Hospital Topics
ISSN: 0018-5868 (Print) 1939-9278 (Online) Journal homepage: http://www.tandfonline.com/loi/vhos20
How the Revised Unit Management Program at Cook County Hospital Eliminated 87 Jobs and Saved $400,000 Ishwar Gupta , John T. Farrell & Haryash P. Gugnani To cite this article: Ishwar Gupta , John T. Farrell & Haryash P. Gugnani (1976) How the Revised Unit Management Program at Cook County Hospital Eliminated 87 Jobs and Saved $400,000, Hospital Topics, 54:5, 35-42, DOI: 10.1080/00185868.1976.9948066 To link to this article: http://dx.doi.org/10.1080/00185868.1976.9948066
Published online: 13 Jul 2010.
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Date: 06 November 2015, At: 13:33
How the Revised Unit Management Program at Cook County Hospital Eliminated 87 Jobs and Saved $400,000. By Ishwar Gupta, John T. Farrell and Haryash P. Gugnani
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A n effective Ward Management program w a s developed and implemented at Cook CounQ Hospital, Chicago, after an elaborate industrial engineering study. Objectives and results are given in this article, as well as implementation strategy, and revised administrative structure. Improved patient care and high annual cost savings have been the dividends.
1. INTRODUCTION This article discusses how a sound and effective administration structure was developed at the Ward level from poor conditions which existed in Cook County Hospital. It has not been an easy task. To get a better perspective of the problems faced by the management of this giant insititution it is important to list some of the historical facts. Cook County Hospital is one of the largest acute care facilities in the country. The hospital with its 2,000” in-patient beds and over 500,000 outpatient visits per year has been providing health care to underprivileged of Cook County for over a century. For many years the large majority of teaching physicians at this hospital had private practices and served as part time faculty. They functioned under the leadership of a voluntary medical staff organization, whose members were affiliated with the five local medical schools. In recent years, these schools formed affiliations with other hospitals, and their faculty (full time and part time practicing physicians) have become affiliated with other hospitals. This then required Cook County Hospital to employ a full complement of faculty physicians to provide the necessary leadership and teaching for a house staff that numbers approximately 500 interns and residents. As the reputation of this faculty grew, the authority of its members’ reputation ultimately grew within the institution, up to a point where each physician became independent in setting up the programs, goals and the organizational structure of his department. Each clinical division enjoyed considerable autonomy. The division chairman could create new wards, without consultation with administration and/or nursing service and without giving due consideraton for nurse staffing, as at that time there were only two lines of communication, namely medical and nursing.
* The bed complement has since been changed to 1501 SEPTEMBER/OCTOBE R 1976
This organizational structure, coupled with the political structure in Chicago, and a very explosive situation with a dissatisfied house staff seriously plagued Cook County Hospital, to the extent that in 1969, it was facing the loss of its accreditation by the Joint Commission on Accreditation of Hospitals. The Illinois State Legislature took action to preserve this major health resource. It created an independent nonpolitical commission, the Health and Hospitals Governing Commission of Cook County, to operate not only Cook County Hospital but all of the County’s hospital and medical facilities. Under these conditions in October of 1970, Dr. James G. Haughton, took charge of the Commission and a new era of improved patient care began at Cook County Hospital.
2. DEVELOPMENT OF UA PROGRAM Prior to 1969, the administrative structure at Cook County Hospital primarily related to physical plant maintenance and service functions. Fiscal, personnel and purchasing functions were the responsibility of the Cook County political organization, with offices in the County Building in downtown Chicago. The Nursing Services were provided on a contractual basis by the Cook County School of Nursing. Doctor Haughton recognized the weak administrative structure and started to develop a strong “ward management” program, where Medical Staff, Nursing and Ward Management (Unit Management) could jointly participate in patient care. a. It was decided that the Unit Administration program would be taken out of Nursing and would report to the Administrator, thus setting up a tripartite structure, i.e. medical stasf, nursing, and administmtion. (Fig. I describes a block diagram of this hierarchy) b. Division of Medicine, representing about 500 be& was selected as the pilot division for setting up the above administrative stnrcture. This divhion was selected because of the
35
COOK COUNTY tIOSPiTAL
Downloaded by [NUS National University of Singapore] at 13:33 06 November 2015
Ishwar Gupta, is Director of the Computer Center at the
Figure I:
Block diagram o f O r g a n i z a t i o n H i e r a r c h y
University of Health Sciences/the Chicago Medical School, responsiblefor all computing and information science activities of the university. Prior to this he wm Director of Management Science at Health andHospitals Governing Commission of Cook County, where he was raponsible for all system design, computer programming, and operations research/industrial engineeringfunctions. Mr. Gupta h m a masters degree in I n dustrial and Systems Engineering from Illinois Institute of Technologyand has published many articles in the field of Computer and Management Science.
coopration and willingnessshown by the Division Chief and the Director of Nursingfor this division. c. To train appropriate st& training program for Unit Managers was developed in concert with the local, Roosevelt Uniwrsity. The 12 semester-hour program in the Department of Public Administration led to a certificate in Public Administration. d. Fi/ty-fiw imcumbent employees already aboard were selected to go through this program and their progress was carefully watched, monitored and evaluated. The education program began in Summerof 1971. e. A separate job classification of Unit Administrators was set up for those who qualified after the completion of the above program. J An Assistant Administrator reporting to the Hospital Administrator was named to head up the UA program in Medicine.
