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Human Resource Management in Hospitals

Chapter · January 2008

DOI: 10.4135/9788132108450.n5

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 HUMAN RESOURCE MANAGEMENT IN HOSPITALS

S.F. Chandra Sekhar

INTRODUCTION

The simple and familiar word "Hospital" represents much but not always understood in its
entirety and complexity. It cares for patients of all ages and backgrounds, some appreciative
and some disgruntled, some happy and some sad. It houses cooks and doctors, cleaners and
nurses, technicians and therapists, ambulance drivers and administrators of different kinds,
and plumbers and clerks, all interacting. It experiences love and despise, hope and despair,
and sympathy and indifference. It is a place which never closes complex equipment, makes
supplies of a wide variety, imposes policies and rules, makes budgets and debts, experiments
and learns and plans for the future (William,1990).

The central theme, that is conspicuous in this statement, gives prominence to the people who
deliver services to the wider constituents of a hospital. Human asset, in modern times, is
considered to be a treasure rather than mere resource in the progressive business
organisations. This is because it is the people who shape the destiny of the business and not
the structures, systems and processes that are effectively formulated in the organisations.
Many a time, the managers comment, “I wish I had a highly competent, motivated and
committed staff working for me”, while setting aside the structures and processes of his
organisation in his mind. Hospitals are becoming large and complex with the increase in
modern health facilities, increased health awareness among people and the advent of new
technologies in medicine. The government intervention in recognising hospital as an industry
and regulating their purpose and performance have also increased, in India.

There have been many success stories documented in the management literature of those
companies whose human resources have turned around the companies from sinking. On the
contrary, there are also stories of some companies that are extinct because of the poor
human resource management practices. Thus, it is evident that effectiveness of a hospital is,
to a large extent, dependent on the quality of services delivered and the work efforts
expended by its employees. Therefore, the Human Resource Management (HRM) function is
critically important and cardinal to the efficient and effective operations of a hospital as an
organisation. Despite this fact, the recurring changes taking place in health care industry
affecting the health services have also been influencing the HRM function considerably. As
aptly pointed out by Armstrong (198*) the fundamental belief underpinning HRM is that
sustainable competitive advantage is achieved through people. They should therefore be
regarded not as variable costs but as valued assets in which to invest, this adding to their
inherent value.

This paper has five-fold objectives. Firstly, it presents the evolution of hospital HRM in India.
Secondly, the objectives of HRM system in the hospitals is explained. Thirdly, the distinction
between personnel management and HRM on one side and the objectives of HRM in
hospitals are dealt with. Fourthly, it enlists and elaborates each of the sub-functions of HRM
vis-à-vis the general management functions (Figure 1 presents framework for such
relationship) and lastly, in brief, suggests how to put HRM into practice, followed by the future
of hospital HRM in the next millennium.

EVOLUTION OF HOSPITAL HRM IN INDIA

HR function is in existence in some form or the other in Indian organisations in general and
hospitals in specific. This is because organisations exist for people. They are made of people
and by the people. Their effectiveness depends on the behaviour and performance of the
people constituting them. However, the organised HR function could be traced to the concern
for employee welfare which started in 1920’s. Today, the status of personnel management
function in hospitals is not much different from what it has been during the last twenty years,
not only in terms of the role and execution but also and more importantly, in terms of an
 2

approach and philosophy towards human resources. Neither the evolution of the function has
been smooth nor any significant progress made later. The evolution of HR function in India is
presented in Figure 1 to provide logical development.

Period Status Emphasis

1920-1939 Clerical Statutory, welfare, paternalism

1940-1969 Administrative Introduction of rules, procedures etc.
1970-1989 Managerial Regulatory conformance, imposition of standards
1990- continuing Executive Human values, productivity through people, Employee
commitment

Figure 1 Evolution of Hospital HRM Function in India

Objectives of an HRM System in Hospitals

The broad objective of HRM is to contribute towards the realisation of the hospital goals. The
specific objectives are :

 achieve and maintain good human relations within the hospital

 enable each employee to make his/her maximum personal contribution to the effective
working of the hospital
 ensure respect and the well being of the individual employee
 ensure the maximum development for the individual to help the employee contribute
his/her best to the hospital
 ensure satisfaction of various needs of individuals for obtaining their maximum
contribution to achieve the hospital goals.

Personnel Management versus HRM

The conceptual differences between personnel management and human resource

management have run into controversies and contradictions. Such differences can be seen
as a matter of emphasis and approach rather than one of substance. The number of
established differences between them are far in number than the similarities that exist.
However, all of such dissimilarities, to a large extent, are related to the philosophical tenets.
Figure 2 presents such differences in philosophy.

Personnel management Human resource management

Employee alienation is ignored Employee commitment,
involvement, identification and
loyalty are encouraged
Fear psychosis is created Trust and confidence promoted
Indifferent to employee problems Supportive to employees
Policing the poor performers, absentees, Understanding, providing autonomy and
late comers, and such like. empowerment
Confrontation is practised Collaboration and counselling are arranged
Power is concentrated Responsibility is shared
Problem’s of Individual solved Problems of group solved
Inequality in accepting ideas Equality of ideas
Anonymity of person Recognition of person
Knowledge conservation is the motive Knowledge dissemination is the motive
Distancing from management Proximity with management
Manage the people Manage the performance and process
Unions are resented Unions are party to HRD programmes

Figure 2 Personnel management and Human resource management

:Differences in philosophy
 3

Today, the emphasis of HRM is on commitment rather than on compliance which is

emphasised by personnel function during the last several years. Despite such philosophical
differences, the functions remain same. But, it is noteworthy to mention that a manager with
personnel philosophy tends to be more traditional in his approach towards the employees.
Whereas, the approach may be more humane oriented if the manager embraces human
resource philosophy. Thus, in this paper, the terms personnel and HRM are not treated
separately while discussing their operative functions in management.

