Application of the Organizational Framework of a General Reference Hospital: Cases of Six Lubumbashi General Referral Hospitals ()
1. Introduction
The hospital is the element of a medical and social organization whose function is to provide the population with comprehensive medical care, curative and preventive (...) it is also a center of medical education and bio-social research [1].
The General Hospital is a hospital where many kinds of illnesses are treated, while a specialized hospital is one where only people with the same disease or age group are cared for. For example, the hospital for lunatics, sick children and the psychiatric hospital [1].
For Chrysostome, the reference system in the context of a district health system organized in two levels could be defined as the process of transferring a patient from one level to another. In general, reference is made in the case where the patient is transferred from the “lower” peripheral level to a higher level which is usually represented by a district hospital. The counter-reference represents the opposite [2].
The hospital is not an organization like any other. Structure multi-stakeholder and registered in a specific environment, it is an organization that can be described as “professional” and, as such, Operating [3].
The organizational framework is a system composed of three interacting elements: 1) a strategic project that aims to determine, and possibly to clarify, the goal pursued and how to achieve it; 2) an organizational structure that specifies the division of roles between each and which results from two processes: the division of labor and the coordination of activities; 3) a management system that characterizes and prioritises the levers to be used to steer the activities and animate the teams [4].
The organizational framework, the emerging face of the “iceberg organization”, is deliberate. Its function is to make the organization more efficient, in both senses of efficiency and effectiveness.
By definition, a strategic project aims to bring about a major change by improving in a sustainable and measurable way a situation considered unsatisfactory or significantly improvable. It also contributes to a purpose of higher interest according to AIGROZ [5].
According to BAELEN [6], the four phases of strategic management development can be summarized as follows:
1) Phase 1: Annual budgets and focused on operation.
2) Phase 2: Multi-year budgets, static resource allocation and gap analysis.
3) Phase 3: Continuous Situation Analysis and Competitive Analyzes, Evaluation of Alternative Strategies and Dynamic Resource Allocation.
4) Phase 4: Well-defined strategic framework, organization focused on strategies, dissemination of thinking skills, reinforced and coherent managerial process (analysis of progress, negotiation of objectives, incentives) and climate and system of enhanced interpersonal support.
This model is probably not directly transposable to the hospital context. We know that there is no standard in strategic management since the action is in the realm of praxis.
In the DRC, the DRC Ministry of Health [7] has defined the organizational, operational, resource, structural and environmental standards of a General Reference Hospital.
A General Reference Hospital is a second-level and obligatory structure within a local health.
According to the DRC (Democratic republic of health) ministry of health, plays the following roles: Research, hospitalisation, diagnosis, quality control and health centres’ (health care first line) supervision [8].
According to MASHINI [9] the synthetic General Referral Hospital indicators of the performance quality are:
1) The bed occupancy rate must be between 60% and 80%.
2) The average length of stay between 5 and 12 days.
3) Intra-hospital mortality rate below 1%.
4) The postoperative infection rate strictly below 1%.
The strategy for strengthening the health system [10] states that:
1) The hospital seems to have been “forgotten” as a structuring element of health district and as a structure responsible for supporting the development of first-level services.
2) Disarticulation or even fragmentation of the Health district services due to insufficient national resources allocated to the sector and, as a result, the loss of the normative power of the Ministry and that of donor coordination by the Ministry.
3) This disarticulation is manifested, on the one hand, by the marginalization of the General Referral Hospital, which competes with the Health Centers (funded by the sector partners), thus disrupting the reference and counter-referral mechanisms, and on the other hand, that these health centers respond more to vertical programs and partners than to the ECZ, which is itself endangered.
This same strategy proposes as a solution to the problems mentioned above that the hospital, the most important, the most complex and the most expensive training, is the one that must be given priority in rationalizing its activities. This will enable the hospital to function effectively as a reference structure by avoiding giving access to primary care users and being ready to meet the demand that will be induced by the rationalization of health centers.
In addition, the National Health Development Plan [10] said that:
The mission of the Ministry of Public Health is to contribute to the improvement of the state of health of the whole Congolese population by organizing quality and equitable health services for the restoration of the health of the people and the promotion of health. Better health status in all communities (Ord n˚ 014/078 of 7 December 2014). More concretely, it is about:
Ensure legislation, regulation, standardization and development of health policies and strategies, and ensure the generation and mobilization of internal and external resources for the implementation of government health policies and strategies. Providing quality health care services that are preventive, curative, promotional and rehabilitative to the entire population living in the country, ensuring equity in the distribution and provision of health services and benefits.
In the 2005 World Bank (WB) “State of Health and Poverty in the DRC” report, 82% of households are not satisfied with the care services offered.
The 2017 annual report of the Provincial Division of Upper Katanga shows:
1) A bed occupancy rate of 45%.
2) Average length of stay between 8 and 18 days.
3) An intra-hospital mortality rate higher than 7%.
4) A post-operative infection rate of 8%.