Essentially, the organizational structure of the Hospital, under the Hospital Director, was set up on a tripartite partnership of Administration, Medicine and Nursing Service; Unit Administration was to replicate this on the wards, and to foster a peer relationship and team collaboration of these three crucial aspects of the delivery of patient care at the point where they most directly affect the patient, on the wards. Implicit in this philosophy and objective was the notion of what one might call “horizontal” and “vertical” authority for the Unit Administrators. The Unit Administrators, and the Ward Clerks as their agents, were expected to exercise a high degree of coordination of all services on the wards, including all support services, such as Dietary, Environmental Sanitation, Transportation, and the like, even though these support services were under the line supervision of other departments.
John T. Farrell, is Assistant Director for Patient Services Administration at Cook County Hospital, Chicago, IIL He is responsible for the Admitting/In-patient I nformation Department, Emergency Services Department, Evening and Night Hospt ial Administrative functions, the Departmen t of Transportation and Unit Administration. He sewed as the Administrative Co-ordinator in the formulation and expansion of the Support Service Departments’ role and functions. Prior to joining Cook County Hospital’s Administrative Staff in October 1973, he was employed at the University Hospital, University of Michigan Medical Center, for 11 years in various Administrative and Managerialpositions. From 1969 to 1971, Mr. Farrell served as an Associa@ Consultant with Foussard-Rossman and Associates, Minneapolis, Minnaota for Unit Management Concepts, systems and procedures. He was Chairman of the organizing Committee, and President, Michigan Hospitals Unit Management Association June I971 to December 1972.
Haryash P. Gugnani, has been a Sr. Project Leader for the Department of Management at the Health & Huspitals Governing Cornmission of Cook County since May, ’73. Mr. Gugnani has a Masters Degree in lndustrual Engineering and Systems Engineeringfrom Illinois Institute of Technologv, Chicago.
Continued on page 38
36
HOSPITAL TOPICS
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Before the program was implemented, role playing sessions between the three disciplines with representation from support services were held. These sessions proved extremely helpful in clarifying and balstering the philosophy of the program and the role of various participants. Everybody understood that the Unit Adrninistration program was to be implemented to relieve Medical and Nursing personnel of clerical and administrative tasks. Soon after the program was implemented, problems started to emerge, such as: a. The all powerful Medical Division Head soon realized that his authority had been cut to nothing, except to take care of the patients. The Hospital Administration had taken control of the Division and its day to day operation. No longer was a Division Head able to open or close wards and change the bed complement on his own volition. Thus the Division Chief became uncooperative and critical of the program. The Nursing Divkwn Head realized the importance of the program so that she was cooperativeand willing to try new ideas. Note the difference in attitude between the Medical and Nursing Sta.& the opposite to experiments conducted in other hmpitals where medical stdf cooperated and nursing was critical. This difference purely reflected uniqueness of Cook County Hospital as a public institution and its traditions of physician autonomy. b. The second mGor problem evolved from the poor leadership qualities of some of the Unit Administrators, and it became difficult for them to properly coordinate with other support services and manage day-to-day ward operations.
The above two problems were resolved by a change in the Medicine Division Head and some of the Unit Administrators. Thereafter, the Unit Administration program became much more successful and was extended to Division of Pediatrics and later extended to OB/Gyn and Surgery Divisions. Thus, by 1972 the program became fully operational and a typical organization chart is shown in Figure 2. Other problems related to the fact that the central support service (supply, housekeeping, patient transportation, etc.) departments were not fully extending their activities to the patient units. Thus Unit Administration personnel were expected to also perform the functions not adequately provided by the central departments. This was both costly and inefficient. In March, 1973, the Hospital Director requested the Commission’s Department of Management to conduct a thorough study of the Unit Administration Department. Initially the Management study would be limited to the Division of Surgery with 556 regular beds and 36 recovery beds.
3. MANAGEMENT STUDY A team of four Industrial Engineers was assigned on a full time basis. The objectives of this study were: 38
1. To evaluate the existing structure and functions of Unit Administration.
2. Given a tripartite structure on the wards (i.e. Medical StafJ Nursing and Unit Administration), to determine how Uqit Administration related to its counterparts. 3. To evaluate the relationship between the Unit Administration and other supportservices. 4. To develop work standards for ihe clerical activities on the wards. 5. To determine optimalstqffing patterns for ward clerks and household attendants. (Attendants at the time reported to Unit Administrators). 6. To define the ward procedures and ideniify problems with the existing procedures.
Work measurement, flow charting, and statistical sampling were used and the following problems were identified: 1. Mxed Responsibility and Unclear Role
The Unit Administration was not only responsiblefor clerial tasks but also directly responsible for tasks such as preparing patienis for transportation, cleaning an area, cleaning and autoclaving instruments, ordering supplies, etc. Such tasks wereperformed by the Household attendants, who reportd to the Unit Administrators. The support service departments obviously were not totally providing these services since the previous organizational plan encouraged each patient unit to be self-sufficient, with only modest assistancefrom central departments. Thus, some of the tasks were similarly pe#ormed by the Patient Care attendants who reported to Nursing Service. The Household attendants were responsiblefor tasks such as cleaning of bathrooms and sinks, etc. Similar tasks were also performed by the Department of Environmental Sanitation. This poor definition of line of responsibility created ‘yingerpointing” exercise on the war&. Even though the Unit Administration organizational structure existed in the Division of Surgev, its relationship to other parts of the hospital was not clearly defined. This lack of clarification resulted in poor cooperationfrom support services and many hours of unnecessary work on the part of Unii Administrators.