Thus, the operative functions of HRM are presented in the following sections. Under each of
the operative function, the tasks, assignments and responsibilities of the HR functionary are
listed out and elaborated in brief.

The general management functions of planning, organising, directing and controlling are the
ubiquitous functions that are carried out by all the clinical and managerial functionaries in the
hospital. Whereas, operative functions are function-specific. Planning involves selecting
missions and objectives and the actions to achieve them; it requires decision making, that is,
choosing future courses of actions from among alternatives. Organising is a function that
involves establishing an intentional structure of roles for people to fill in organisations.
Directing is influencing people so that they will contribute effectively to organisation and group
goals. It has to do predominantly with the interpersonal aspect of managing. Controlling is
identifying, measuring and correcting the individual and organisational performance against
goals and plans, showing where deviations from standards exist, and helping to correct them.

FEEDBACK

General Management Functions of Human

Functions Resource Management

Procurement

Planning Development

Organising Compensation

Directing Integration

Controlling Maintenance

Separation

Figure 3 General management Vs. HRM Functions

Procurement of Human Resources

Procurement is the planning, organising, directing and controlling of the activities that are
related to the acquisition and deployment of human resources. The activities of the HR
functionary under the procurement sub-system are:
 job analysis – which includes,
 designing job descriptions,
 making job specifications and
 making person specifications.
 4

Then he/she will perform activities related to human resource planning for estimating the right
number and best fit of the people needed to start the activities in the hospital. Lastly, on the
basis of the human resource plan, he/she has to formulate a recruitment programme, followed
by selection and induction programmes separately.

Job Analysis

Job analysis is the primary function in HRM. It is the pre-requisite for all processes leading to
recruitment, selection, performance appraisal, training and development of staff. It is defined
as the scientific process of generating job description, job specification and person
specification.

JOB DESCRIPTION
Job description is an organised and factual statement of duties and responsibilities of a
specific job in the hospital. It should tell what is to be done, how is it done and why is it done.
It sets out the purpose, scope, duties and responsibilities of a job. In specific, it contains,
 job title
 objectives
 tasks
 standards
 responsibilities
 environment
 training required
 prospects and
 employment conditions.

JOB SPECIFICATION
Job specification is a statement of minimum acceptable human qualities necessary to perform
the job effectively. It is a statement of
 skills
 knowledge and
 attitudes
needed to perform the job.

PERSON SPECIFICATION
Person specification is the interpretation of job specification in terms of the kind of person
needed to perform the job effectively. This could be further expressed as,
 physical qualities
 skill attainments
 formal education and intelligence
 special aptitude
 interests
 disposition and
 essential or desirable qualities.

All these three elements put together is called job analysis. There are four methods to collect
data for doing job analysis.
1. Direct observation
2. Interviews
3. Diaries and
4. Questionnaires.

Since hospital managing involves a diverse workforce, in broad terms the staff can be
classified into the following types.
 Medical
 Allied professionals (medical)
 Nursing
 Midwifery
 Technical
 5

 Scientific
 Ancillary
 Administrative
 Maintenance
 Ambulance,
 Operations or works
 Others

Invariably, for all of them, job analysis needs to be done.

Human resource planning in hospitals

MANPOWER ESTIMATION
Human resource planning is a process of generating a plan showing the demand for staff over
a period of time based on assumptions about productivity and costs associated with the
employee. The supply of the resource available within the hospital and the shortfall that may
have to be procured from outside are also estimated. The estimates of demand for and supply
of human resources are always generated in relation to the job analysis.

Human resource planning is a continuous activity in the organisation since people come and
go. Further, as and when recruitment and selection are to be done, it helps the HR manager.
It is the process of forecasting, developing and controlling the resource level by which a
hospital is assured that it has the right number and kind of people at various activity nodes,
doing the work when needed and for which they are useful and suited in economic terms.
Thus, it consists of projecting future manpower requirements and developing manpower plans
for the implementation of the projections. It helps in procuring personnel with necessary
skills, knowledge and attitudes. If the hospital has a corporate plan this exercise will form a
part of it.

The estimate of the future requirements of manpower in a hospital, by department, by

specialisation, by grade and the like are made by applying many simple and complex
statistical models. Some of the statistical methods like correlation and regression analysis,
stochastic models etc. can also be made use of in estimating the demand. Operations
research is yet another quantitative approach that could be used to estimate the demand for
doctors, nurses and other staff in Out Patient and In Patient sections of hospital service.
However, the following are some of the easy and ready methods that help the managers to
update their HR plans.

i) Employee turnover index

Number leaving in a year

= -----------------------------------X 100
Average number employed

ii) Employee stability index

Number of employees exceeding

one year’s service
= -------------------------------------------X1 00
Number of employees employed
one year ago available and that
predicted as really required.

Interestingly, in the domain of HR planning, there is often a conflict that arises from two
constituents of the hospital management function - the HR related estimates of hospital
planning and the estimates generated by HRM function. More often than not, the hospital
planning estimates are accepted as rule of thumb. As such, HR planning is not paid much
attention to in the hospitals. Taylor, the father of scientific school of management thought,
suggests that there is a need for replacing rules of thumb with scientific rationality. Therefore,
 6

there is a need for close relation between these two entities for effective and efficient
utilisation of human resources in the hospitals.