In view of this situation, we asked ourselves the following questions:
Do the Lubumbashi General Reference Hospitals have organizational frameworks?
Can these organizational frameworks improve the performance of these hospitals?
How can we explain the underperformance of these hospitals?
2. Methodology
We carried out a cross-sectional descriptive study to verify the level of application of the organizational framework in the general hospitals of reference of the city of Lubumbashi by referring to the conceptual framework that we established for this purpose.
We conducted a comprehensive sampling of general reference hospitals that met our inclusion criteria below. Thus, we included in our sample the general reference hospitals of the following health zones:
• Kamalondo Health district;
• Kampemba Health district;
• Katuba Health district;
• Kenya Health district;
• Kisanga Health district;
• Ruashi Health district.
Included in our study, the general reference hospitals of the city of Lubumbashi fulfilling the following conditions:
- To be recognized by the provincial division of health.
- Be integrated in the health zone.
- Being in a health zone whose boundaries do not go beyond the city limits.
- Have a number of beds greater than or equal to fifty.
We administered a closed-ended questionnaire to one of the members of the hospital’s management committee, whether it be the Medical Director, the managing director, the Chief Medical Officer or even the Director of Nursing for a structured interview.
We did a manual analysis of the data, focusing on the comments and the comments of the interviewees on our research.
3. Results
The data are presented in a disaggregated way and this presentation is articulated around the following axes:
• The identification of the interviewees,
• The strategic project;
• The quality management system.
The majority (75%) of the interviewees are either Physicians Directors or Managing Directors who make up the strategic summit of the Strategic Summit and we are reassured to have answers that reflect the reality of hospitals (Table I).
The majority (75%) of interviewees are male with a sex ratio of two men to one woman. The parity advocated by the authorities has not yet reached the strategic peaks of our hospitals (Table II).
The majority (60%) of those interviewed were aged under 50 with an average of 46, a median of 42, a minimum of 41 and a maximum of 53. In these conditions, the interviewees are already at an old age, which makes their response more or less credible (Table III).
Only half (50%) of those interviewed have seniority in the service of less than 15 years with an average of 16 years, a median of 16 years, a minimum of 8 years and a maximum of 24 years. In these conditions, the interviewees all have seniority of over 5 years in the service and are therefore experienced which makes their answers more or less credible (Table IV).
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Table I. Distribution of interviewees by function.
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Table II. Distribution of interviewees by gender.
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Table III. Distribution of interviewees by age.
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Table IV. Distribution of interviewees by seniority in the service.
Two-thirds of those interviewed had seniority in the hospital less than 10 years old with an average of 9 years, a median of 7 years, a minimum of one year and a maximum of 18 years. In these conditions, the interviewees all have seniority of more than 5 years in the hospital and are therefore experienced which makes their answers more or less credible (Table V).
Five out of six managers met had seniority in the function of more than 5 years with an average of 9 years, a median of 10 years, a minimum of 6 months and a maximum of 18 years. In these conditions, the majority of interviewees have seniority of more than 5 years in the function and are thus experienced which makes their answers more or less credible (Table VI).
Strategic project
Regarding the strategic project we noted that:
• No hospital has a strategic project;
• No hospital has a multi-year plan;
• No hospital does not control budget;
• No hospital analyzes differences between forecasts and achievements;
• No hospital changes budget during the fiscal year;
• No hospital compares its results to those of other hospitals.
Only one in three hospitals (33%) reported having an annual plan against two (67%) who said they did not have an annual plan (Table VII).
Only one (50%) hospital could actually show us its annual plan versus one (50%) whereas in reality the effectiveness had to be 100% because both declared to have an annual plan (Table VIII).
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Table V. Distribution of Interviewees by seniority in the hospital.
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Table VI. Distribution of interviewees by seniority in the position.
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Table VII. Distribution of hospitals according to the presence of the annual plan.
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Table VIII. Distribution of hospitals according to the actual presence of the annual plan.
The only hospital (17%) that has its annual plan, also has its annual budget, and four hospitals that reported having no annual plan plus one having reported having it also do not have the annual budget of 83%) (Table IX).
Le budget est reparti de la manière suivant: 30% pour le fonctionnement, 10% dans l’investissement et 60% pour autres besoins. Cependant, selon BAELEM, dans le cadre du développent du management stratégique, le budget le budget passe par quatre phases dont la première est la focalisation sur le fonctionnement (Table X).
The organization chart is a document showing the positions planned in an organization (forecast organization chart) and/or positions filled (functional chart) as well as the different hierarchical lines, five out of six hospitals or 83% showed their organization charts against only one (17%) (Table XI).
Two out of six hospitals (33%) (67%) reported having job descriptions while job description is a very important tool within an organization in order to limit anarchy to optimize performance efficiently (Table XII).
Regarding the effectiveness of the presence of job descriptions, both hospitals (100%) reported having job descriptions, as shown (Table XIII).
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Table IX. Distribution of hospitals according to the presence of annual budgets.
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Table X. Average distribution of hospital annual budgets.
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Table XI. Distribution of hospitals according to the actual presence of organizational charts.
