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Hospital Organisation Structure

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DOI: 10.4135/9788132108450.n3

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 Source : Managing Modern Hosptial, Sage Publications,2000, A.V.Srrinivasan

HOSPITAL ORGANISATION STRUCTURE

S.F.Chandrasekhar

Introduction

Hospital as a healthcare organisation has been defined in varied terms as any

institution that is either involved in preventive, curative/ameliorative, palliative or
rehabilitative services. However, the definition that is given by WHO is quite exhaustive
and exclusive in which it is defined as “ an integral part of the medical and social
orgnaisation of which is to provide for the population complete healthcare both curative
and preventive; and whose out-patient services reach out into the family in its home
environment. The hospital is also a center for the training of health workers and for bio-
social research.

Hospitals, these days, also provide bio-social research; teaching and training facilities
for all members of the hospital and health team which means not only doctors and
nurses but also para-professionals, para medicals, pharmacists, etc. (Singh, 1997).
Operationally, hospital could be viewed as out-patient, in-patient, general wards,
emergency, special wards, ICU, O.T, delivery suite, support services like pharmacy,
radiology and imaging, CSSD, blood bank, laboratory etc.

In India, there are at present 1,32730 subcentres, 21,854 PHCs, 3,100 CHCs, 480
District hospitals, 300 teaching hospitals and other total hospitals are 5,200. The total
bed strength being 9.5 lacs. The ratio between government and private hospitals
including NGOs and corporate hospitals is 55:45 (Ghei, 1997).

On the other hand, the emergence of corporate hospitals in Indian healthcare sector is
relatively recent. This trend has revolutionised the whole healthcare scenario in the
country. Consequently, the hospitals have been functioning in a very competitive
environment. Most of these hospitals are more professionally managed with the aims to
provide prompt, adequate, continuous and satisfactory services to the patient
community because, they have realised that they should have cardinal concern for both
delivery of quality healthcare and profit making. It has been well established fact that
 2

hospitals that are dynamic, growth oriented and surviving are the ones that give priority
to quality of services and profit-making. On the other hand, more corporate and trust
hospitals are mushrooming to further increase the competition that has been triggered
by the earlier ones. In such context, the hospitals need to design and redesign their
strategies for assuring or providing quality care and survival.

The Unique Features Of Hospitals And Healthcare Organisations

Hospitals and healthcare organisations are often described as unique or at least

different from other types of organisations; in particular, different from industrial
organisations. Further, these differences are felt to be significant in the management of
hospitals. Some of the most frequently mentioned differences culled from the works of
Darr and Rakich (1992), Shukla (1996), Wieland (1981), Stephen and Arnold (1988),
and Massie (1989) are the following:

 Defining and measuring output are difficult.

 The work involved is felt to be more highly variable and complex than in other
organisations.
 More of the work is of an emergency and nondeferrable nature.
 The work permits little tolerance for ambiguity or error.
 The work activities are highly interdependent, requiring a high degree of
coordination among diverse professional groups.
 The work involves an extremely high degree of specialization.
 Organisational participants are highly professionalised, and their primary loyalty
belongs to the profession rather than to the organisation.
 There exists little effective organisational or managerial control over the group most
responsible for generating work and expenditures: physicians.
 In many hospitals organisations, there exists dual lines of authority, which create
problems of coordination and accountability and confusion of roles.

Though some of these features may be refuted with an argument, however, it is beyond
the confines of this paper. One major point that warrants relationship to the main
objective of this paper is that the design of hospital organisations to improve their
effectiveness, efficiency, adaptability and survival depends upon structuring the roles,
 3

positions and functions of the people. Such structuring needs to be done while keeping
the features of hospital in mind.

The purpose of this paper is three fold. Firstly, it intends to draw the readers attention to
how a hospital organisation is designed from systems point of view while clarifying
some of the misconceptions that are widely held in recent times. Secondly, it provides
few illustrative structural configurations (hierarchies/organograms) of some select
hospitals of different ownership in the twin cities of Hyderabad and Secunderabad.
These will be analyzed from the standpoints of orgnaisation theory. Lastly, implications
will be drawn for the effective organisational structures that are need for the future
hospitals which operates in a highly competitive environment.

What is a Structure ?