RECRUITMENT
Recruitment is undertaken as an activity to fill vacancies from external or internal sources to
comply with the human resource plan. It is the process of identifying the number and quality
of people required for the hospital, identifying the sources of availability – internal or external
to the hospital, preparing a press announcement containing the job description, job
specification, person specification, a brief note on career prospects on one hand and the
history, mission/vision, image and future plans of the hospital on the other; inviting
applications, shortlisting the applicants on the basis of the conditions specified; intimating the
prospective candidates for selection tests. In summary, recruitment is a process of attracting
a large pool of applicants for small number of jobs , thus creating an opportunity to pick the
best from the lot.

SELECTION
As recruitment attracts large number of applicants, the process of selection is used for
choosing the few for further consideration on the basis of the predetermined criteria. It is
matching between the specified job requirements and the candidate’s achievements, the
principle of best fit. By and large, selection of the candidates is done with the basic
assumption that people are different and job related skills and abilities could be measured.
Thus, some of the tests that could be utilised in selection of the candidates are
I) achievement tests,
II) aptitude test,
III) interest tests,
IV) personality tests,
V) interview, and
VI) IQ tests.
Recently, the intelligence tests are questioned for their inability to predict accurately
and comprehensively the job performance. It has been questioned for their poor
reliability to assess real work

iii) Absenteeism index

Number of man-hours lost

=------------------------------------------ X 100
Total possible man-hours worked

iv) Accidents index for frequency

=-------------------------------------X 100,000*
Number of man-hours worked

*100,000 is total number of hours in average working life Number of lost time accidents

v) Health statistics compiled according to department, location, occupation, grade, sex, age,
etc.

Five year manpower plan for an hospital is illustrated in Figure 4.

Year 1Yr 2Yr 3Yr 4Yr 5Yr

Stock 50 50 48 52 58
Intake 10 10 12 16 20
Losses 10 12 08 10 12

Require- 50 55 60 65 70
ments
Additio-nal 00 7 8 7 4
need
Balance 50 48 52 58 66
Figure 4 Five Year Manpower Plan
 7

Stock is the current number of staff employed. Intake is the predicted demand for the number
of staff. Losses is historical turnover rates, that is the number of leavers as a percentage of
staff in post. Balance is from stock and adding the recruits and subtracting the leavers.
Requirements is by examining workload predictions, service changes and possible future
expansion of services. Additional need is the difference between the ‘balance’ which is likely
to be the stock performance. Often these tests predicted performance only to the extent of
20%. Rest of the 80% of work performance is predicted by what is called the emotional
intelligence quotient (EIQ). Thus, these days, EIQ is being given importance. Since rest of
the 80% of job behaviour is dependent on emotional IQ of the candidates, there is a need for
deeper understanding of its utility and the right way of its application during selection. HR
functionaries should have needs scrupulous regard in this aspect. Therefore hospitals need
to be careful in administering selection tests to the candidates.

Emotional intelligence quotient is characterised by an individual’s self-awareness, mood

management, self-motivation, impulse control and people skills. It is strongly suggested that
EIQ is far better than mere IQ tests because it is EIQ test that separates the stars from the
average performers (Goleman, 1996). Service orientation is yet another personality attribute
that is imperative on the part of the hospital employees. Service orientation is helpful,
thoughtful, considerate, co-operative, and kind-hearted disposition which is an important
attitude needed in all kinds of jobs that involve dealing with people and patients in a hospital.
As such, as part of personality assessment, the selection programme should also include
scope for assessing service orientation of the employees. A scale to measure service
orientation of the hospital employees was developed and tested over 19 jobs in a large
corporate hospital (Chandrasekhar, 1998). The scale was tested and found highly reliable.
A brief description of this instrument for illustration is given under.

Each item of the instrument is measured applying Likert’s 5-point response pattern; where
strongly agree is given the score of 5, agree is given the score of 4, neutral is given the score
of 3, disagree is given the score of 2 and strongly disagree is given the score of 1. Illustrative
sample items of the Service Orientation Scale are as given below.

 I Willingly assist other hospital personnel.

 I Communicate clearly and courteously with others.
 I always notice when people are upset.
 I never resent when I don’t get my way through.
 The service I perform is completely done by me.
 I can tell the impact of my job on the service.
 I have got chance to serve the patients here.
 I feel I am rendering meaningful service to the patients.
 A lot of patients are benefited by my service.
 This job gives me an opportunity to fulfil my motive to service and work.

Interview is yet another popularly used selection test. There are five types of interviews. They
are,

I) preliminary interview
II) stress interview
III) depth interview
IV) patterned interview
V) panel interview.

The expectation here is that this instrument can obtain reasonably accurate information from
the incumbents. However, a plethora of research works revealed that interviews are notorious
for their very poor reliability in obtaining accurate and complete information from the
candidates. The reasons are varied, but predominantly, it is found that virtually in all the
interviews, the element of subjectivity can never be entirely precluded. Despite its failure, it
is still in vogue in every sector of business. However, it can be made reliable and effective
by taking care of the following aspects.
 8

 Interview should be based on a checklist of what to look for in a candidate. Such checklist
is based on job analysis
 Specific set of guidelines for the interview should be prepared before the event
 Interviewers need an orientation on how to evaluate the interviewees’ performance
objectively
 There should be consistency in questioning to put the candidate in ease
 The interview setting should be disturbance free and the interview should be conducted in
a relaxed physical setting.

INDUCTION OR SOCIALISATION
This is a formal programme, designed and partly carried out to introduce new employees to
the organisation, in all its social and work aspects. It is a systematic, planned introduction to
the company. It is also a scientific approach to help solve the problems of the new worker and
his/her integration into the organisation of the hospital. The purpose of this programme is,
I) to build the confidence of the new employee in the hospital
II) to promote a feeling of belonging and loyalty, and adjustment to the new
circumstances
III) to give information, about the essentials like, working conditions and terms of
employment.