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Table XII. Distribution of hospitals according to the presence of job descriptions.
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Table XIII. Distribution of hospitals by actual presence of job descriptions.
The Medical Director was cited as a decision-maker in all hospitals while the other members of the Board of Directors were cited in five whereas the other officers were not mentioned in any hospital (Table XIV).
4. Discussion
Regarding the strategic project;
1) Planning
No hospital has a strategic project and no hospital has a multi-year plan.
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Table XIV. Distribution of hospitals according to the people making the decisions.
Nobre (2017) found that the lack of internal coordination of hospitals led to the use of dashboards to control the processes involving the various actors and services in order to complement the financial and budgetary approaches that were essentially developed until then. .
According to HABIB and VANDANGEON-DERUMEZ [11], a strategic project or a multi-year plan allows:
a) Energize the hospital in its internal functioning: make work together people and trades unaccustomed to rub shoulders, register in an overall approach of the institution and not according to very professional logic compartmentalised, generates a significant internal dynamism, where some and the others want to work together (Tables I-VI). The project then appears as a important change lever, to strengthen the identity of the organization;
b) Make the hospital more dynamic in the eyes of users and partners: by showing the efforts undertaken and implementing actions concrete, visible to the public, the hospital finds a part of its raison d’être. It legitimacy can then be rehabilitated.
• Only one in three hospitals reported having an annual plan (Table VII).
• Only one hospital was able to show us its annual plan (Table VIII).
2) Budgeting (Table IX and Table X).
• The only hospital that has its annual plan, also has its annual budget.
• No hospital does budget control.
• No hospital analyzes differences between forecasts and achievements.
• No hospital changes budget during the fiscal year.
• No hospital compares its results to those of other hospitals.
A report from the Ministry of Health of Burkina Faso [12] shows that the implementation of a budgeted health action plan has enabled the operation and production of interesting results.
According to Nicolas Berland [13], the questioning of the budget process has intensified in recent years and has sometimes led to the abolition of the budget and he has made five criticisms of the budget:
a) The fiscal year consumes resources (time, people), few performance and no longer meets expectations.
b) The budget is turned to the past and extrapolates it. SSB now wants to orient its reflection efforts towards the future and anticipating difficulties.
c) The budget is rigid; Once developed, it can not be easily changed in progress year. This is not a convenient simulation tool.
d) The budget covers a period too short (one year) for the strategy but too long for the control of operations. Managers are not encouraged to have a long term vision.
e) The budget does not promote an ambitious, “breaking” culture that management wants to put in place but promotes reproduction in the same way.
f) For Georgescu and Naro [14], budget pressure is accompanied by role conflicts, resistance and a tendency to manipulate data.
g) Launois [15] said that the hospital works in non-competitive conditions.
Three factors seriously limit the competition that should be faced the hospital administration:
h) Obstacles to the arrival of new producers,
i) Consumer ignorance,
j) The powerlessness of the supervisory authorities to grasp what is really happening in institutions.
As regards the organizational structure
Health district Standards Compendium in the DRC [7] lists the functional organization chart as one of the tools for managing human resources in a hospital:
• All hospitals reported having organizational charts (Table XI).
• Five hospitals out of six showed their organizational charts.
• Two out of six hospitals reported having job descriptions (Table XII).
• Both hospitals reported having job descriptions, we showed them (Table XIII).
• No hospital has established an instruction.
The Medical Director was cited as a decision-maker in all hospitals while the other members of the Board of Directors were cited in five whereas the other leaders were not cited in any hospital (Table XIV).
As regards quality management:
• All of these opinions and considerations are not in line with quality assurance and quality management
For the Canadian Ministry of Health (2014) [16], a Quality Improvement Plan (QIP) is a formal, documented set of quality commitments consistent with the priorities of the system and provincial priorities that takes a health care organization to its patients, clients and residents, staff and community to improve quality through targeted measures and goals.
5. Conclusions
We conducted a cross-sectional descriptive study on the application of the organizational framework in the general hospitals of reference of the city of Lubumbashi. Our sampling is comprehensive and is six general reference hospitals selected according to defined criteria. Our results show that half (50%) of those interviewed had seniority in the service of less than 15 years with an average of 16 years, a median of 16 years, a minimum of 8 years and a maximum of 24 years. The majority (75%) of the interviewees are either Physicians Directors or Managing Directors. Only one in three hospitals reported having an annual plan and only one (17%) hospital that has an annual plan and has submitted it.
On average, 60% of the budget is devoted to other expenses, 30% to the operating and 10% to the investment always concerning the budget, no hospital does not analyze the differences between the forecasts and the realizations, no hospital modifies of budget in progress and no hospital compares its results with those of other hospitals. Five out of six hospitals or 83% have an organization chart; Two out of six hospitals (33%) reported having job descriptions. The Medical Director was cited as a decision-maker in all hospitals. No hospital has a strategic project and no hospital has a multi-year plan. Not all opinions and considerations are in line with assurance and quality management.