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At the GHK healthcare group in Guayaquil, Ecuador, there are some problems of efficiency. These problems could be solved in a number of different ways. Through examining these problems and their potential solutions in terms of the organizational culture present on site, and the politics and resistance that have to be engaged in the reforming process, this essay aims to present a thorough and comprehensive analysis of how this particular medical group could be made more efficient, and how international healthcare groups could become more efficient overall.
This essay is divided into different sub-sections in order to provide the most comprehensive analysis of this issue. Within the introduction, this essay will cover a brief description of the problems encountered, and an appropriate solution. Further into the essay, this literature review will examine how the organizational culture of a medical group or other corporation is a crucial factor in any systemic change. The politics and resistance to these reforms is also discussed in more detail below, before a thorough discussion of all of these issues, and a conclusion which presents a synthesized analysis of how this problem should be solved, and what consequences will arise as a result.
The GHK is a Healthcare group in Guayaquil , Ecuador, consisting of 3 different hospitals around the city, whose population is 3 million people. One of the main healthcare systems which the group deals with is through its Diagnostic Imagenology Center (DCI). At this centre, all of the EKG, CAT and MRI scans take place, among others. At each of the group's hospitals, there is a DCI with exactly the same equipment. Although these DCIs are at different locations, each DCI is run with central management, where monthly goals are set centrally. Each DCI has 2 or 3 senior radiologists, as well as at least 2 junior doctors, all of whom are able to administer the exams, some of which can provide results within one hour. For the 3000 monthly patients, this hour long period is nearly as efficient as possible.
However, some of the tests can take a longer period of time to deliver results. The MRI and CAT scans, two of the most popular and in demand procedures, generally take between 24 and 36 hours to be processed through the radiologists, and back to the medical practitioners who deal with the patients. The radiologists claim that this problem with excessive wait time is the result of their over-large workload.
The GHK group has invested over 5 million dollars in implementing new technology at the DCIs, which includes the scanning equipment as well as the digitalization equipment, including the fibre optic network and impax web programs. Both the IT aspects of GHK's technology (Impax and others) and the diagnostic stations are underused, specifically by the radiologists who do not demonstrate adequate mastery of the communication networks which would reduce patient's waiting time before results. These radiologists have generally been at the group for long periods of time; 3 of the senior radiologist have over 30 years experience with the group. These doctors are paid by the exam, depending on the specialty.
What could a solution to this complicated problem be? I argue that it would be important to remove the radiologist from the DCI, so that the healthcare practitioners who deal with the patients send the scan information through to a centralized place where a core group of radiologists analyses the results and quickly sends them back to the healthcare provision site. These radiologists should be in a remote location, working in shifts of 8 hours in groups of 3 or 4. If the impax technology is used correctly, the radiologists do not need to be near the hospitals; diagnosis can take place equally quickly off site.
Dicom technology would be in place to send images to the new centre, requiring basic training, which would entail hiring a specialized support staff at the off-site centre for diagnostics. However, even with the specialized support staff needing training, rates of efficiency in terms of dollars spent per assignment completed would be significantly higher.
Instead of the specialist radiologists, junior doctors could be the primary attendants of the DCI, and they could cover the shift of the ecographist. By using the voice recognition software that is in the diagnostic stations, it would be possible to reduce the waiting time for the patients' results and at the same time to improve the overall performance of staff on-site. Altogether, this means that doctors will be able to attend more patients in less time.
But it is important to place this problem and solution in the broader context of how the healthcare management group currently works, and how it would work once these changes were implemented. In the literature review below, theory about organizational culture and politics are examined in order to illuminate further the conditions at GHK.
'Healthcare organizations exist in a turbulent political and social environment, in which their actions and behaviours are highly visible and much scrutinized. Leadership and management take place in this 'goldfish bowl,' where their performance and process can be just as important as their outcomes,' (Walsh & Smith 2006:3).
This literature review will first examine ways of approaching organizational culture. This is relevant to the rates of efficiency at GHK. Work patterns and relationships establish how efficient a company is, among other things; therefore the qualitative approach that looking at the organizational culture of the facilities entails will demonstrate where inefficient patterns and uses of technology may lie.
Secondly, another way in which improved efficiency at GHK can be approached is through the political situation that is found in Ecuador as a whole in relation to health care distribution. Access to healthcare is a very political issue in Latin America in general, and Ecuador in particular. The politics of the situation can be approached at a national, citywide and corporation wide level. Resistance has been presented to changes such as the solution proposed above, and examining that resistance in its political context
Anthropologists have been studying what societies' 'cultures' are for over a century. When this is applied to the business world, the same issues are examined. What are the myths and rituals? What is the symbolism all employees know how to read? What is the power structure? These questions are equally relevant in the workplace as they are in exotic climates.
