CONCEPTUAL FRAMEWORK This chapter discusses the conceptual framework of the study.

Specifically, this chapter presents information, theories, opinions and observations by various authors, related to the study on the operations and management of a hospital. These are information on the hospital as social institutions, health care system, type of health service organizations, and hospitals as a system and its functions patient care function and treatment, and functional relationship of services. FIGURE 1 CONCEPTUAL FRAMEWORK

Effectiveness

Efficiency

OPERATIONS AND MANAGEMENT OF AN ESTABLISHMENT

Economy
Figure 1 presents the schematic diagram which shows the concept of operations and management of an establishment, of which DCHI is one. Kreitner (1983) describes an organization as a system of consciously coordinated activities of forces of two or more persons. Therefore, when people gather together and formally agree to combine their efforts for a common purpose, an organization exists. How should an organization be managed? This brings to mind operations management. As a concept, this encompasses the design, implementations, operation and control systems made up of men, materials, capital, equipment, information and money to accomplish some set of objectives. Organization objectives therefore are targets to be strived for, one which an establishment hopes to achieve. Management then sets in where it works with and through others to effectively achieve organizational objectives. How does this done? This is done by efficiently using limited resources in a changing environment. There are factors in management situations that affect the quality of an organizational operation. The quality of operations is gauged through organizational effectiveness, efficiency and economy. If an organization is so structure as to help the enterprise accomplish its objectives at a minimum of unsought consequences or cost, such an efficiency is very clear. Effectiveness entails achieving a stated objective. Under situations where resources are limited, efficiency alone is not enough. Efficiency enters into the picture when the resources required to achieve an objective is weighed against what was actually accomplished. In the sense, managers of establishments are possible for balancing effectiveness and efficiency. Economy on the other hand, determines whether the funds and other resources of an establishment devoted to an activity are not wasted or spent unnecessarily. Duplication of operations, cumbersome systems and procedures, non-productive activities, faulty procurement and personnel practices, misuse of equipment, overstaffing are just examples on the unnecessary uses of funds and property. THE HOSPITAL AS A SOCIAL INSTITUTION

Hospitals are socio-economic amenities which have permeated the lives of the people and the community in general. These have become, all these years, an integral part of the economy. Over the years, these have touched everyones life, that their mission have evolved up to the point where these have become the center of communitys medical care. How does a hospital function? What are the major components that make up a hospital? Who are the personnel and the staff that run the hospital? What are their roles in the organization? How does it grow? Where does the hospital fit into the larger medical system? These are questions basic to the understanding of how the hospital function and how it was evolved from that of the simple one of the most complicated institution. Hospitals as social institutions have often been regarded as merely health establishments for curative and restorative services. Thus, according to Snook (1987), it is surprising to find hospitals viewed as physicians workshops. The practice of the medical profession in the past has conjured this traditional view and has been stamped in the minds of the public and the medical practitioners themselves. The modern concept of what hospital should be, and must perform, clearly points to the need for reorientation of the real hospital role in the health care delivery not only as to the extent of the services the hospital should provide, but also as to its proper functions within the health and medical system. Snook (1987) further contends that hospitals being indispensable elements of the health care delivery system of the country under modern dispensation should be able to serve the full range of health service in varying degrees. Hospitals then should always be open for use as health care facilities to all authorized practicing medical professionals in order to make them truly serve as the center of community health. Truly significant to the so-called reorientation, is a need for developing high standards for physicians and hospital workers. These are situations that demand specialization and professionalism. According to Mayuga, et al, (1987), the effectiveness and efficiency of operations are the main goals of the nations health care delivery system where hospital play the most important role. HEALTH CARE Every government adopts a national policy founded on a concept that health is one of the basic human rights. This implies that every government must come up with a program of health among others must have the following objectives: to serve every citizen regardless of creed and material capability; help the citizen attain a high quality of life that shall engender a healthy and happy nation. (Schultz, et al, 1983) There are basic patterns of health service organization. These are of varied forms and degrees depending on their influence of or responses to the local needs and traditions of the country involved in the health program. To have uniform standard of health care among countries, the World Health Organization (WHO) declared that health is the state of complete physical, mental and social well-being of man and not just the absences of disease or infirmity in him Mayuga, et. Al (1987). Accordingly, WHO laid down the principle that: enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without discretion of race, religion, political beliefs, economical or social conditions; and this responsibility of maintaining the health of the people is the task of their respective governments. (Mayuga, et. Al, 1987) The aforementioned implies then that every countrys effort to develop and implement health care program must conform with the WHO principle. Accordingly, it implies the needs to institute adequate health and social measures which will involved the selection of what type of health service organization is considered most appropriate to meet the health needs of the people.

