Basically there are two categories of people working in Isalu Hospitals.
These are what I coin as: (a)Professional healthcare practitioners (b)Professionals in healthcare practice PROFESSIONAL HEALTHCARE PRACTITIONERS These are people who have received education and training in hospital-related courses such as medicine, nursing, pharmacy, laboratory science and so forth. They are our doctors, nurses, pharmacists, laboratory scientists/technicians etc PROFESSIONALS IN HEALTHCARE PRACTICE All healthcare workers coming from backgrounds different from medicine and other allied courses are referred to as professionals in healthcare.
These professionals are recruited from areas like Accounting, Banking and Finance, Business Administration, Marketing, Personnel Management, Economics, Mass Communication etc to be part of the problem-solving process in the hospital environment. Isalu Hospitals, like other healthcare organisation, is segmented into sundry departments based on the two categories mentioned above. Though some jobs are more professional oriented than others in this hospital, the jobs of the two categories are inextricably intertwined to achieve the desired objective, which is high standard.
In order to continue to achieve professional excellence in our healthcare system, through human capital development, members of staff should undergo periodic training relevant to their background and job description. Human Resource Management: The most valued assets of any organisation are the people who may make or mar the quality management in such an establishment. Otherwise known as Human Capital Management (HCM), Human Resource Management is the strategic function of managing an establishment’s most valued assets—the staff of such an organisation.
The human resources department of any organisation is charged with not only employing but training, developing, directing and managing various talents in the workforce and as well putting in place development process in the organisation. The department responsible for recruiting the workforce in the healthcare, be it private or government-owned, should be competent enough to hire the right people. Both professional practitioners and other professionals in the profession should comprise this department. This will give room for people of right attitude, coupled with academic merits, to harness the system.
Corporate Social Responsibility: Both private and government healthcare should be socially responsible to their immediate society. Isalu Hospitals for instance, publishes and distributes tracts that treat different topics in medicine. As part of its social responsibility, between 2008 and 2009 alone, more than N1m was expended on some portions of Wempco Road by the management of the hospitals not only to ease the traffic congestion but to alleviate motorcycle accidents on the sharp bend of the road to the hospital from Agidingbi Road. CONCLUSION AND RECOMMENDATIONS
Since the primary aim of establishment of healthcare institutions in Nigeria and elsewhere in the world is to save lives as well as care for people in pains and sicknesses, owners and administrators of hospitals and HMO’s should ensure quality management in this respect. National Health Insurance Scheme (HNIS) which constitutes the compass between the primary/secondary providers and the HMO’s should not renege on its efforts to separate the grain from the chaff in healthcare industry in Nigeria to ensure quality healthcare standard we deserve.
In January 2010, the NHIS suspended further accreditation of Health Maintenance Organisations (HMO’s) and Healthcare Providers (HCP’s) for one year, justifying, inter alia, that “Only 816 of the 3, 012 accredited primary healthcare providers have 500 lives (patients/enrollees) and above” and there was the need “ to strengthen the scheme and improve quality of healthcare services delivery through re-accreditation processes” The Governing Council of the NHIS further stated in the advertorial that “( i) Only twenty-seven (27) of the sixty-one (61) HMOs operating under NHIS formal sector programme have lives (ii) Reports of re-accreditation exercises show that HMOs have not made sufficient progress in folding in Organised Private Sector (OPS) and other tiers of government into the scheme……………….. (iv) The need to shift focus to re-accreditation processes of HMOs with the view to improving access to quality healthcare. ” The National Health Insurance Scheme should be further encouraged by the Federal Ministry of Health in making the quality management realistic. To achieve quality management in both government and rivate healthcare in Nigeria, only competent healthcare practitioners and other professionals who are ready for the challenges of the job should be employed and continually trained. It is also high time all the healthcare administrators as well as practitioners valued the sanctity of human lives. There should be a way of instituting a health security system where people’s lives will be guaranteed first—whether in times of accident, serious illness or delivery—whenever they are rushed into the hospitals in Nigeria. This may be through the HMOs or government hospitals. Hundreds of thousands of Nigerians have lost their lives because there was nobody to make financial deposit on their behalf for doctors to commence treatment.
The social security gesture in the health sector should start from the government, perhaps through some allocation of some sort from the yearly budgets to the government hospitals in the first instance. Other registered healthcare with the government and the NHIS should be considered. GLOSSARY OF TERMS OPD: The out-patient department of a hospital where patients wait to be attended to by a nurse or doctor. It is a large room where people also wait to see the in-patients—hospital reception. HMO: Also known as Health Insurance, Health Maintenance Organisation (HMO) is responsible for insuring people’s health through a payment called capitation. GP: General Practitioner (GP) is a doctor who has been trained in general medicine.
IN-PATIENTS: Patients who are on admission in a hospital because they need special attention by the doctor. PAEDIATRICS: A branch of medicine that deals with care and treatment of children. A paediatrician is a specialist who diagnoses and treats children of their illnesses. SURGERY: A branch of medicine concerned with treatment of diseases, deformities, and injuries through operations on patients. GYNAECOLOGY: A branch of medicine that deals with diseases and fertility especially in women. A gynaecologist is a specialist in this area. OPHTHALMOLOGY: A specialisation in medicine concerned with the function, care as well as the disorders which affects the eyes.
An ophthalmologist is a specialist that treats eye disorders. ENROLLEE: A patient who has registered with an HMO to receive medical care from a provider (hospital). TOTAL NURSING CARE: The kind of care that requires all the attention of the nurses to the patients during illness, accident and recovery. PROVIDER: A hospital that provides medical service to enrollees especially under HMO DOCTOR-PATIENT CONFIDENTIALITY: Professional secrecy in medical profession where patients enjoy confidentiality in matters relating to their health. It is unethical of a doctor and other health practitioners to divulge such information without the patient’s consent.
VITAL SIGNS: The basic signs and symptoms of illness taken by nurses to assist doctors in diagnosis. They are routine checks including the temperature, pulse, blood pressure, blood/urine analysis and physical examination to evaluate organ function. FEE FOR SERVICE: A medical fee charged on an enrollee who has enjoyed medical service in a healthcare where they are not covered or registered under an HMO. Bibliography 1) Katib, I. K. (2008) Corporate Identity: Telephone Reception for Isalu Hospitals Limited A customer service presentation. 2) Katib, I. K. (2009) Isalu Hospitals: Beyond the Competitive Stage, A Paper Presentation at Isalu
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