Here the employer gives the first impression to the incumbent about the uniqueness of his
organisation (hospital). A representative of the HRM department or the head of the
department with the coordination from HRM department will carry out the induction
programme. The topics to be covered in the induction programme are,

The hospital and its services

I) the geographical location of the hospital
II) the structural and functional aspects of the hospital
III) terms and conditions of employment
IV) standing orders and various provisions
V) HR policy
VI) the department and its employees.

It is important for the concerned HR functionary to carry out the follow up of induction
programme. This is it done by creating informal contacts between the HR functionary and the
head of the department periodically to provide first hand information about the performance
and personality of the incumbent. Brief monthly reports till end of the probation period will
support decision-making later. Counselling the employee in a friendly and impartial manner,
in case he/she is not shaping well, will correct the employee’s behaviour and attitude.

PLACEMENT
This is the last in the series of activities to ensure that the right man for the right job, as a
principle, is followed all through. The new incumbents need to be provided with intensive
training programme in various departments before ultimately deciding to which job they are
placed. This helps in proper placement. Many organizations which experience high turnover
in the initial months of employment indicate unsuitable placement.

In brief the tasks of HR functionary include

 Reviewing the vacancies
 Writing job advertisements
 Calling candidates for interview
 Making and obtaining acceptance of offer
 Sending for references and arranging medical screening
 Informing unsuccessful candidates
 Contract preparation, signing etc.
 Induction & placement programme

Development Of Human Resources

 9

Development is the planning, organising, directing and controlling of the programme that
contains wide range of activities relating to the human resources development (HRD) in
terms of enabling employees to acquire competencies needed for future job requirements.

Human resource development is a continuous process to ensure the development of

employee competencies, dynamism, motivation and effectiveness in a systematic and
planned manner (Rao, 1990). It essentially deals with bringing about such improvements in
physical capacities, relationships, attitudes, values, knowledge and skills of the employee as
required for achieving the purposes of the hospital (organisation) (Balaji, 1998). If employees
are effective, their contribution to the hospital will be effective, consequently the hospital will
also be effective in accomplishing its mission goals. Human resource development in a
hospital is achieved through three sub-functions, which should be well planned and organised
in their execution. They are,
 Training
 Performance and potential appraisal and
 Career development.

Training
The aim of any training programme is to provide instruction and experience to new employees
to help them reach the required level of performance in their jobs quickly and economically.
For the existing staff training will help develop capabilities to improve their performance in
the present jobs, to absorb new technologies or procedures and to prepare them to take on
increased and higher responsibilities in the future.

Training is formal and informal instruction designed to ensure and improve the individual’s
performance at work. It helps the individual to achieve the stipulated or expected
performance standards. Training needs may be derived from appraisal reports, dedicated
surveys, human resource plans and corporate strategy; or assessed for the new entrants to
the posts in question. Why training needed? An employee’s value is measured not only in
terms of the costs of employing them, but in terms of the investment made in their training,
development and on the job learning. Post-experience training in the hospital should focus on
the improvement of quality of services and use of better or new technologies. There is
enough evidence to show that employees who were trained on a regular basis are the ones
who provided higher quality of services to the patients.

In hospital, there is need for continuous training of the staff in the areas of patient care
services. How to identify the needs for? The training needs are assessed through task
analysis and performance analysis which could be done through surveys or from the
information furnished by the heads of the department. There are two ways of conducting a
training programme- through established HRD department, or through the external trainers
coordinated by the HR department. These days, hospitals have recognised the need for
training and re-training their staff in order to develop a competitive edge over their competitors
in the market.

Performance Appraisal
Performance appraisal is a formal technique for assessing individuals with a view to, advising
them of their progress, improving their performance, judging their merit and identifying any
personal difficulties. It is considered a powerful tool in controlling performance and
productivity of human resources. Used effectively, it can have tremendous strategic potential
for governing employee behaviour and in using it for selection, training, career planning and
reward systems in the hospital. It provides data about past, present and expected
performance of the hospital employees which is helpful in taking decisions on several
constituent functions of HRM. Unlike traditional appraisal systems, which were policing in
nature, the modern systems are geared towards helping the employee build his/her potential
for future performance. Of the several methods of performance assessment. three are
relevant to the hospitals. They are,
I) Management by Objectives:
A method by which every employee sets his/her own objectives in consultation with his/her
superior and accounts for success or failure in accomplishing those objectives in the
stipulated period of time
 10

II) Behaviourally Anchored Rating System (BARS):

A system by which good and bad behaviour could be described and measured against a
scale of performance levels and
o
III) 360 feedback
A procedure by which all concerned superiors, subordinates, and colleagues around the
employee give their ratings of his/her performance for a period of time. This system should
always be carefully designed and executed with the objective of enabling employees identify
their strengths and weakness, rather than making use of it as a basis for reward. If the later
takes place instead of the first then the employees tend to resent and develop a kind of
aversion to it which consequently affects their performance badly. What is needed in this
regard is a development oriented performance appraisal rather than a strictly reward-oriented
appraisal.

Career Development
Career is a sequence of positions occupied by a person during the course of his/her
professional life. It is affected by the changes in values, attitudes and motivation that occur as
a person grows old. Career planning is important because the consequences of career
success or failure are linked closely with the individual’s concept of self, identity and
satisfaction with career and life. It is a common understanding that career planning of the
employees has a direct bearing on the productivity and quality of life. As such hospitals
should be sensitive to the concerns of career management. In Japan, employees make a
lifetime career commitment to the organisation because of the well-planned career path for
the employees. Though the same may not be possible in Indian organisations, yet a
consistent career could be arranged for the employees because, the hospital invests large
amounts of money in its employees right from procurement to the separation of them. It is
unwise to let people leave with all the skills, knowledge and attitudes after having imparted to
them.