What type then of health service organization should the country adopt? This can be best served by an aphorism which says that the political structure best suited to the needs and wants of the people to be governed is likely to be the most fitting and proper form of government that they can have. The choice of the most appropriate scheme has become a problem. Nevertheless, Snook, (1987) recommended that the common factor must be that the responsibility of health care administration must be placed under the health authority or administrator, who shall have the power to direct, coordinate, supervise in a unified manner all health activities and programs within his entire jurisdiction. According to Mayuga, et al, (1987), there is diversity however in the field of service coverage and in the organizational and functional relationship existing in the provision of the curative and preventive health services. In some instances these two are related but in some they have separate administration. TYPES OF HELATH SEVICE ORGANIZATIONS IN the foregoing, the types of health service organizations shall be discussed. Each type has its own positive and weak points depending on the perspective, through which it is viewed. There are inherent disadvantages or deficiencies because of some external factors that unavoidably interfere and or interplay with the organizational set-up itself. Sometimes incidental complexity develop in the course of achieving these goals of the health program. These are the following: Public Assistant Model This pattern of health service organization is principally adopted by countries where the majority of the population cannot afford to finance needed health and medical services whether through direct payment or through health insurance. In urban centers, however, there are private medical practioners who cater only the relatively or few middle and upper classes of people. In this type therefore, almost all health and hospital facilities are owned by the government, and most services are delivered by health workers. In the Philippines, this type of model is still applied in some sizeable sector of the economy. Mayuga, et al, (1987). Oftentimes the availability of the free health services is not enough to meet the eligible needs. Universal Services Pattern This type covers everyone regardless of economic standing without restriction to the quantity and quality of care. This is a case where complete medical case is virtually provided a public benefit for all persons. The benefits are given regardless or with no bearing to whatever contributions or payments made by the patients. The DOH under this type, has authority over all preventive and curatives services, with an administrative hierarchy consisting of three levels: The national, the district and the local levels. The health officer for each of these areas therefore, has a responsibility over its jurisdictions. These are operated and managed by the government through revenues collected from the people. Social Insurance Pattern Under this pattern, most of the population receive the major part of their medical and health care services through schedule of health services. In the case of the Philippines, these are the benefits derived from the MEDICARE as authorized by RA No. 6111 otherwise known as Philippine Medical Care Fund. Free Enterprise Scheme This is otherwise known as Private Enterprise Scheme. Under this model, the population receives most of medical and health care services under privately financed arrangements administered by voluntary organizations and societies. Services then may be provided by physicians in their respective private clinics and hospitals. DCHI belongs to this category.