The culture of an individual organization is very important to the organization's overall success. Different authors have put forward different definitions. Handy refers to organizational culture as the 'sets of values and beliefs-reflected in differing structures and systems,' (1985:186). This is a helpful initial definition, setting the theoretical perimeters of how an organization works and what it believes in. More pragmatically and also more broadly, Mullins writes that an organizational culture is 'the collection of traditions, values, policies, beliefs and attitudes that constitute a pervasive context for everything we do and think in an organization,' (2005: 891). Barr and Dowding present an even more concrete illustration of what organizational structure is, citing that 'cultures are affected by: the past, the climate of the present, the involved technology, the type of work, the aims, the kind of people who work there, [punctuation not in original,]' (Barr & Dowding 2008:175). These definitions demonstrate that it is a broad set of relationships within any organisation that affect how the organization works on a day-to-day level.
The formality or informality of an organization as well as the allocation of duties is definitive to how that company works. French and Bell's 1990 model of the corporate iceberg shows the difference between formal and informal decision-making and relationships. The formal aspects of a company entail what its stated goals are, what technology it presents and uses, what its official structure is, its stated policies and procedures, the products it creates, and the financial resources that it records; the informal aspects include the beliefs and assumptions of a company, the perceptions of its varied staff members, the attitudes of the people who work there, their individual feelings and values, and the unstated group norms of behaviour (French and Bell 1990:91). This is not a model of how organizational culture works, but this model does demonstrate the crucial element of how an organization works: that all is not what it may seem on paper. An organisation's culture is one of the ways in which those important informalities are reflected.
Handy (1985) presents 4 different types of organizational culture. He breaks them down into 'role,' 'task,' 'power,' and 'person,' with different organizations working according to a set of characteristics that these four groups refer to. The categories that are most relevant to this essay is the 'role category,' where the organization takes its employees' delegated roles very seriously, and the 'person category,' where the organization is more individual-based and horizontal. At GHK, the structure is currently more horizontal, with multiple people tackling the same task at the actual test centres. This has many benefits, such as people operating independently to complete one task from start to finish. While this is a more pleasant working environment in many ways than the more hierarchical, and often rigid organizations, more explicit delegation of duty, more barriers between departments, might actually help the situation illustrated above, with more specialized individuals tackling only parts of a task that they are most qualified for.
Schein (1985) established a relationship between culture formation at an organization and their leadership patterns. On one extreme, the emphasis is on independence and the individual. People are responsible for their own work and govern themselves, sorting conflict through group interaction. On the other extreme, there are organizations where the responsibility for decision-making is far more centralized, and management based. Relationships are more vertical, and problems are sorted out through delegating to inferiors and superiors. This model is important to analyzing GHK's problems. Once again, GHK is on the more informal side of the spectrum, and more formality and delegation between the departments will improve the rates of efficiency.
These two models so far demonstrate the differences between more formal and more individual-based corporate structures and cultures. Johnson and Scholes (1989) present yet another model which emphasizes the two extremes less, and shows that multiple factors go into establishing an organizational structure. Rituals, myths, symbols, structures and all of the other elements of 'organisational culture' equally affect what is the established 'corporate paradigm,' which affects how decisions are made, and relationships are established. This model is important to analyse how an organization works, although it does not lend itself to providing solutions or avenues of improvement for a company's efficiency.
These models show that organizational structure is a complicated and varied phenomenon. It is directly related to efficiency of decision-making, and in the case of GHK the efficiency of the delivery of their results to patients. If the specialized individuals at the different branches had more specific instructions of what decisions to make and which ones not to make, organized from a central agency, the time it would take to produce results would be greatly reduced.
Politics and Resistance
'Policy-making authority might be highly centralized or widely dispersed across multiple levels. In some countries, unions and/or corporate structures are strong factors in determining social policy and might, in effect, have a veto power over proposed policy changes made by the government. Likewise, the influence of the medical industry and medical associations varies widelyâ€¦in shaping health policy,' (Blank & Burau 2007: 31).
The politics of a country and corporation are very important to how the company is run, and how efficient it is, especially in the medical industry. A country's diversity has a significant affect on what people are being provided with healthcare (Blank & Burau 2007: 35). Is it a population with people of all ages? Different classes? Different diets and related health problems? While Ecuador is not as diverse ethnically as some countries, in terms of class there is a large spectrum. 'It is estimated that 63% of the total population was affected by some degree of poverty in 1995, compared with 54% in 1990; 40.3% of the total population has at least one unmet basic need, ranging from 60.8% in rural areas to 27.0% in urban areas. Forty percent of the total population is poor and 15 % is indigent,' (WHO 2010).