Designing a complete HRD system could benefit the hospitals in a big way, rather than
initiating it on a piece meal basis. First, a HRD climate assessment should be done to know if
the hospital is prepared to have HRD programmes. Next will be the creation of HRD function
or department in the hospital and as a consequence employing a professional who will design
all the HRD processes. All this requires a systematic planning, controlling and development
of HRM function.

There are three aspects that an HR manager should take into consideration before initiating
HRD programmes in the hospital.

 Conduct an HRD climate survey to assess whether ‘developing climate’ exists in the
hospital
 Generate a report based on the survey, abstracts of which could be submitted to the top,
middle and lower levels of management
 Assess the top management’s belief in and support to HRD
 Develop the OCTAPAC culture (Openess, Confrontation for cause, Trust, Authenticity,
Proactive, Autonomy and Collaboration)
 Design HRD mechanisms
 Implement the HRD mechanisms like training, career development, performance
appraisal etc. simultaneously.

Compensation of Human Resources

Compensation is the process of planning, organising, directing and controlling of the wages
and salaries related to the pay policies and programmes of the hospital. In many cases, it is
also called wage and salary administration. The determinants of wages and salaries in the
hospital are,

I) Financial position and corporate philosophy of the hospital

II) Statutory regulations pertaining to wages and salaries
III) Job evaluation
 11

IV) Cost of living index and

V) Benchmarking

Statutory regulations, like payment of wages act, minimum wages act, equal remuneration act
and payment of bonus act are all applicable to hospitals also. Thus, the provisions under
these laws are to be observed while developing a wages and salaries policy. Job evaluation is
a method of estimating the relative worth of a job compared to other jobs in the hospital so
that all the occupational titles could be graded and such relative worth of each job could be
expressed in monetary values. Though such a procedure seems scientific it is cumbersome.
Virtually no organisation is practicing this method of determining wages and salaries.
Consumer price index or cost of living index is to be taken into account before finalising the
general wage and salary levels in the organisation. Lastly, yet another practice is, to conduct
benchmarking- a wage survey with the objective of knowing the wages/salaries and benefits
offered in comparable hospitals. HR consultants often conduct such surveys since it is a
confidential area of HR function which no HR functionary would like to share with their
counterparts. But it is worthwhile to employ consultants to know the details about pay-related
issues in similar organisations. This will also help revise or reformulate the corporate pay
policy. Now, many organisations are adopting a kind of corporate policy in regard to pay,
which is to,

I) lead the market in pay

II) pay on par with other similar organisations and
III) pay less but give more fringe benefits.

Incentives are another type of compensation and reward. It is an additional financial

motivation. They are planned to improve the efficiency and productivity of the processes in
the organisation. This is the cheapest, easiest, quickest, surest means of increasing
productivity. But they suffer from their design considerations in many organisations and
particularly in hospitals because the jobs are not done individually. Group linked incentives
could be worked. Non-wage incentives are more value driven in motivating the employees
than wage incentives. They could be planned.

Integration of Human Resources

Integration is the process of planning, organising, directing and controlling of the broad range
of relationships in the hospital in order to ensure that there is a proper interface between the
individuals and the organisation.

Most of the hospitals have mission statements. A mission statement defines the purpose and
aim of a hospital and gives it a clear focus (Rigby, 1998) in the society. Evidences show that
even the best mission statements are of no use if they are not followed through and made a
part of company culture. Thus, it is the responsibility of HR manager to see that employees
use the mission statement to work towards combined aims. This is possible only when the
needs of the employees are tied up with the needs of organisation. Some of the activities that
need to be performed to see that greater integration takes place are,

1. Building Morale and Motivation

2. Managing Change Programmes
3. Managing good Industrial Relations.

BUILDING MORALE AND MOTIVATION

Morale or ‘esprit de corps’ is the extent to which an employee’s needs are satisfied and the
extent to which the individual perceives that satisfaction as stemming from his total job
situation. Morale involves interactions among group members and is akin to the common
concept of team spirit. It often stated that when an employee has few frustrations, he seems
to possess ‘high’ morale and that when he possesses relatively numerous frustrations or
intense frustrations, he appears to have ‘low’ morale. Research evidences show that morale
affects productivity and job satisfaction in the organisations. In hospitals, such effects are
 12

severe and sometimes incorrigible. The factors and situations which affect employee morale
in the hospital are,

 frustrations resulting from lack of recognition.

 frustrations caused by the belief that promotions and pay hikes were unfair.
 frustrations caused by jealousies between departments and between persons
 frustrations from fear of being inefficient.
 practice of blaming than praising.

Some of the severe outcomes of low morale in the hospitals are,

 absenteeism and tardiness

 disciplinary problems
 fatigue and monotony
 grievances
 employee unrest
 less commitment, and
 turnover.

In order to improve morale in the hospital, human relations approach with its emphasis on
employee participation, effective communication, promoting teamwork, ensuring fairness in all
aspects of work should be practiced. More appealing are the attempts like paying bonus to all
and encouraging employee investments in the company’s shares etc.

There are ample theories of work motivation. What motivates employees has been a
continuous question of all those theories. After all of them, today we are back to the crux of
motivation. It is, “work itself is the greatest motivation”.

Some believe that hospital staff are either motivated or they are not and that appealing to
an employee's need for material gain will not make any difference to their inherent
motivation level. Monetary inducement will simply cause instrumental behaviour designed
to get the reward. In hospitals a strong argument exists that staff are motivated to deliver
services and care to the level they have been trained to provide. As Handy (1994) puts it,
“the wealth creation of a business is as worth doing and as valuable as the health creation of
a hospital”. There is a point of view that plays a large part in the employee's reason for being
at work and that performance will improve if a monetary reward lies at the end. A point to
reckon with is, if individual employees know they will gain cash or other tangible benefits they
will work harder.