The Philippine Model\ The Philippines adopted a social insurance model when it passed the Philippine Medical Health Care of 1969, otherwise known as RA no. 6111. It has declared as a matter of government policy that a total medical service shall be gradually provided to the adoption and implementation of a comprehensive and coordinated medical care program. (Mayuga, et al, 1987). There are two basic programs namely: for SSS member and GSIS members. After over two decades of its implementation, this progress. For instance, bebefits derived by members are found not consistent to the realities of the time. It has yet to make changes in the coverage, services and other related services. These constraints have drawback on the financial capability of private hospitals to provide efficient services without directly or indirectly affecting that of the patients capability. THE HOSPITAL AS A SUBSYSTEM IN THE HEALTH CARE The hospital, big or small, government or private forms part of the health care delivery system of the country (Lee, et. al, 1984). It is a known fact that the health care of the population is an all-embracing responsibility being placed under the DOH. (Mayuga, et. al, 1987). Health care as a function is not just performed by private practitioners but it draws upon the whole spectrum the functions of the different health disciplines. Thus, health services must take into account, social and economic factors. According to Lee, et. al (1984), it includes proper nutrition, housing and sanitation, the level of health knowledge of the population, and the supply of health services including the availability of the needed facilities and equipment. Lee, et al (1984) contends that the focal point of the hospital system is the basic relationship that exists between the physicians who provide medical care in the institution, and the hospital which provides services and facilities for the care and treatment of confined patients. Mayuga, et al (1987), support this by saying that a hospital should not exceed the needs of the physicians in the medical management of patients, while the medical practitioners should not undertake to treat their patients in institutions which lack the capability to adequately support the plan care required for the patients. The aforementioned is supported by some very significant observations. Small hospitals are needed to serve small communities. By their very nature, they are not able to provide services that would fully meet the patients needs. Unless, they tie up with larger hospitals, they would always find themselves in a predicament of not being able to raise the standard of their services in terms of facilities and even medical expertise and qualification. As observed, it cannot provide many services needed; it does not have the ability to handle complex and difficult cases. Thus financial constraints is often a drawback in the provision of quality and eligible services. The question that has been the subject of considerable research is whether costs vary by size. One would assume that there are some economies of scale. Larger hospitals should be more economical than smaller ones. A number of economists suggest that there are economies of scale to a point, beyond which the economies begin to diminish. Berki (1972) suggests, the answer from the literature is clear: The exact general form of the function is unimportant, but whatever its exact shape and depending on the methodologies and definitions used, economies of scale exists, but in any case according to theory, they ought to exist. Current trends in hospital management include alliances and linkages with related agencies. The Philippine Hospital System operates on this concept of networking where close formal coordination among all various types and sizes of hospitals is made to bring about the efficient working relationship in terms of service output. Referral hospitals are then tapped to provide special medical services. At the top of the Philippine Medical System therefore in the Medical Centers being complimented by Regional Centers, the latter being designed as teaching and training hospitals. Then come the provincial hospitals serving as intermediate hospitals for cities, municipalities and barangays. HEALTH CENTERS AND HOSPITAL RELATIONSHIPS

The role of the private hospital is crucial to the concept of networking in the Philippine Hospital System. Although there are advantages in the forged alliances, the formulation of workable relationships among private and public hospitals in the sharing and using of each others facilities, one has to contend with unresolved issues on cost and benefits. As pointed by Mayuga, et al, (1987), the public sector shall primarily be responsible for the health care benefits for the indigents, while capable of paying for the medical and hospital bills. Observers have noted the growing number of sick-poor members of the population. This poses constraints on the health resources of the government, that there is a need of a sizeable portion of the indigents to be served free by private funds. This means that hospitals exercise redistribution allocation whereby payments generated from those who can afford to pay are spread out to cover the cost incurred in rendering services to the indigents. This implication on cost and profit relationship of the private hospital-owners that has greatly affected the delivery of services. With the hospital care systems predicament, the establishment of health centers has come to be of relevance. Health centers have to be established as primary care units of every barangays. They shall be provided with adequate health care services. The following preventive medical services shall be offered: immunization, health education, environmental sanitation, nutrition education, early assessment of health problems, collecting and reporting of heath data. All these if properly implemented will reduce incidence of complex medical problems and cases and ultimately reduce cost. The presence of hospitals, whether public or private, in the community where health centers are located could enhance the capability of the hospital health care system. Close coordination and working relationship among health centers and community hospital would enhance the delivery services for the interest of the patients. With the referral system, cost of treating the patient has become cheaper. In their instance, patients are treated near their homes where the health centers and the community are both located. They can further be outpatients thus reducing the costs of hospital maintenance. THE HOSPITAL AS A SYSTEM AND ITS FUNCTIONS According to Mayuga, et al (1987), the hospital is one of the most complex organizations in our society. It is basically an open system where the operation and administration of its activities are founded on theories which are either articulated by the hospitals administrators themselves or just simply are practiced through insights and shared knowledge. In the early decade of the twentieth century we tend to view enterprises as formal organizations that provide a structure or cradle, within which the various employees performed their tasks (Koontz, et al 1982). In this concern, the formal design of the structure was emphasized where each person should know his or her position and function. Thus, as a result, rationality was emphasized and an unemotional state was desired even to the extent of viewing the employee as a predictable self-motivated person given specific assignments to be performed. This particular approach to hospital management as pointed by Snook, 91987), was generally not accepted by hospital administrators. This type of approach is applicable to an industrial setting where high degree of specialization exists. According to Mayuga, et. al (1987), the functional development of hospitals must view it not just traditionally and mere refuge of the persons and the social outcasts nut an expressions of love we have for each other and the clearest evidence of societys continuing concern for the need to provide some means of keeping the humanity physically and mentally well. There are still however proliferation of autocratic administrators, who adhere to the rules of bureaucracy and whose tendency is to adhere to rules and regulations. Another theory of organization believes that a happy, well satisfied employee is a productive one. Koontz, et al (1982). Hence, why not contribute to (manipulate) an employees satisfaction and happiness in order to increase productivity? There are a number of studies though, which questioned the relationship between job satisfaction and productivity. Thus, it is advanced that productivity itself causes job satisfaction. It is known fact that no one wants to be manipulated and administrators who adhere to this approach may be a suspect, thus hindering productivity effectiveness to be achieved.