2. Organization Due to the various levels of Management and Supervision, as shown in Figure #2, problems were created in communication, supervision and control of the unit related activities as performed by the Ward Clerk and Attendants. 3. Staffing of Ward Clerks
It was determined that the work volume varied from ward to ward and from shift to shift. The AM shift (7AM to 3PM) had the heaviest workload while the nite shift (IIPM to 7AM) had the least. The clerical s t g f was fairly well utilized during the AM and PM shifts, while poorly utilized during the nite shift. The scheduled number of hours during the nite shift far exceeded the productive work hours, as shown in Figure 3. This raised the question of redistribution of work among shifts and realignment of clericalstdfing. Also the ward clerks were not scheduled in accordance to the needs of respective wards. For example, as shown in Figure 4, there was little relationship between the work load and the scheduled number of hours.
HOSPITAL TOPICS
D I RECTOR FIG.2
CRGAFI I Z A T l ONAL STRUCTURE P R I O R TO R E O R G A N I Z A T I O N OF U N I T A D M I N I S T R A T I O N A T COOK COUNTY HOSP 1 T A L
ASSOCIATE
KFi ADt4 I N I STRATO I
r
4
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A0 I N I S T R A OR
I ASS IS T A N T ADMINISTRATOR
I ASS I S T A N T ADMINISTRATOR
I I ADMl N I S T R A T I VEI ASS IS T A N T
%J-
4. Staffing of Attendants A D M l N I S T R A T I VE ASS I S T A N T
I
It became apparent that given the philosophy of Unit Administration program, the functions performed by these attendants did not belong to Unit Administration. This raised the question of reorganization of not on& Unit Administration but also of Support Service Departments.
5. Supervision and Reporting The Unit Administrators placed too much emphasis on occurrence reports andpaper work rather than problem solving.
6. Staffing Training The large clerical stsff wm poor& trained, resulting in poor performance and low morale. 7. Policies and Procedures Policies and procedures did exist on the wards, but they were either inw mplete, obsolete or misunderstood.
Scheduled Hours
WARD N O . 24
NlTE
SHIFT
R e l a t l o n s h l p Indicates:. s c h e d u l e d h o u r s v s . p r o d u c t i vc h o u r s
In
;
1
u-
4
0
z" 3.
SEPTE MBE R/OCTOB E R 1976
39
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In summary, the Unit Administration program was less than effective. Specifically, deficiencies related to not having uniform job descriptions, no uniform established policies and procedures, no quality control mechanisms for the Household Attendants, Ward Clerks or Unit Administrators, and poorly trained personnel. Unit Administrators performed some routine basic functions but primarily acted as a “backstop” or “gofer” for the other support service departments. There was a great need for improving the support systems. The Management study final report* was published during October of 1973 and reviewed by the Hospital Director and the Associate Director for possible implementation of recommendations and developing future plans. In mid October 1973, a new Assistant Director for Unit Administration was hired to implement a revised program and the Management study utilized as a source document. It became immediately evident to the Assistant Director that the problems found in the Division of Surgery were widespread throughout the entire As a the Management study team was asked to conduct work measurement studies in three other divisions. These studies were completed 1974*As these studies were going by began* The major reorganization process effort is discussed below. 4. REORGANIZATION
In early December, 1973, the philosophy of Unit Administration was reaffirmed, in that Unit Administration would represent Hospital Administration in the tripartite structure, functioning at the patient care level, with the Medical and Nursing staffs. This philosophy of a patient care team on the Patient Units (Medical, Nursing and Administration) is a practical plan for providing patient service in a highly complex setting. Each -~ member of the team is inter-dependent on each other and ultimately the entire team requires the complete and cooperation Of the departments that provide patient services. The patient care triad and the supporting departments dependent on each other evolves from the notion that each team member provides an important service to the total team effort. The services would be clearly defined, responsibility assigned and effectiveness measured against standards jointly developed by the team. In most instances, these standards of service are a product of a close relationship between Nursing Service, Unit Administration and supporting services. Unit Administration would be responsible for providing all non-nursing, non-medical, supportive *Copies Jrrporr arr aiurlahlr in rhr Munuxrmmr Depprrmrnr/ilr/firrhrinrere~rrd reudrn
40
and clerical functions as defined and detailed by the leadership of the Nursing Department and Administration as follows: Direct supervision of the Ward Clerk activities. Monitor the housekeeping-stdf in the performance of their duties, even though they are responsible to a Central Housekeeping Department. Monitor the Patient Transportation stdf in the performance of their duties, even though they are responsible to a Central Transportation Department. Monitor and assure the availability of services and supplies from all support departments in accordance with established schedules andstandards of services. 9 Requests and monitors correction of maintenance defciencies.
Assumes responsibility for safe environment on the patient unit in accordance with hospital, local, state and federal codes. Assumes responsibility for functions that are unique to each patient units as agreed upon by Nursing Service and A dm inistration.
Unit Administration has clearly defined thanriels of authority to assure that patient units receive all necessary services, even when those services are under the direct responsibility of other elements of Hospital Administration. It was determined that the above objective would be best served under a Patient Services Administration Division within the Hospital’s Administrative structure. Unit Administration, thus, became a part of a much broader Patient Service Division. Figure 5 shows the new organizational structure. After delineating the objectives of the Unit Administration program, the plan for the implementation of the Patient Services Division and the implementation of the Management Report recommendations was developed. The implementation process consisted of the following three phases. PHASEI: To concentrate on unit related activities and ward clerk functions. As a result, job descriptionsfor the Ward Clerk and Unit Administrator would be developed and functions to be performed by the support and ancillary services would be identifed. Thirphare was to lastfor 7months. PHASE 11: To develop and produce training materials and programs for the Unit Administrators and the Ward Clerks. Also to initiate and complete a total reorientation of all existing personnel, based upon the new program. To implement a Quality Control and Quality Assurance Program for Patient Service Administration. To realign Ward Clerk S t d f n g patterns based upon the job functions as decided under Phase I. This phase was to last approximately 10 months. PHASE I l l : Re-evaluate Phases I and 11, with continual effort on proper s t d f n g alignment. Simultaneously, the s u p p o ~service func-
HOSPITAL TOPICS
In I
9.