Contrary to this understanding, the theory propounded by Hackman and Oldham (1976)
claims that if all the core dimensions exist in the jobs carried out by the people they are well
motivated to perform The core dimensions of a job are,

 skill variety
 task identity
 task significance
 autonomy and
 feedback.

Skill variety is the degree to which the job requires a variety of different activities so
the worker can use a number of different skills and talents. Task identity is the degree to
which the job requires completion of a meaningful whole and identifiable piece of work.
Task significance is the degree to which the job has a substantial impact on the lives or
work of other people in the organisation. Autonomy is the degree to which the job
provides substantial freedom, independence, and discretion to the individual in scheduling
the work and in determining the procedures to be used in carrying it out. Lastly, feedback is
the degree to which carrying out the work activities required by the job results in the
individual obtaining direct and clear information about the effectiveness of his or her
performance.
 13

It is somewhat understood that if the first three dimensions exist in a job, the participating
employees would feel that their job is meaningful, important, valuable and worthwhile.
Autonomy gives them a feeling of personal responsibility for the results and if job provides
feedback, the employees will know how effectively they were performing and this will lead to
learning. In order to measure this level of motivation, Hackman and Oldham (1976) have
suggested the scale, Motivating Potential Score (MPS) for a job. The formula to compute
MPS is,

MPS = 1/3[ Task Variety + Task Identity + Task Significance] X (Autonomy) X (Feedback)

With the help of MPS, every individual employee’s motivation level can be periodically
assessed and decisions to improve his/her job could be made timely. This way, all jobs in the
hospital could be made powerful in their motivational potential. A scale to measure MPS of
hospital employees has been developed and used in a corporate hospital by Chandrasekhar
and Ramesh (1998). Nearly, 19 corporate hospital jobs are diagnosed with the help of this
scale.

MANAGING CHANGE PROGRAMMES

Change in the social and economic environment is an inevitable phenomenon. These forces
which are external to the organisation necessitate adjustment in the internal structure and
process of the hospital. Some of the sources of major change affecting hospital management
are,

 Innovations in medical technology leading to new services and methods of delivery of

services
 Greater competition, especially as a result of lower tariffs
 Changes in government regulations and taxation
 New tools of management such as computers
 Changes in the employee background, training and occupation of those employed.

Employees look upon changes with suspicion and generally resist them. Such resistance
could be due to the following reasons,

 The pressure to maintaining equilibrium in their current work lives

 Habits are not easily changed
 Selective perception and retention
 Feeling of insecurity of their job, status, position etc.
 Attitudes do not change easily

Therefore one of the difficult tasks of HR functionary is to make employees responsive to

change. These days organisations are resorting to planned organisational development (OD)
programmes to achieve this. OD is a long term, systematic and comprehensive change
programme involving all levels in the organisation. This is carried out by an external change
agent, an OD consultant, and an internal change agent, the HR manager. They together
coordinate and initiate the change programmes in the organisation.

MANAGEMENT OF INDUSTRIAL RELATIONS

Industrial relations in the hospital are bifurcated into, individual relations and collective
relations. With regard to individual relations, the hospital HR manager deals with some of the
significant issues like grievance procedure, disciplinary procedure, counseling, etc.

Grievance is dissatisfaction or discomfort an employee has with regard to the terms of

employment or conditions of work in the hospital. Grievance procedure is a mechanism by
which a hospital ensures that the employee grievances are redressed as expeditiously as
possible to the satisfaction of the employee. It is a kind of assurance to the employee that
there is a mechanism available to him, which will consider his grievance in dispassionate
manner. In some organisations, this procedure facilitates multiple levels of redressal. That is,
in case the employee is not satisfied with the decision by his supervisor he/she can go to the
next higher level in the hierarchy.
 14

Discipline is orderliness, obedience, conformity with rules, regulations and procedures of the
organisation. Employees are expected to adhere to established norms and regulations,
thereby creating a state of order in the company. This is also one of the

principles of management stated by Henry Fayol. Indiscipline refers to absence of discipline

or non-conformity to rules, regulations and procedures. A hospital cannot afford it because it
affects morale, involvement and motivation of other employees, often leading to chaos,
confusion, reduced organisational efficiency, strikes, go-slows, absenteeism, loss of
production, and hence loss of profit and wages. Some forms of indiscipline are,

 inconsistent discharge of duties.

 immoral acts.
 acts that trigger unfaithfulness.
 insulting and insubordination behaviour that affects relations.
 abusive acts.
 habitual negligence in discharging duties.
 Indecent behaviour with the patients.

In order to ensure discipline in the hospital, there is a need for a code of discipline and a
disciplinary procedure that can handle indiscipline or misconduct cases. This should be
reinforced with “hot stove rule”. It is a sound disciplinary system having the following
characteristics:

 advance warning
 immediacy of action
 consistency and
 impersonal.

Like hot stove, that burns anything touching it in the same manner penalty for violation should
be immediate and automatic to all.

As part of collective relations, a major task of the manager will be to work with trade unions,
followed by participating in collective bargaining. Trade union movement is also increasingly
growing in the hospitals these days. Trade union is a collective of wage earners for the
purpose of improving conditions of employment. More often than not the HR manger resents
when he hears the word, ‘union’. But he should take time to find answers to questions, such
as, “why did it happen”, “how did it happen”. The simple answer is, people join unions
because managers could not protect the employees’ rights and privileges. Unions assure
them of getting those rights. Hence they join unions. The existence of unions may create
the following problems in hospitals,

 inter-union rivalry
 vested interests
 productivity decline
 services coming to standstill and
 poor image.