Ecuador's healthcare policy is modelled on the American system (WHO 2010) which consists of a joint private-public system. Like many things in Ecuador and elsewhere, healthcare is high quality for the private sector, and of worse quality for the public sector. GHK works with private insurance companies, therefore delivering a high-end service to largely middle class and wealthy patients. This means that there is an increased demand for efficiency, which there might not be if GHK worked within the public sector. This demand for increased efficiency and the reduced time between undergoing the test and receiving the results is an example of how politics is a very important aspect of how the healthcare groups in Ecuador work.
This private aspect of GHK and other healthcare groups in Ecuador brings up the issue of resistance within the politics of healthcare. Ecuador has many public health problems, including a variety of infectious diseases (WHO 2010). Many people in that country believe that fewer resources should be put into the private healthcare industry, and more should go into curbing these public health problems, which are very serious, including tuberculosis, pneumonia and other curable diseases.
So while a healthcare group such as GHK may not experience direct resistance to a new company-wide policy of increasing efficiency in this particular format, there is resistance within the region against money being spent on systems such as this to begin with. Just as many British citizens have tried to stop doctors from practicing exclusively within private healthcare (Barr & Dowding 2008:164,) Ecuador faces similar political resistance to increased privatization of the healthcare system, perhaps even more so.
This literature review covered two relevant aspects of the theory that approaches some of the issues that GHK is presently faced with. Organisational culture, as well as politics and resistance, are ways in which an individual healthcare group can be analysed. The particular changes which have been proposed in this essay for GHK will now be approached in the discussion section, in light of the themes of organisational culture and politics and resistance to certain healthcare practices within Ecuador.
The main problem in the GHK DCI centres appears to be one of efficiency. People are being assigned a complete task form start to finish, when different parts of the procedure could be performed by a smaller number of more specialized professionals. The technology is in place to facilitate this change. This would entail junior doctors administering tests at each DCI centre, and digitally transmitting the scan information to a central facility where the information could be decoded and analysed more quickly by radiologists than by the on-site doctors who have patients to deal with as well.
This would entail a change in the organisational culture. In light of the literature reviewed above, both Schein and Handy's 1985 models of organisational culture work best to show that there is a trade-off between hierarchical and more horizontal corporate structures and cultures. While in many cases, increased decision-making and inter-level communication is a positive solution, in this case there is evidence for a need for more specifically delegated duties and responsibilities.
Incorporating this hi-tech system of Impax and other IT should not cause any problems. Radiologists and junior doctors alike will al have their level within the company hierarchy maintained. Specialization could in fact bring about a more high prestige position within the medical group. The radiologists appear to deliberately avoid using the Impax technology, and perhaps, respecting the organisational culture of GHK which places the radiologists very high up the ladder, a better format for explaining this technology to the doctors is more important than simply installing the technology in the first place.
This is related to the politics behind these developments at GHK. Within Ecuador, there is an extensive variety of types of healthcare provided, to an extensive variety of people. GHK can of course continue within the private sector, and exist alongside the large amount of public disagreement with increased privatization of the healthcare system. While it should not be ignored, this public opinion can be incorporated into the organisational culture, where many of the practitioners and employees of the GHK group understand the sentiments surrounding the facilities.
These two ways of approaching GHK's present problems reveal that there are many aspects to the issues surrounding the corporate structure, and the possible ways that those problems could be solved. Theory regarding the organisational culture of a healthcare group provides insight into how GHK could move from a individual-centric facility to one with more specialization within individual processes. The politics and resistance theory demonstrates that GHK is posed against some national and public issues. In both of these cases, the way to handle these issues is through people-based communication, both within the healthcare group, and towards the public on the outside.
Presenting an answer to a problem in healthcare management at a particular healthcare group provides only part of the solution. Implementing those chosen changes can potentially bring up an entire new set of problems. In the case of GHK's Guayaquil DCIs, the problem was one of efficiency. The proposed change to solve that problem was to create an off-site centre where all of the scan analysis could take place and be returned to the doctors on site. But finding a solution does not mean that all of the related personnel will be able to respond immediately in the prescribed way. GHK's radiologists are apparently finding it difficult to adjust to the digital technology, and are under-using the facilities. This cannot be solved by simply pointing out the benefits of the digital technologies. The organisational culture, as well as the external politics of the situation must be taken into account of how to implement these necessary changes.
Slight changes in the organisational culture of GHK would help to implement these solutions to the problem of inefficiency that the radiology centres are currently experiencing. Creating a culture more apt for specialization and collaboration, rather than one individual starting and completing a task on their own, would allow for more patients to be examined, scanned and diagnosed within a given period of time. Placing this in the national political context, where healthcare is not as accessible to many people as it should be, increased efficiency and the ability to treat more people in a short space of time would be ideal. Therefore taking account of some of the less explicit aspects of healthcare management, i.e. organisational culture and the politics and resistance perceived by the management group, is necessary for a smooth operation of a healthcare facility.