6.
Lc
O
7.
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z 0 6.
FIG.4 WARD NO. 23
A.M.SHIFT Scheduled Hrs. v s . Productlve Hout-_s_
J J ' ME
(From 6/4/ t o 6/24/73] I
tions identified earlier would undergo appropriate reorganization and shifr of functionsfrom the unit administrator to the appropriate support service departments. Thisphme wm to lmt approximately 12 months.
Following is the status of various actions which have taken place from January 1,1974 to February 28,1975. In early January 1974, with the cooperation of the Director of Nursing Service, a Committee was formed with participants from all levels within Nursing Service and Patient Services Administration. The objective was to review the existing practices and procedures on the unit with emphasis on the Ward Clerk activities. As a result, new standard practices and procedures were developed and implemented throughout the Hospital. The Committee remained active for 8 months and was responsible for developing over 25 practices and drafting recommendations for several hospital policies. The support services functions to be transferred to appropriate departments in two major divisions, Medicine and Pediatrics, consisting of 672 beds and in separate buildings were reorganized; the Household Attendant positions were deleted and functions that they formally performed were transferred to the appropriate support service departments. The functional transfers involved the department of Environmental Services, Central SEPTEMBER/OCTOBE R 1976
Sterile Supply, Materials Management, Linen and Laundry, Central Transportation, Pharmacy and Nursing Services. In February 1974, the Admitting/Emergency Service Department was added to the Patient Services Administration Division. In May, the Department functions were separated, forming a Division of Emergency Services and the Admitting/Patient Information Department. The Administrative Activity in Emergency Services became a division of Patient Service Administration while the Admitting/Patient Information became a separate department with distinct functional responsibilities. Both departments are presently undergoing complete reorganization. In November of 1974 a position was carved out of Unit Administration and transferred to the Department of Training and Education. This position is serving as a liaison to Unit Administration in providing the necessary training and education skills required by Unit Administration personnel. The purpose of this was to take advantage of the resources available within that section. All basic introductory training as well as inservice education would be conducted by the Training Division. Secondary or on the job training would be provided and supervised by Unit Administrators. By late Spring of 1975 complete training programs were developed and a reorientation 41
for Ward Clerks and Unit Administrators completed. I n early February 1975, the Department of Transportation and Messenger Service was also added to the Division of Patient Services Administration. The purpose of this Administrative transfer was for ease in managing the Patient Services objectives performed by this Department. 5. CONCLUSION
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The reorganization of Patient Services Administration has proven extremely beneficial and has had an impact on the Hospital’s financial picture. As a result, the Housekeeping Department is now responsible for all routine cleaning in patient areas where before cleaning was done by 3 separate depart men ts. All routine supplies, i.e. pharmaceuticals, medical-surgical, linens and general supply items are being delivered to these units on a par stock basis by the Supplying Departments. A Central Nursing Equipment Service has been developed and provides a 24 hour 7 day service. Most patients requiring movement throughout the Hospital are now being transported by the Central Transportation Department. Centralizing the functions formerly performed by Household attendants under several major support service departments, has allowed us to consolidate staff and reduce the number of personnel required. As a result of the new division, 107 positions in Patient Services Administration were affected. Of
the 107 positions 52 were dispersed among the various support service departments, 19 were redistributed within the Patient Service Administration Division and 36 are being held vacant. By vacating those 36 positions, the fiscal budget for Patient Service Administration has been reduced by approximately $400,000. Following table compares personnel within the Unit Administrative structure as of October 1973, and February 28,1975. OCTOBER I 9 73
FEBRUAR Y I975
I 4 5 54 242 2 8 I1 4 167 498
4 4 51 236 4 3 4 I03 409
Training Coordinator Assistant Adminsitrators AdminissratiwAssistant111 Unit Administrators Ward Clerks Clerkly Clerk 111 Clerk I1 Secretary1 Administrative Aides
Assistant Administrators AdmmhiveAssistant 111 Unit Administrators Ward Clerks Secretary1 Clerk I V Clerk111 Administrative Aide
Cook County Hospital is undergoing a complete reorganization of its patient support service functions. Continuing at the most economical level. Through the efforts of many disciplines, Administration has been extended to the patient level and Quality Assurance programs developed to monitor the level of performance. Nursing Service is functioning at the patient bedside, equipment and supplies are more readily available and in good repair and patients are being treated and cared for in a cleaner, safer environment. rn
DIRECTOR -CCH
FIG.5 ORGANIZATIONAL STRUCTURE P A T I E N T S E R V I C E S ADMINISTRATION MARCH I , 1975 ASSISTANT D I R E C T 0 PT. SVC. ADMIN.
A s s t . Adm.
A s s t . Adm. Surgery
A s s t . Adinin.
Peds
A s s t . Admin. Med i c I n e
A s s t . Admin. Eincr. Svcs.