A discussion or analysis of an organisation invariably begins with description of its

general context and an illustration of its organisation structure. Organisational context is
defined conventionally as the social and economic setting in which an organisation
chooses to operate (Pugh, et.al, 1969). It also refers to all the conditions and factors
external to the organisation under consideration (Van De Ven and Ferry, 1980).
However, any discussion on the organisational context is beyond the confines of this
paper).

Organisational structure is defined in many respects. For instance, it is defined as the

“hierarchical pattern of authority, responsibility, and accountability relationships
designed to provide coordination of the work of the organisation; the vertical
arrangement of jobs in the organisation (Hodge and Anthony, 1984). Pugh, et.al (1993)
refers to it as a formal system of interaction and coordination that links the tasks of
individuals and groups to help achieve organisational goals. Child (1972) defined
structure as “ the formal allocation of work roles and the administrative mechanisms to
control and integrate work activities, including those which cross formal organisational
boundaries”.

Van De Ven and Ferry (1980) defined it in terms of the skeletal organisation chart . Its
underlying dimensions are the degrees of vertical, horizontal, and spatial differentiation;
 4

the forms of departmentation; and the allocation of administrative overhead. In a most

elaborate form, Miles and Snow (1985) states that the organisation chart, when
supplemented with the perceptions of informants on the question “ Who makes what
decisions where?” also provides an overall understanding of the structure of authority in
an organisation. The reason why we focus on these structural dimensions is because
they are basic to solving the organisation design problem at the overall Organisational
level of analysis. The organisation design problem is principally concerned with (I)
division of labour in terms of degrees of differentiation and forms of departmentation, (ii)
the interdependence and suboptimization among organisational components that
division of labour creates, and (iii)the structure of authority

This common practice is not just a formality or habit. It is necessary to provide the
uninitiated with an overview of the social and economic domain in which the
organisation operates and a simple “picture” of the structural configuration of the
organisation as a whole.

What is the purpose of it?

One of the purposes of organisational structure is to channel information to the

appropriate manager so that their level of uncertainty is reduced when they make
decisions. Secondly, to effectively distribute the authority to make decisions so that
organisation members can implement their plans smoothly and cohesively at every
level. Hodge and Anthony (1984) state structure, basically as a managerial tool that aids
in guiding the organization toward its foals and can be considered the skeleton of the
organisation body. Lastly, the organisation structure defines and governs the
relationships among the various work units, ensuring that all work is assigned and
completed in an orderly fashion, which contributes to overall organisational
performance (Duncan, 1979).

What are the structural dimensions of an organisation?

In order to understand the organisation structure well, there is a need to understand first
the constituent elements of the structure. Hage and Aiken (1970) focused on some
variables that form the organisational structure. They are namely (i) Formalisation (ii)
centralization (iii) specialisation (iv) complexity and (v) configuration. Till recently, there
 5

is a misconception that Organisational structure is merely an Organisational hierarchy

that depicts designations of and the relationships among people in the organisation and
nothing else. Therefore, it is felt that there is a need to mention briefly about all the dimensions
of organisational structure so that we can better understand the concept of configuration as an
emergent of interrelationships among structure properties of organisation and not merely
structure in itself.

Formalization represents the extent to which jobs are governed by rules and specific
guidelines. Hodge and Anthony (1984) define it as the degree to which policies,
procedures, and rules are formally stated in written form. This aspect of organisation is
typical of bureaucracies. Measures of formalisation can be attempted in a number of
ways. One may count the number of rules that apply to jobs, as these are found in
formal job descriptions, rules manuals, or employee work books. There are some
evidences that the greater the degree of formalisation, the lower the rate of
programme change. Rules and norms discourage search for better ways of doing
things.

Centralization is a measure of the distribution of power within the organization. Hage

and Aiken state that the fewer the occupations participating in decision making and the
fewer the areas of decision making in which they are involved, the more centralized the
organisation. They also found that the higher the organisations’ degree of centralization,
the lower its rate of programme change. In a decentralized organisation, where
decision-making power is more widespread, a variety of different views will emerge from
different occupational groups. This variety of opinion can lead to conflict, but also to
successful resolution of conflict and to problem solving. In any situation, decentralization
appears to foster the initiation of new programmes and techniques, which are proposed
as solutions to various organisational problems. Further, it is likely that the decentralized
organisation will experience more initiation of change and a greater number of actual
programme changes than the centralized organisation.