One way of preventing unionism, if need be, is through extensive HRD programmes and
good HR policies. In case unions are already prevalent, slowly HRD programmes should be
introduced in order to win the confidence of the employees. But it should be handled carefully
because employees in unionised organisations suspect the motives in management decisions
and initiatives.

Collective bargaining is another challenge that has to be faced by HR managers in unionised

hospitals. Collective bargaining is a procedure by which the terms and conditions of
employment of workers are regulated by agreements between the bargaining agents- union
representatives and management representatives. Pre-requisites for successful bargaining
are,

 preparation by the managers and union members

 15

 realistic charter of demands

 mutual trust.
 Willingness to arrive at agreements on the part of both parties.

Management in India still does not realise trade union’s position. Understanding them is very
important and involving them in the strategic management will benefit the organisation in the
long run.

Participation takes place when management and employees are jointly involved in making
decisions on matters of mutual interest where the objective is to produce solutions which will
benefit all concerned. At job level encouraging participative management is a task of HR
functionary. Groups may be called on an ad hoc basis to consider a particular situation, such
as, works committee, joint management council, quality circle, project teams etc. Successful
organisations are characterised by higher degree of employee participation and involvement.

Maintenance of Human Resource

Maintenance is the process of planning, organising, directing and controlling of health, safety
and welfare programmes that contain wide range of activities related to the sustenance of the
human resource in the hospital.

It is a recognised fact that the health, safety and welfare functions within the organisation has
been very much the ‘Cinderella’ of HRM despite the enormous human and economic benefits
that can flow from a well conceived and properly implemented health and safety policy within
the company (McKenna and Beech, 1997). There have been counter arguments also as to
why an organisation should take care of the health, safety and welfare needs of its
employees. These services are provided by the hospital to ensure acceptable standards of
performance and that where the hospital can prevent personal difficulties from inhibiting
performance. Therefore, welfare of the individual should be taken into account.

Factories Act, 1948

Factories Act, 1948 by the Government of India makes it obligatory for the employer to
observe the provisions contained in the act. Some of the main provisions are on health,
safety, welfare and working conditions. However, this act is not applicable to a hospital since
a hospital is not a factory as per the definition. Hence only the first three are relevant though
the provisions are found to be reasonable and complete. It becomes the moral obligation, in
the absence of a legal requirement, of the employer to provide the following to the hospital
employees.

HEALTH
Health provisions need to be provided by the management with a view to ensure that they
have healthy staff working for them. Healthy staff makes healthy organisation. Most of these
health programmes are concerned with the identification and control of occupational health
hazards arising from toxic substances, radiation, noise, infection, fatigue and the work stress
imposed upon the employees. Good housekeeping, periodic medical examinations, regular
environmental checks, vaccinations, training etc would prevent deterioration of the health of
the employees. Hospitals need have a separate health programme since employee health
could be part of its regular activity.

SAFETY
Safety is prevention of accidents by identifying actual or potential causes. Process of
identifying them is mainly one of conducting inspections, checks and investigations. Most of
the accidents are related fundamentally to the system of work and some of them are also
related to personal factors, which in many cases arise from the system of work. In hospital,
there are several places where accidents could occur. They could occur in the case of
electrical or electronic equipment which may give violent electrical shock. Diagnostics, where
inexperience or carelessness could result in an accident. Some of the hospital staff in clinical
departments may get HIV infection while handling the patients without taking proper
precaution- use of gloves, syringes or other equipment. Poor housekeeping– congestion,
 16

blocked gangways or exits, inadequate disposal arrangements for swabs or other waste and
infected materials, lack of storage facilities, unclean working conditions, assaults on staff
members by outsiders, fire, etc could cause accidents. Almost all of these could be prevented
if a carefully worked out safety policy is adopted.

In many instances, an activity in a hospital could cause health and safety problems. Some
times they may be inseparable. A faulty handling in diagnostics could cause an infection,
which is not only an accident but also a health problem. Hence there may be a need for
combined health and safety policy.

WELFARE
Welfare is for the total well-being of the employee. It is for improving the morale and
commitment of the employees. Some of the welfare measures that could be provided are,
transport facilities, housing, cooperatives, canteen, education for the employees’ children, and
other benefits or facilities where the families of the employees also get benefit like for
instance, paid holidays etc.. In this case families influence the employee’s decision to stay or
leave the organisation in the long run.

Separation of Human Resources

Separation is the process of planning, organising, directing and controlling of the activities
that deal with physical separation of human resources as and when required or provided by
the separation policy in the hospital. Organisations have to pay attention to this particular
function because there is a general feeling that there is not much benefit derived from
executing this function in elaborate form. However, a planned separation programme could be
more useful to the hospitals.

In these days of fierce competition, hospitals have to ensure that they have the right number
and right quality of employees. A single extra employee could result in additional cost.
Further, as the saying goes, “an idle man’s brain is a devil’s workshop”, a single employee
with no work could cost much to the hospital in terms of discipline and unionism. Reducing
the number of employees who are not needed in a systematic and also reducing employee
costs without tears is a perplexing question. Many a time, the cases in labour courts will be
pending, causing additional cost to the hospital. Separation programme will also help
hospitals downsize when they realise that the hospital is overstaffed. Thus, there is a need to
have a well planned separation programme. On the other hand, hospitals can also learn their
mistakes from those who are leaving as to what made them pursue their jobs elsewhere. The
activities that go into the Separation programme are listed here.

1. Exit interviews should be conducted for all leaving members. In this they could be asked
to frankly give their reflections about the hospital in general, their activities in it, its HRM
operations and suggestions for consequent improvement.
2. Voluntary retirement schemes could be formulated that would be economical to the
hospital in the long run and implemented.
3. In anticipation of the probable turnover reformulating the manpower plan further.