Dir. T r a n s p o r fa t ion
ard Clerk
r
42
HOSPITAL TOPICS
ISSN: 0018-5868 (Print) 1939-9278 (Online) Journal homepage: http://www.tandfonline.com/loi/vhos20
How the Revised Unit Management Program at Cook County Hospital Eliminated 87 Jobs and Saved $400,000 Ishwar Gupta , John T. Farrell & Haryash P. Gugnani To cite this article: Ishwar Gupta , John T. Farrell & Haryash P. Gugnani (1976) How the Revised Unit Management Program at Cook County Hospital Eliminated 87 Jobs and Saved $400,000, Hospital Topics, 54:5, 35-42, DOI: 10.1080/00185868.1976.9948066 To link to this article: http://dx.doi.org/10.1080/00185868.1976.9948066
Published online: 13 Jul 2010.
Submit your article to this journal
Article views: 1
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=vhos20 Download by: [NUS National University of Singapore]
Date: 06 November 2015, At: 13:33
How the Revised Unit Management Program at Cook County Hospital Eliminated 87 Jobs and Saved $400,000. By Ishwar Gupta, John T. Farrell and Haryash P. Gugnani
Downloaded by [NUS National University of Singapore] at 13:33 06 November 2015
A n effective Ward Management program w a s developed and implemented at Cook CounQ Hospital, Chicago, after an elaborate industrial engineering study. Objectives and results are given in this article, as well as implementation strategy, and revised administrative structure. Improved patient care and high annual cost savings have been the dividends.
1. INTRODUCTION This article discusses how a sound and effective administration structure was developed at the Ward level from poor conditions which existed in Cook County Hospital. It has not been an easy task. To get a better perspective of the problems faced by the management of this giant insititution it is important to list some of the historical facts. Cook County Hospital is one of the largest acute care facilities in the country. The hospital with its 2,000” in-patient beds and over 500,000 outpatient visits per year has been providing health care to underprivileged of Cook County for over a century. For many years the large majority of teaching physicians at this hospital had private practices and served as part time faculty. They functioned under the leadership of a voluntary medical staff organization, whose members were affiliated with the five local medical schools. In recent years, these schools formed affiliations with other hospitals, and their faculty (full time and part time practicing physicians) have become affiliated with other hospitals. This then required Cook County Hospital to employ a full complement of faculty physicians to provide the necessary leadership and teaching for a house staff that numbers approximately 500 interns and residents. As the reputation of this faculty grew, the authority of its members’ reputation ultimately grew within the institution, up to a point where each physician became independent in setting up the programs, goals and the organizational structure of his department. Each clinical division enjoyed considerable autonomy. The division chairman could create new wards, without consultation with administration and/or nursing service and without giving due consideraton for nurse staffing, as at that time there were only two lines of communication, namely medical and nursing.
* The bed complement has since been changed to 1501 SEPTEMBER/OCTOBE R 1976
This organizational structure, coupled with the political structure in Chicago, and a very explosive situation with a dissatisfied house staff seriously plagued Cook County Hospital, to the extent that in 1969, it was facing the loss of its accreditation by the Joint Commission on Accreditation of Hospitals. The Illinois State Legislature took action to preserve this major health resource. It created an independent nonpolitical commission, the Health and Hospitals Governing Commission of Cook County, to operate not only Cook County Hospital but all of the County’s hospital and medical facilities. Under these conditions in October of 1970, Dr. James G. Haughton, took charge of the Commission and a new era of improved patient care began at Cook County Hospital.
2. DEVELOPMENT OF UA PROGRAM Prior to 1969, the administrative structure at Cook County Hospital primarily related to physical plant maintenance and service functions. Fiscal, personnel and purchasing functions were the responsibility of the Cook County political organization, with offices in the County Building in downtown Chicago. The Nursing Services were provided on a contractual basis by the Cook County School of Nursing. Doctor Haughton recognized the weak administrative structure and started to develop a strong “ward management” program, where Medical Staff, Nursing and Ward Management (Unit Management) could jointly participate in patient care. a. It was decided that the Unit Administration program would be taken out of Nursing and would report to the Administrator, thus setting up a tripartite structure, i.e. medical stasf, nursing, and administmtion. (Fig. I describes a block diagram of this hierarchy) b. Division of Medicine, representing about 500 be& was selected as the pilot division for setting up the above administrative stnrcture. This divhion was selected because of the
35
COOK COUNTY tIOSPiTAL
Downloaded by [NUS National University of Singapore] at 13:33 06 November 2015
Ishwar Gupta, is Director of the Computer Center at the
Figure I:
Block diagram o f O r g a n i z a t i o n H i e r a r c h y
University of Health Sciences/the Chicago Medical School, responsiblefor all computing and information science activities of the university. Prior to this he wm Director of Management Science at Health andHospitals Governing Commission of Cook County, where he was raponsible for all system design, computer programming, and operations research/industrial engineeringfunctions. Mr. Gupta h m a masters degree in I n dustrial and Systems Engineering from Illinois Institute of Technologyand has published many articles in the field of Computer and Management Science.
coopration and willingnessshown by the Division Chief and the Director of Nursingfor this division. c. To train appropriate st& training program for Unit Managers was developed in concert with the local, Roosevelt Uniwrsity. The 12 semester-hour program in the Department of Public Administration led to a certificate in Public Administration. d. Fi/ty-fiw imcumbent employees already aboard were selected to go through this program and their progress was carefully watched, monitored and evaluated. The education program began in Summerof 1971. e. A separate job classification of Unit Administrators was set up for those who qualified after the completion of the above program. J An Assistant Administrator reporting to the Hospital Administrator was named to head up the UA program in Medicine.