Specialisation refers to the extent to which an organisation has a remarkable division of

labour. In hospitals, specialisation of roles and functions therein reach extremely high
levels both in intensity and extensiveness. Here people with extremely different skills
and abilities and very unlike backgrounds are in frequent interaction, within a work
structure whose requirements for functional interdependence and close cooperation are
 6

unmatched when compared to the great majority of complex human organisation of

similar size. Work in the system is highly specialized and divided among a great variety
of roles and numerous members with heterogeneous attitudes, needs, orientations and
values. A certain degree of specialization among and within organisations, and
professions and occupation, is indispensable to efficient role performance, individual
adaptiveness, and organisational effectiveness. In hospitals, as understood, medical
and nursing specialization undoubtedly lead to improved patient care, just as
administrative professionalisation leads to improved hospital functioning. Georgopolus
and Jackwon (1970) support that it is clear that properly regulated specialization in
organisations with high internal social integration will eliminate the dysfunctional nature
of the organisations.

Complexity refers to the extent of knowledge and skill required of occupational roles
and their diversity. Hodge and Anthony (1984) define it as the degree of sophistication
and specialization that results from the separation of work units for the purpose of
establishing units of responsibility. Organisations employing different kind of
professionals are highly complex. Among the service organisations, hospital is the most
complex form of organisation. One way to measure complexity is to determine the
number of different occupations within an organisation that require specialized
knowledge and skills. An organisation can be considered complex when it employs
numerous kinds of knowledge and skills and when these occupations require
sophistication in their respective knowledge and skill areas. In a hospital, typically
employees of different occupational groups will appear on the wards in the course of 24
hours. One will find a variety of doctors, administrators, nurses, dieticians, x-ray technicians,
laboratory technicians, occupational therapists, social workers, housekeepers, engineers, and
others. Hage and Aiken found that in organisations where there is greater complexity, there the
greater rate of programme change.

Configuration

Organisation structures occur in a limited number of configurations. On what basis,

these structures are formed? As mentioned earlier, Child’s (1972) definition involves
both division of work as well as means of integrating this differentiation. Thus, any
structural configuration must include criteria by which various roles, activities and
coordination mechanisms can be differentiated as well as grouped together in the
 7

organisation (Shukla, 1996). Thus, the terms, organisational structure, design,

hierarchy, chart, model, organogram are interchangeable used since they are
understood in a similar way.

Mintzberg (1983) proposed a rational approach to the formation of structures. According

to him, an organisation can be seen as composed of five basic elements which are as
follows.

i) The Strategic Apex - this includes top-level management which is vested with ultimate
responsibility for the Organisational effectiveness. Here, the top management could be
a team or a single individual

ii) The operating core - this includes employees who perform the basic work related to
the production of goods or services of the organisation.

iii) The Middle Line - consisting of people who connect the strategic apex to the
operating core. These are intermediate managers who transmit, control and help in
implementing the decision taken by the strategic apex.

iv) The Technostructure - this includes staff functionaries and analysts, who design
systems for regulating and standardizing the formal planning and control of the work.
For instance, this function is looked after by departments such as finance, production
planning, human resources etc.

v) The Support Staff - this includes people who provide indirect support to the work
process and are not involved directly in it. Services like cafeteria, mailing, transport, etc.
are considered to part of it.

Mintzberg (1983) states that by putting all these elements together, we can get the
whole organisation. However, all organisations are not identical; they differ in terms of
the part which exercises greater control, and the manner in which the activities of the
operating core are coordinated and similarly with other elements of the organisation
structure. Mintzberg (1989) reported from the study of 129 organisations that only
about half could neatly fitted into certain categories. The other were hybrids, confirming
to two or more configurations. This is likely since organisations are complex entities,
 8

with different parts facing different environmental demands, and, therefore developing
along the lines of different configurations.