Another approach to emotion is the behavioral model which emphasized the interaction between employees may it be individually or in groups and the behavior of the organization itself. The expected change is hoped to better or improve working relationship. Other than these approaches, there had been emphasis in decision-making models, communication networks and mathematical models in studying an organization. The aforementioned theories in the study of an organization focus on the internal environment of the hospital. In the 1960s however, it had become apparent that the hospital like any manmade institution, must consider external relationship like any manmade institution, must consider external relationship. This is necessary in the formulation of policies upon which its delivery system is founded upon. Two conclusions therefore can be deduced in the study of organizational theories affecting hospital administration. There are: a more comprehensive and accurate theory or explanation becomes possible as more are learned about administration and organization. Secondly, the administrator or the manager is the creator of the period in which he lives. With the increased concern for the patient, customer, client, or recipient of goods and services, attention is being directed to the outside of the organization for external relationships. The study of the hospital function as an assemblage of external relationships views that hospital itself an open system. One notes that when a patient enters a hospital, a great many groups are involved both inside and outside the hospital. Inside the patient is concerned with admissions, doctors, nurses, dietetics, then business office, and housekeeping. These are just a few of the numerous internal relationships that a patient must contend with. Externally, the patient is involved with his family, friends and relatives and even a third party-payer as in the case of the government providing medical insurance benefits. The hospital administrator is not divorced from these predicaments. These are forces which converge or impinge upon hospital policies and administration thereby affecting its productivity and efficiency. How does then a system operate? A system converts inputs into outputs. The patient, in the hospital, is the key input. The skills and knowledge of the doctors, the equipment used, the support people such as the nurses are all part of the total input. Thus, the progress of the patient in the hospital according to Schultz, et al, (1983), follow five stages: admission, diagnosis, treatment, inspection and control. Further, he said that these stages are locked together in two dimension: by the availability and the capacity of the physical resources themselves; and by the network of power and communication through which the decisions are generated and transmitted. These in effect, control experiences of the patient in any one stage and his transfer to the next. The aforementioned stages simply imply that the medical practitioner must consider the patient flow, or treatment for the patient, as his workers key or basic system. The patient himself is affected by several subsystems. These are affected by hospitals size and needs of the patient which include: admitting, medical staff, nursing services, occupational or physical therapy, housekeeping, patients accounts and many more. Thus to sum up the internal hospital system with the patients as the core, includes the following components (Mayuga, et al, 1987); 1.) The medical staff who diagnose, admit and treat patients and perform quality control procedures through their medical staff organization; 2.) Programs for the direct care and cure of the patients such as nursing, x-ray and laboratory; 3.) Support and administrative serves such as: governance, administration and business services HOSPITAL FUNCTION AND PATIENTS CARE SYSTEM Systems exist to serve a function or functions, (Snook, 1987). Hospitals have multiple functions which are not only changing over time but in some respects conflicting. The hospitals, as earlier stated