Essentially, the organizational structure of the Hospital, under the Hospital Director, was set up on a tripartite partnership of Administration, Medicine and Nursing Service; Unit Administration was to replicate this on the wards, and to foster a peer relationship and team collaboration of these three crucial aspects of the delivery of patient care at the point where they most directly affect the patient, on the wards. Implicit in this philosophy and objective was the notion of what one might call “horizontal” and “vertical” authority for the Unit Administrators. The Unit Administrators, and the Ward Clerks as their agents, were expected to exercise a high degree of coordination of all services on the wards, including all support services, such as Dietary, Environmental Sanitation, Transportation, and the like, even though these support services were under the line supervision of other departments.
John T. Farrell, is Assistant Director for Patient Services Administration at Cook County Hospital, Chicago, IIL He is responsible for the Admitting/In-patient I nformation Department, Emergency Services Department, Evening and Night Hospt ial Administrative functions, the Departmen t of Transportation and Unit Administration. He sewed as the Administrative Co-ordinator in the formulation and expansion of the Support Service Departments’ role and functions. Prior to joining Cook County Hospital’s Administrative Staff in October 1973, he was employed at the University Hospital, University of Michigan Medical Center, for 11 years in various Administrative and Managerialpositions. From 1969 to 1971, Mr. Farrell served as an Associa@ Consultant with Foussard-Rossman and Associates, Minneapolis, Minnaota for Unit Management Concepts, systems and procedures. He was Chairman of the organizing Committee, and President, Michigan Hospitals Unit Management Association June I971 to December 1972.
Haryash P. Gugnani, has been a Sr. Project Leader for the Department of Management at the Health & Huspitals Governing Cornmission of Cook County since May, ’73. Mr. Gugnani has a Masters Degree in lndustrual Engineering and Systems Engineeringfrom Illinois Institute of Technologv, Chicago.
Continued on page 38
36
HOSPITAL TOPICS
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Before the program was implemented, role playing sessions between the three disciplines with representation from support services were held. These sessions proved extremely helpful in clarifying and balstering the philosophy of the program and the role of various participants. Everybody understood that the Unit Adrninistration program was to be implemented to relieve Medical and Nursing personnel of clerical and administrative tasks. Soon after the program was implemented, problems started to emerge, such as: a. The all powerful Medical Division Head soon realized that his authority had been cut to nothing, except to take care of the patients. The Hospital Administration had taken control of the Division and its day to day operation. No longer was a Division Head able to open or close wards and change the bed complement on his own volition. Thus the Division Chief became uncooperative and critical of the program. The Nursing Divkwn Head realized the importance of the program so that she was cooperativeand willing to try new ideas. Note the difference in attitude between the Medical and Nursing Sta.& the opposite to experiments conducted in other hmpitals where medical stdf cooperated and nursing was critical. This difference purely reflected uniqueness of Cook County Hospital as a public institution and its traditions of physician autonomy. b. The second mGor problem evolved from the poor leadership qualities of some of the Unit Administrators, and it became difficult for them to properly coordinate with other support services and manage day-to-day ward operations.
The above two problems were resolved by a change in the Medicine Division Head and some of the Unit Administrators. Thereafter, the Unit Administration program became much more successful and was extended to Division of Pediatrics and later extended to OB/Gyn and Surgery Divisions. Thus, by 1972 the program became fully operational and a typical organization chart is shown in Figure 2. Other problems related to the fact that the central support service (supply, housekeeping, patient transportation, etc.) departments were not fully extending their activities to the patient units. Thus Unit Administration personnel were expected to also perform the functions not adequately provided by the central departments. This was both costly and inefficient. In March, 1973, the Hospital Director requested the Commission’s Department of Management to conduct a thorough study of the Unit Administration Department. Initially the Management study would be limited to the Division of Surgery with 556 regular beds and 36 recovery beds.
3. MANAGEMENT STUDY A team of four Industrial Engineers was assigned on a full time basis. The objectives of this study were: 38
1. To evaluate the existing structure and functions of Unit Administration.
2. Given a tripartite structure on the wards (i.e. Medical StafJ Nursing and Unit Administration), to determine how Uqit Administration related to its counterparts. 3. To evaluate the relationship between the Unit Administration and other supportservices. 4. To develop work standards for ihe clerical activities on the wards. 5. To determine optimalstqffing patterns for ward clerks and household attendants. (Attendants at the time reported to Unit Administrators). 6. To define the ward procedures and ideniify problems with the existing procedures.
Work measurement, flow charting, and statistical sampling were used and the following problems were identified: 1. Mxed Responsibility and Unclear Role
The Unit Administration was not only responsiblefor clerial tasks but also directly responsible for tasks such as preparing patienis for transportation, cleaning an area, cleaning and autoclaving instruments, ordering supplies, etc. Such tasks wereperformed by the Household attendants, who reportd to the Unit Administrators. The support service departments obviously were not totally providing these services since the previous organizational plan encouraged each patient unit to be self-sufficient, with only modest assistancefrom central departments. Thus, some of the tasks were similarly pe#ormed by the Patient Care attendants who reported to Nursing Service. The Household attendants were responsiblefor tasks such as cleaning of bathrooms and sinks, etc. Similar tasks were also performed by the Department of Environmental Sanitation. This poor definition of line of responsibility created ‘yingerpointing” exercise on the war&. Even though the Unit Administration organizational structure existed in the Division of Surgev, its relationship to other parts of the hospital was not clearly defined. This lack of clarification resulted in poor cooperationfrom support services and many hours of unnecessary work on the part of Unii Administrators.