Hospital organisations also followed some of the configurations that are similar to the
manufacturing organisations. However, during their evolution, they developed unique
features. The most important is an arrangement called the triad, the foremost example
of which is found in private and teaching hospitals. The triad includes the governing
body, chief executive officer and the medical staff organisation (Darr and Rakich, 1992).
In
theory, the triad permits power sharing among the three. It is best characterized as an
accommodation, however, and results from the independent contractor status of the
physicians, who treat patients in the hospital, and the governing body’s need to
delegate responsibility for day-to-day operations to the CEO and senior managers.

Thus, leatt and Fred (1985) state that the common organisational designs seen in
health services organisations are namely : i)functional design, ii)divisional design iii)
corporate design, iv) matrix design and v) parallel design. These design are
briefly explained in the following section.

I) Functional Design : Most of the hospitals in health care field are familiar with a
functional design where the labour is divided into specific functional departments, e.g.
finance, nursing, pharmacy, housekeeping etc., This arrangement is most prevalent in
relatively small hospitals with lesser than 200 beds, offering single specialty services.
This design is most appropriate in small organisations that provide limited range of
services and with only one main goal. The primary advantages of the functional design
are that it facilitates decision-making in a centralized and hierarchical manner and
career paths for managers in departments are clear. It is inappropriate when an
organisation is involved in major growth or diversification. At such times, lateral
coordination and decentralized decision-making are required. It is also inappropriate for
organisations operating in complex, dynamic environments because it cannot
accommodate and process the rapid information flow generated by the environment.

ii) Divisional Design : The divisional design is often found in large teaching hospitals
and some times in few private hospitals that operate under conditions of high
environmental uncertainty and high technological complexity because of intensive
 9

research activities, exacerbated by relationships with the medical college. It is most

appropriate for situations where clear divisions can be made within the organisation and
semiautonomous units can be created. Conventionally, in teaching hospitals the way of
grouping units has been relatively clear cut,; units have been grouped according to the
accepted medical specialties, such as medicine, surgery, pediatrics, radiology and
pathology.

Divsionalisation decentralizes decision-making to the lowest level in the organisation

where the key expertise is available. Individual decisions have considerable autonomy
for the clinical and financial operations. Each division has its own internal management
structure. Difficulties with the divisional design tend to occur in times of resource
constraints, when priorities must be set at higher organisational levels. For example, a
large teaching hospital may have difficulty arriving at a consensus about which patient
programmes should be given priority if divisional managers cannot see the perspective
of the whole organisation. In times of resource constraints, greater sharing of resources
between divisions is required and more effective horizontal integrating mechanisms
need to be established (Phillips, et,al, 1985). Care also must be taken to ensure that
the goals of each division are in keeping with the overall mission and goals of the
organisation.

III) Corporate Design : There is an increasing use of the term “corporate model” in the
hospitals these days. In business terms, it means, any organisation which is legally
incorporate (Leatt and Fred, 1985). The true structure envisages I) Governing body, and
ii) Top management. With regard to governing body, they say, the board members who
are also salaried corporate executives typically include a chairman, vice-chairman etc.
There is a full time chairman of the board who functions as the executive of the
corporation. the board members are elected and paid a fee for attending meetings.

With regard to top management, the chairman is a voting member of the board. The
senior management is made up of general managers. There is a group of corporate
staff who provide ongoing long-range support services to the general managers.
Typically, these staff provide support in such functional areas as human resources,
public relations, data processing, legal affairs and planning and lastly, there is a great
emphasis on a team approach to management and decentralization of decision-making.
 10

This design is most useful in large, complex organisations which have several goals and
which operate in changing environments. Corporate structures often develop where two
or more hospitals merge. This design is less suitable for a small organisation where
conversion to a corporate structure would mean simply change in titles for the senior
managers. the design is also inappropriate if the CEO is not prepared to delegate
responsibility and authority to other members of the senior management team or if
management team members do not possess the necessary skills to assume the
delegated authority.