Human Resource Information System (HRIS)

HRIS, earlier called personnel information system (PIS), uses computer hardware, software
and data base. The information pertaining to all human resources are incorporated into the
computer system, as far as possible, in numerical form. These numbers can then be
manipulated in HRIS to provide the type of information necessary for planning and controlling,
decision-making or preparing reports on all operational functions of HRM. Computer
systems have simplified the task of analysing vast amounts of HR data. It is an invaluable tool
for HRM, providing capability for preparing payroll process to the retention and retrieval of
record .

HOSPITAL HRIS
 17

A hospital HRIS may consist of the following modules:

Personal profile– name, age, sex, domicile, marital status, and address of the employees
Career profile– performance appraisal, job title changes, salary changes, promotions,
transfers, career paths designed for the employees
Skill profile– education, training, license, degrees, skills, hobbies and interests
Benefits profile– insurance coverage, provident fund or pension, holidays, leaves, bonus, etc.

HRIS will help the hospital know the core competencies of its human resources- managerial,
supervisory, clinical and operative competencies. Such reports will enable the hospital make
right decisions for probable merger and acquisition on a future date.

Putting HRM into Practice

The most important task of the HRM manager is implementing HRM function. Many
managerial initiatives fail sooner than they are commissioned. Some of the organisations
have poor attitude towards HR function as a consequence of faulty implementations.
Therefore, the modus operandi for implementing HRM is as follows.

 Elicit top management’s belief on the importance of HRM and their full commitment .
 Formulate a comprehensive HR policy for the hospital. This will include issues, such as,
(a) emphasis on strategy, (b) concern for cultural change, (c) concern for empowerment,
(d) importance of resourcing, (e) stress on performance, and (f) focus on quality and
customer care.
 Establish an HRM department and allocate budget for its operations.
 Develop and execute the subsystems of HRM as explained above.
 Periodically monitor the effective execution of all subsystems in order to avoid errors or
deviations. If needed correct them and continue their implementation.
 Generate reports periodically on the effectiveness of each subsystem for designing the
strategic HRM for future considerations.

The Future of HR Function in Hospitals

Modern organisations are moving from a monolithic, vertical, homogeneous, slow paced to a
divergent, horizontal, centralised, heterogeneous, flat, network based, fast paced
organisations. Hospitals also have to be alert and responsive to the changing times and
demands. They should- be multifunctional; multidisciplinary, multisectoral; develop skills of a
think-tank ; disperse rapidly new knowledge, new capabilities; and have a reservoir of
knowledge about people.

Therefore the challenges that will be faced by the hospital HR managers in understanding
and solving the problems of the future will be related to,

 Increasing size of workforce

 changing psychosocial system
 satisfying the higher level needs of the employee
 creating equitable social system
 absorbing medical and technological advances
 taking advantage of computer aided information system
 adjusting to the changes in legal environment of hospitals and
 management of human relations
 the emerging concept of knowledge worker
 developing a highly committed workforce

They should also examine and improve their ability to learn. Today people do not want to be
‘used’ by the organisation as ‘victim’ or ‘pawn’. They want to have a sense of ownership over
the resources they own, to feel that the tasks they perform have significant impact on others
in the organisation, to feel that they are meaningful to them. They expect to be empowered to
take decisions on their own, and desire to have a climate for learning and personal
development.
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18

As mentioned earlier, the future hospitals need to have a well-designed and operational HRIS
to keep track of the changing status of their human resources. It will play a revolutionary
developmental role in managerial decision-making process. It will have an increasing impact
at the coordinating and strategic level of the hospital. Thus, the endeavour should be to
redesign and restructure the HRM system which will enable the hospital to have the best of
employees working for it.

At this juncture it will be worthwhile to recollect the contributions of corporate culture analysts,
Pascale and Athos (1981) and Peters and Waterman (1982). They have suggested a number
of attributes for successful organisations which have influenced the thinking on HRM
regarding the need for commitment and strong culture.

Pascale and Athos emphasised the importance of ‘superordinate goals’ – the significant
meaning of the guiding concepts or values with which an organisation influences its members.

Peters and Waterman suggested that the excellent organisations are characterised by the
following attributes,

Productivity through people – the belief that the basis for productivity and quality is the
workforce. Therefore encouraging commitment and getting everyone involved in the
organisation is important.

Hands-on and value-driven – the people who run the organisation get close to those who
work for them and ensure that the organisation’s values are understood and acted upon. This
is very important in the context of a hospital.

Visionary leadership – the value–shaping leader is concerened with “soaring lofty visions that
will generate excitement and enthusiasm. Clarifying the value system and breathing life into it
are the greatest contribution a leader can make”. Thus, excellent oragnisations are
characterised by visionary leadership.

In conclusion, management of human resources in the hospital is a very challenging job

because of the dynamic nature of human element. Since human resources decide the destiny
of the hospitals, there is a need for properly organised HRM department. The HR functionary
is a dynamic, formally qualified professional who understands the need for personnel in the
hospital and plans the entire HR strategy which includes procuring, developing,
compensating, integrating, maintaining and separating the human resources in the hospital.
These days, emphasis is laid on transformation from personnel philosophy to human
resources philosophy which is called, “from control perspective to commitment perspective”.
such transformation is needed in the existing hospitals in order to gear this resource for
efficient and effective functioning of the hospitals.

References

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Hospital administration, Hyderabad.
Chandrasekhar, S F (1998), Service Orientation and Continuance In Work : A Study of Corporate Hospital Employees, Term
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Goleman, (1996). What’s Your Emotional IQ?, Reader’s Digest, February, 148, pp 33-37.
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Pascale,R.T and Athos,A.G (1981) The art of Japanese management, Simon & Schuster, New York.
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