2. Organization Due to the various levels of Management and Supervision, as shown in Figure #2, problems were created in communication, supervision and control of the unit related activities as performed by the Ward Clerk and Attendants. 3. Staffing of Ward Clerks
It was determined that the work volume varied from ward to ward and from shift to shift. The AM shift (7AM to 3PM) had the heaviest workload while the nite shift (IIPM to 7AM) had the least. The clerical s t g f was fairly well utilized during the AM and PM shifts, while poorly utilized during the nite shift. The scheduled number of hours during the nite shift far exceeded the productive work hours, as shown in Figure 3. This raised the question of redistribution of work among shifts and realignment of clericalstdfing. Also the ward clerks were not scheduled in accordance to the needs of respective wards. For example, as shown in Figure 4, there was little relationship between the work load and the scheduled number of hours.
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D I RECTOR FIG.2
CRGAFI I Z A T l ONAL STRUCTURE P R I O R TO R E O R G A N I Z A T I O N OF U N I T A D M I N I S T R A T I O N A T COOK COUNTY HOSP 1 T A L
ASSOCIATE
KFi ADt4 I N I STRATO I
r
4
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A0 I N I S T R A OR
I ASS IS T A N T ADMINISTRATOR
I ASS I S T A N T ADMINISTRATOR
I I ADMl N I S T R A T I VEI ASS IS T A N T
%J-
4. Staffing of Attendants A D M l N I S T R A T I VE ASS I S T A N T
I
It became apparent that given the philosophy of Unit Administration program, the functions performed by these attendants did not belong to Unit Administration. This raised the question of reorganization of not on& Unit Administration but also of Support Service Departments.
5. Supervision and Reporting The Unit Administrators placed too much emphasis on occurrence reports andpaper work rather than problem solving.
6. Staffing Training The large clerical stsff wm poor& trained, resulting in poor performance and low morale. 7. Policies and Procedures Policies and procedures did exist on the wards, but they were either inw mplete, obsolete or misunderstood.
Scheduled Hours
WARD N O . 24
NlTE
SHIFT
R e l a t l o n s h l p Indicates:. s c h e d u l e d h o u r s v s . p r o d u c t i vc h o u r s
In
;
1
u-
4
0
z" 3.
SEPTE MBE R/OCTOB E R 1976
39
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In summary, the Unit Administration program was less than effective. Specifically, deficiencies related to not having uniform job descriptions, no uniform established policies and procedures, no quality control mechanisms for the Household Attendants, Ward Clerks or Unit Administrators, and poorly trained personnel. Unit Administrators performed some routine basic functions but primarily acted as a “backstop” or “gofer” for the other support service departments. There was a great need for improving the support systems. The Management study final report* was published during October of 1973 and reviewed by the Hospital Director and the Associate Director for possible implementation of recommendations and developing future plans. In mid October 1973, a new Assistant Director for Unit Administration was hired to implement a revised program and the Management study utilized as a source document. It became immediately evident to the Assistant Director that the problems found in the Division of Surgery were widespread throughout the entire As a the Management study team was asked to conduct work measurement studies in three other divisions. These studies were completed 1974*As these studies were going by began* The major reorganization process effort is discussed below. 4. REORGANIZATION
In early December, 1973, the philosophy of Unit Administration was reaffirmed, in that Unit Administration would represent Hospital Administration in the tripartite structure, functioning at the patient care level, with the Medical and Nursing staffs. This philosophy of a patient care team on the Patient Units (Medical, Nursing and Administration) is a practical plan for providing patient service in a highly complex setting. Each -~ member of the team is inter-dependent on each other and ultimately the entire team requires the complete and cooperation Of the departments that provide patient services. The patient care triad and the supporting departments dependent on each other evolves from the notion that each team member provides an important service to the total team effort. The services would be clearly defined, responsibility assigned and effectiveness measured against standards jointly developed by the team. In most instances, these standards of service are a product of a close relationship between Nursing Service, Unit Administration and supporting services. Unit Administration would be responsible for providing all non-nursing, non-medical, supportive *Copies Jrrporr arr aiurlahlr in rhr Munuxrmmr Depprrmrnr/ilr/firrhrinrere~rrd reudrn
40
and clerical functions as defined and detailed by the leadership of the Nursing Department and Administration as follows: Direct supervision of the Ward Clerk activities. Monitor the housekeeping-stdf in the performance of their duties, even though they are responsible to a Central Housekeeping Department. Monitor the Patient Transportation stdf in the performance of their duties, even though they are responsible to a Central Transportation Department. Monitor and assure the availability of services and supplies from all support departments in accordance with established schedules andstandards of services. 9 Requests and monitors correction of maintenance defciencies.
Assumes responsibility for safe environment on the patient unit in accordance with hospital, local, state and federal codes. Assumes responsibility for functions that are unique to each patient units as agreed upon by Nursing Service and A dm inistration.