IV) Matrix Design : This design was developed initially in the aerospace industry, which
is characterized by a dual authority system where individuals have two or more bosses
(Davis, and Lawrence, 1978). This design is evolved to improve mechanisms of lateral
coordination and information flow across the organisation (Shukla, 1996). The structure
is usually drawn as a diamond form with functional heads and programme managers on
the top edges of the diamond. This arrangement is intended to increase the opportunity
for lateral co-ordination and communication which frequently emerge as problems in
other design configurations. Functional heads, e.g. nursing, medical records, pharmacy,
housekeeping etc are responsible for the standards of services provided by their
department. Typically functional heads bring stability and continuity to the organisation
and sustain the professional status of staff. Programme managers, eg., oncology,
nephrology, pediatrics, neurology, etc have responsibility for individual multidisciplinary
programmes and co-ordinate team functioning. It is the responsibility of the CEO to
maintain balance between both sides of the matrix.

This design is useful in highly specialized technological areas that focus on innovation.
This design allows programme managers to interact directly with the environment vis-a-
vis technological developments, Usually, each programme requires a multidisciplinary
team approach; the matrix structure facilitates the coordination of the team and allows
team members to contribute their special expertise.

The disadvantages of this design are I) individual workers may find having two bosses
to be untenable, since it creates conflicting expectations and ambiguity. ii) The matrix
design may also be expensive in that both functional heads and programme mangers
may spend a considerable amount of time in meetings be incurred because of the
 11

frequent requirement for dual accounting, budgeting, control, performance evaluation,

and reward systems. Hospitals, however, are accustomed to working with multiple
authority lines; in fact, some experts suggest that most hospitals have a de facto
informal matrix model.

V) Parallel Model : This is design which has been developed as a mechanisms for
promoting quality of work life in the organisations (Stein and Kanter, 1980). the
bureaucratic or functional organisation retains responsibility for routine activities in the
organisation, while the parallel structure is responsible for complex problem solving that
requires participatory mechanisms. The parallel structure is a means of managing and
responding to changing internal and external conditions. It also provides an opportunity
for persons occupying positions at various hierarchical levels in the bureaucratic
structure to participate in organisations decisions (Kanter, 1983). It is on this basis, the
parallel organisation has potential for building a high quality of working life. Within the
parallel organisation a series of permanent committees are established with
representation from all levels in the formal hierarchy as well as from all departments,
depending upon the problem or task at hand.

Parallel design is appropriate where organisations are faced with critical and complex
problems with no easy solutions. This is useful when it is necessary to include a broad
range of disciplines in the development of policies and procedures. Organisation
performance may be improved not only by identifying solutions to difficulty problems but
also by cross-fertilization of ideas which result from the interdisciplinary approach.

Problems may arise with the parallel model if the parallel arm of the structure begins to
assume decision-making responsibilities which should remain with the functional arm.
There may be differences in priorities set by each side of the structure. Also individuals
at lower levels in the origination may end up spending a great deal of time at meetings,
thus interfering with their abilities to do their job.

In reality, most hospitals have elements of a parallel design, particularly as a

mechanisms for involving physicians and other health professionals informing
organisational policies.
 12

Configurations of Select Hospitals

There are specific design options that are available for health services managers,
keeping in mind that the choices will depend on environmental demands, the
organization’s strategies, the activities of the hospital can be grouped, and decisions are
made (Leat, and Fried, 1985).

In most health care organisations, decisions about organisational structure traditionally

have been made in an informal and somewhat ad hoc manner. Design is often a
reactive process with minor changes made in the organisational chart as individuals
leave or enter the organisation. It is rare that a hospital engages in a systematic and
proactive assessment of the total organisation with consideration given to the range of
possible alternative organisational models. Yet such fragmented approaches to the
organisational structure are likely to have unanticipated effects on other parts and
frequently lead to incomplete organisational design, inefficiencies, and compromised
performances.

Since organisational design is a conscious deliberate process which is essential for all
hospital organisations on an ongoing basis, it has many implications for the changing
roles of chief executive officers (Darr & Rackich, 1992).

In the following sections, configurations of four select hospitals have been utilised to
understand their structure. The first one is a Government hospital which is the largest
1000 bedded government hospital with multispeciality treatment facilities offered free of
charge to the patients. The second is a trust, 1000 bedded hospital established with
multispeciality and multimodel treatment facilities. The third one is a largest corporate
hospital with state-of-the art technology, 250 bedded, offering superspeciality services.
The last one is a University hospital, 700 bedded university hospital which offers
multispeciality services with the primary aim of research and services.