have evolved from that of a mere charitable institution of refuge to that of a more complex function of health care and a workshop for decisive medical practice (Schultz, 1983) An intensive working relationship exists in a modern hospital system. This involves the responsibility of the hospital to the practice of medicine performed within its walls and the responsibility of the medical staff in assuming protection over the hospitals interest over the care and treatment of patients being served by it. In this case, the hospital-physical relationship that exists spells the internal functional organization of the hospital. In the Philippines, with in the hospital structural set-up, there are few but distinct related organizations; namely: one for the doctor to take good care of the patients; the other two provide facilities, personnel and supply for the doctors to be able to serve these patients. These few are valid variables to consider the effectiveness of the hospital system thus the DOH have prescribed standard for hospital functions. These are the proper selection of physicians for memberships in the organization of the medical staff which then gives them the privilege to practice medicine in the hospital subject to the limitations specified; and the proper supervision of the members in their professional conduct in the care and treatment of their patients while in the hospital confinement. The prescribed standard for hospital functions is reflective of the principle of organizational efficiency. According to Koontz, (1982), an organization is efficient if it is structured to aid the accomplishment of the enterprise objectives with a minimum of unsought consequences for cause. Pauly, 1972, contends that efficiency and not merely cutting cost must be the objective sought of hospital administration. Standards of highquality or good medical care are set in the light of current medical practice, and inefficiency exits when care in excess of in any way differing from these standards is provided. . . waste therefore occurs when current methods are not used. As observed, on effectiveness for instance, public and private hospitals services are often subject to comparison. Public hospitals often provide excellent medical care but the patients usually must endure long waits and less-than adequate attention, while in the private hospitals have better equipment or doctors than state facilities. It is supposed to be superior in terms of providing comfort and personnel attention, thus people come to it. Although devoted to saving lives, private hospitals can even make extra efforts when it comes to death. (World Executives Digest, 1994). According to A, Pisithpun, deputy director of Bumungrad Hospital: service is the fundamental reason that people are willing to pay more to private care. The service equation are: offering a choice of physicians, better food and even small things like quality of bed sheets. But the most important difference with private care is that it gives people a more effective use of their time. And time becomes more valuable to someone who moves up the economic scale. (World Executives Digest, 1994). The functions earlier discussed are crucial gauge to determine the productivity of the medical staff under given hospital setting. That the place of hospitals in medicines and the place of physicians within the hospital are significant basis on the appraisal of the performance of the hospital management. This is because the hospital has become the center of medical practice within the community, and that under this concept the responsibility of the physicians in the institution has been extended beyond their patients to include the other patients under the principles underlying the organization of the medical staff. PATIENT CARE FUNCTION AND TREATMENT Responsibility for the provision of services and facilities for the use of members of the medical staff in the medical management of their patient, falls under the following functional element: nursing, paramedical and administrative services, (Mayuga, et al, 1987). These are the following:

1.) Nursing Service. This unit of the hospital is primarily responsible for patient-care administration.
In carrying out its assigned function, it provides professional nursing services. It coordinates with the function of the various diagnostic therapeutic, and scientific services set-up in the hospital. It also performs other activities delegated by the hospital administrator. All these are features of professional nursing as embodied in the provisions of professional nursing as embodied in the provisions of the Philippine Nursing Law, otherwise known as RA 877. The authority given to nurses, by legal mandate, includes the responsibility of diagnosing and treating human responses to

actual or potential health problem through such services as case finding, health-teaching, health counseling and provision of care supportive of, or restoration of life and well-being.

What do nursing services consists of? These consist of the Nursing Administration headed by the chief nurse, the patient care units, the surgical and obstetrical nursing floor, nurseries and the dispensary and emergency treatment forms. As practiced, the nurses are assisted by the registered midwives and nursing attendants. In Philippine experience, the patient-watcher, help provide nursing care under proper, institution and supervision.