Unit Administration has clearly defined thanriels of authority to assure that patient units receive all necessary services, even when those services are under the direct responsibility of other elements of Hospital Administration. It was determined that the above objective would be best served under a Patient Services Administration Division within the Hospital’s Administrative structure. Unit Administration, thus, became a part of a much broader Patient Service Division. Figure 5 shows the new organizational structure. After delineating the objectives of the Unit Administration program, the plan for the implementation of the Patient Services Division and the implementation of the Management Report recommendations was developed. The implementation process consisted of the following three phases. PHASEI: To concentrate on unit related activities and ward clerk functions. As a result, job descriptionsfor the Ward Clerk and Unit Administrator would be developed and functions to be performed by the support and ancillary services would be identifed. Thirphare was to lastfor 7months. PHASE 11: To develop and produce training materials and programs for the Unit Administrators and the Ward Clerks. Also to initiate and complete a total reorientation of all existing personnel, based upon the new program. To implement a Quality Control and Quality Assurance Program for Patient Service Administration. To realign Ward Clerk S t d f n g patterns based upon the job functions as decided under Phase I. This phase was to last approximately 10 months. PHASE I l l : Re-evaluate Phases I and 11, with continual effort on proper s t d f n g alignment. Simultaneously, the s u p p o ~service func-
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In I
9.
6.
Lc
O
7.
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z 0 6.
FIG.4 WARD NO. 23
A.M.SHIFT Scheduled Hrs. v s . Productlve Hout-_s_
J J ' ME
(From 6/4/ t o 6/24/73] I
tions identified earlier would undergo appropriate reorganization and shifr of functionsfrom the unit administrator to the appropriate support service departments. Thisphme wm to lmt approximately 12 months.
Following is the status of various actions which have taken place from January 1,1974 to February 28,1975. In early January 1974, with the cooperation of the Director of Nursing Service, a Committee was formed with participants from all levels within Nursing Service and Patient Services Administration. The objective was to review the existing practices and procedures on the unit with emphasis on the Ward Clerk activities. As a result, new standard practices and procedures were developed and implemented throughout the Hospital. The Committee remained active for 8 months and was responsible for developing over 25 practices and drafting recommendations for several hospital policies. The support services functions to be transferred to appropriate departments in two major divisions, Medicine and Pediatrics, consisting of 672 beds and in separate buildings were reorganized; the Household Attendant positions were deleted and functions that they formally performed were transferred to the appropriate support service departments. The functional transfers involved the department of Environmental Services, Central SEPTEMBER/OCTOBE R 1976
Sterile Supply, Materials Management, Linen and Laundry, Central Transportation, Pharmacy and Nursing Services. In February 1974, the Admitting/Emergency Service Department was added to the Patient Services Administration Division. In May, the Department functions were separated, forming a Division of Emergency Services and the Admitting/Patient Information Department. The Administrative Activity in Emergency Services became a division of Patient Service Administration while the Admitting/Patient Information became a separate department with distinct functional responsibilities. Both departments are presently undergoing complete reorganization. In November of 1974 a position was carved out of Unit Administration and transferred to the Department of Training and Education. This position is serving as a liaison to Unit Administration in providing the necessary training and education skills required by Unit Administration personnel. The purpose of this was to take advantage of the resources available within that section. All basic introductory training as well as inservice education would be conducted by the Training Division. Secondary or on the job training would be provided and supervised by Unit Administrators. By late Spring of 1975 complete training programs were developed and a reorientation 41
for Ward Clerks and Unit Administrators completed. I n early February 1975, the Department of Transportation and Messenger Service was also added to the Division of Patient Services Administration. The purpose of this Administrative transfer was for ease in managing the Patient Services objectives performed by this Department. 5. CONCLUSION
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The reorganization of Patient Services Administration has proven extremely beneficial and has had an impact on the Hospital’s financial picture. As a result, the Housekeeping Department is now responsible for all routine cleaning in patient areas where before cleaning was done by 3 separate depart men ts. All routine supplies, i.e. pharmaceuticals, medical-surgical, linens and general supply items are being delivered to these units on a par stock basis by the Supplying Departments. A Central Nursing Equipment Service has been developed and provides a 24 hour 7 day service. Most patients requiring movement throughout the Hospital are now being transported by the Central Transportation Department. Centralizing the functions formerly performed by Household attendants under several major support service departments, has allowed us to consolidate staff and reduce the number of personnel required. As a result of the new division, 107 positions in Patient Services Administration were affected. Of
the 107 positions 52 were dispersed among the various support service departments, 19 were redistributed within the Patient Service Administration Division and 36 are being held vacant. By vacating those 36 positions, the fiscal budget for Patient Service Administration has been reduced by approximately $400,000. Following table compares personnel within the Unit Administrative structure as of October 1973, and February 28,1975. OCTOBER I 9 73
FEBRUAR Y I975
I 4 5 54 242 2 8 I1 4 167 498
4 4 51 236 4 3 4 I03 409
Training Coordinator Assistant Adminsitrators AdminissratiwAssistant111 Unit Administrators Ward Clerks Clerkly Clerk 111 Clerk I1 Secretary1 Administrative Aides
Assistant Administrators AdmmhiveAssistant 111 Unit Administrators Ward Clerks Secretary1 Clerk I V Clerk111 Administrative Aide
Cook County Hospital is undergoing a complete reorganization of its patient support service functions. Continuing at the most economical level. Through the efforts of many disciplines, Administration has been extended to the patient level and Quality Assurance programs developed to monitor the level of performance. Nursing Service is functioning at the patient bedside, equipment and supplies are more readily available and in good repair and patients are being treated and cared for in a cleaner, safer environment. rn
DIRECTOR -CCH
FIG.5 ORGANIZATIONAL STRUCTURE P A T I E N T S E R V I C E S ADMINISTRATION MARCH I , 1975 ASSISTANT D I R E C T 0 PT. SVC. ADMIN.
A s s t . Adm.
A s s t . Adm. Surgery
A s s t . Adinin.
Peds
A s s t . Admin. Med i c I n e
A s s t . Admin. Eincr. Svcs.
Dir. T r a n s p o r fa t ion
ard Clerk
r
42
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