The organisational structure of hospitals has been referred to as a wobbly three-legged

stool. The legs are the board of trustees, the medical staff and administration. The
 13

board of trustees bears ultimate responsibility for the performance of the hospital – its
medical and management staff. The board makes the overall governing policies and
establish the hospital’s bylaws. The difference between the boards of trustees of
corporate business enterprises and most hospitals are based on the fact that, industry is
an economic enterprise with social overtones. The hospital, on the other hand is a
social enterprise with deepening economic overtones. A hospital’s board is frequently
composed of community and business leaders. They do not own or have financial
interest in the hospital and are accountable for the conduct of the institution to the public
rather than to shareholders of the corporation. In not-for-profit hospitals, the fiscal
concern may be that the surplus be kept modest in keeping with the public service
nature of the hospital’s goals (Evertt and Johnson, 1982).

In several hospitals, the medical staff is the group of physicians to whom the board of
trustees has granted privileges to admit patients. The medical staff is not paid by the
hospital (in some they are employed and paid by the hospital). The medical staff is not
responsible for seeing that the hospital is available and there is no direct reporting
relationship to administration. However, the medical staff is responsible for the quality
of medical care given to the patients and for the conduct of its members in accordance
with the medical staff by-laws established by the board. The medical staff is
accountable to the board of trustees and has responsibility to participate in the
functioning of the hospital by serving on hospital committees and directing technical and
clinical services.

Administration is responsible directly to the board for management of the hospital and
implementation of policies approved by the board. Administration is responsible for the
financial, hotel service, physical plant, and personnel functions of the hospital. All the
people who work in the hospital, aside from most of the physicians, formally report
through administration channels.

The organisation charts presented in figures 1-4 depicts the formal hierarchical lines of
authority and departmentalization within the hospitals. The operating divisions may be
grouped in a number of ways, but frequently are divided into nursing, F&B services,
patient care, ancillary diagnostic/therapeutic support and finance. The hospitals’ medical
departments are usually organized according to medical specialty – cardiology,
oncology, pediatrics, and so forth. Patient care, however, is actually accomplished
 14

through a matrix organisational structure, with the medical staff directing the specialized
members of the medical care teams in each of the various departments.

The government and the teaching hospitals’ structure on several counts are divisional
structure, where clear divisions could be seen within the organisation and
semiautonomous units created. Here the way of grouping units has been relatively clear
cut; units have been grouped according to the accepted medical specialties, such as
medicine, nephrology, neurology, pathology, radiology, etc. Figure 1 shows the
physicians in-charge of each clinical service as the person with direct authority overall
divisional operations. Each division has a head for nursing, medical and non-medical
areas. These are accountable to the medical superintendent who in turn reports to the
Directorate of Medical and Health Services, a directorate of the Government.

Figure 2 shows the Dean being the overall authority for the departmental medical
services. Executive registrar is accountable for the accounts, establishment and
planning activities of the hospital. Medical superintendent is accountable for the
supportive
 15

Directorate of
Medical and Health Services

Medical Superintendent

Medical RMO Nursing Suptd Non-medical

Administration

Professors Out patient Matrons Lay Secretary

(Heads)

Additional Ward boys Senior Purchase officer

Professors Sisters

Assistant Ayas Staff Nurses Office Suptnd

Professors

Lecturers Probationary nurses UDC

P.G. Auxiliary nurses LDC

Students

Interns Dias Class IV

employees

Figure 1: Configuration of a 1000 beded Government Hospital

 16

Governing Council

Executive Board

Works Committee Director Purchase Committee

Dean Academic Security Finance Medical

Council Committee Superintendent

Faculty Executive Registrar Audit & claims Hospital services

Cash counters OPD & IP
Professor CCU MRD
Additional Billing (IP&OP) Mortuary
professor Animal House
Associate professor

Assistant
professor
Dept. Dept. Dept. Nursing services
Residents Reg Reg Reg Civil dept
P.G’s Accounts Estab. Planning Elec.dept.
JCF & Clinical BMD
Assistants Suptend Suptend Suptend Stores
NON P.G’s Utilities
UDC UDC UDC MSW
Princiapl Nursing Health inspector
LDC LDC LDC Ambulance
School & College Canteen
Library Typist Typist Typist Incineration
Tel.exch
Computer Div.

Figure 2: Configuration of a 700 bedded University Hospital

 17

Chairman Board of Directors

Director Different Committees

Administrator

Assistant
Administrator Assistant Assistant Assistant Assistant
Administrator Administrator Administrator Administrator
Finance
Diagnosis Medical Nursing Supportive
Lay Secretary- Services
2 Superintenden Superintendent Nursing
t Lay
Secretary -1

Secretary Secretary Secretary Secretary Secretary

Assistant Assistant Assistant Assistant Assistant

Figure 3: Configuration of a 1000 beded Trust Hospital

 18

Chairman

Managing
Director

Chief Director Medical Project

Executive Services Director

Front Office QAO Consultant HRM

non-medic

Billing DCO Dy . Medical

Supdt & RMO

Maintenance QAO Dy. Nursing Supdt Fire Safety

–Medical & Nursing dept.

Material Medical Depts.

Bio-medical Lab services

GRO Blood bank

IT Registrars &
residents

AEH Medical Social

worker

DGM HIM
Operation

Hospitality
Services
(F&B, HK)

Figure 4: Configuration of a 250 bedded Corporate Hospital

services and para medical services of the hospitals. All of these report directly to the
Director or Vice-chancellor.

Figure 3 depicts the organisational chart of a trust hospital. This structure is pattern after
a functional design. Here, the basic hospital services like, finance, medical, diagnostic,
nursing and supportive services are separated. Each service is headed by an assistant
administrator. This design enables divisions to be made on a centralized and
hierarchical basis. All these assistant administrators are accountable for their functions
to the administrato4rs who in turn reports to the Director.
 19

Figure 4 shows the separation of hospital services into administration and medical. CEO
is the overall authority for the administration which includes several services like, front
office, billing, etc. on one hand and quality assurance programme on the other. The
project director is overall authority for the HRM/HRD issues and the fire/safety services
of the hospital. Director of medical services is accountable for the medical services of
the hospital. All these report to the Managing Director who in turn gives the account of
the overall performance of the hospital to the chairman.
Implications for Future designs
From the preceding sections, we come to terms that there are atleast five organisations
designs that are possible in hospital organisations. Are these exhaustive? Virtually, no.
Organisations are quite varied and distinct from each other. In fact, Mintzberg’s (1989)
study itself reveled that only about half of the 123 organisations studied would be neatly
fitted into these five categories. The others were amalgamated, confirming to two or
more configurations. This is quite possible since the organisations are complex entities,
with different parts facing different environmental demands, and therefore, developing
along the lines of different configurations. In the same organisation, for example, it is
quite logical to expect that the configuration of the functional design of cardiology would
be quite different from that of a neurology department.
Designing Organisations for long-term growth and stability
There is often a need to reassess the organisation’s mission and strategic plan in light
of changes occurring as time passes.
As organisations consider issues related to long-term growth and stability, accountability
becomes particularly important. It may be necessary to change the organisation’s
design to make health professional more accountable for heir behaviour, especially
when there are pressures from external environment to control costs. This may involve
decentralized structures or the creation of lateral relationships.

Management/clinical information systems, reward systems, and evaluation systems that

are consistent with the new designs must be created.

The compatibility between changes in job design, unit design, and overall organisation
design must be considered. For example, expanding into new service areas may
require, different administrative support and different patterns of linkages with other
departments.
 20

Conclusion

In this paper an attempt has been made to present first some of the significant features
of the hospitals in distinguishing them from the non-hospital entities. Secondly,
organisational structures of select hospitals in the twin cities of Hyderabad and
Secunderabad, while enumerating the distinct differences in the understanding that is
prevailing in regard to the organisational structure and the attributes of such structures.
Thirdly, a detailed note on the pre-conditions for designing the organisational hierarchy
has been presented while grounding the explanations on the theoretic framework.
Lastly, implications for future organisational design are drawn. Lastly, it could be said
that there is no one right structure that is appropriate for al l organisations. There are
structures that are more appropriate for a particular organisation, given the
circumstances in which that organisation finds itself. It is important to examine carefully
the number of layers of hierarchies between the chairman/chief executive and the
patient on a regular basis. The flatter the structure the closer the decision-making is to
the patient and the more efficient the work process.

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