Hospital Bureaucracy: Navigating The System

Hospitals are a prime example of a bureaucratic institution, with a clear hierarchy and rules that govern the organization. This is evident in the precedence of doctors over other staff members, such as nurses, food service workers, and cleaners. While bureaucracy can bring order and structure to hospitals, it may also hinder progress and innovation due to its rigid nature. The impact of bureaucracy in hospitals is a widely discussed topic, with varying opinions on its advantages and disadvantages. Some argue that bureaucratic processes can lead to higher administrative costs without necessarily improving patient care, while others highlight the challenges of post-bureaucratic reforms on care provision and the relationships between care providers and receivers.

Hierarchy and rules

Hospitals are a prime example of a total institution, where people live and work, cut off from the outside world, and perform routine activities controlled by the rules of the organization. The hospital's bureaucracy is revealed within its hierarchy and rules. The nursing staff, food staff, and doctors all have their place in the hierarchy, with doctors having precedence over everyone else. This is evident when a doctor enters a room, and everyone else clears out without being asked.

The bureaucracy within a hospital setting can be dysfunctional, as seen when a patient's family had to bring in outside food due to the patient not receiving any food from the hospital. The family had to find ways to circumvent the hospital's rules. Hospitals also have high administrative costs due to the additional work of pursuing "profit opportunities," which can lead to higher costs without improving patient care.

The impact of bureaucracy on healthcare service delivery has been studied in government hospitals in Nigeria, where it was found that bureaucratic impersonality and formal rules and regulations hindered quality service delivery. The bureaucratic processes were criticized for being time-consuming, unproductive, hindering innovation, and causing goal displacement, termed "bureaucratic dysfunction."

Post-bureaucracy in hospitals is associated with a loss of professional autonomy and protocol-based care, impacting the relationships between care providers and receivers. Standardized clinical care, performativity demands, litigation risks, and rising administrative obligations can challenge the provision of patient-centred care, particularly in disciplines like midwifery, which is founded on relationships.

Max Weber's bureaucratic theory of management and the concept of a "total institution" by sociologist Erving Goffman provide insight into the bureaucracy within hospitals. The theory discusses the entrenchment of orderliness and productive means of achieving goals through bureaucracy, while the "total institution" describes the all-encompassing nature of hospitals, where individuals must conform to the hospital's routines.

Staffing decisions

Hospitals are complex organisations with a clear hierarchy, where doctors are at the top, followed by nurses, and then food and cleaning staff. Hospitals are restructuring the way they staff their units, departments, and care teams to maintain their economic viability and adapt to changes in healthcare delivery.

Hospitals face the challenge of staffing shortages, which can lead to higher labour costs and limited profitable services, affecting their ability to serve patients and generate revenue. The COVID-19 pandemic exacerbated an existing crisis, with nursing vacancies, physician burnout, and non-clinical workers leaving the healthcare sector. Hospitals can respond to staffing shortages by paying premiums and improving working conditions.

To address labour shortages, hospitals may establish partnerships with local schools to develop pipelines for certified medical assistants and nurses. They can also collaborate with other healthcare organisations in their region to pool clinical and non-clinical staff. Involving nursing staff in restructuring decisions brings professional knowledge and experience to the table and ensures staff commitment to the changes.

The proportion of Registered Nurses (RNs) on a nursing staff positively influences severity-adjusted Medicare mortality rates. A professional practice environment, including decision-making and peer review, also has a beneficial impact on mortality rates. Hospitals are encouraged to match nursing resources with patient needs to assure quality care.

While bureaucracy can bring orderliness and productivity to organisations, it may not suit the unique nature of hospital operations. Bureaucratic processes can hinder innovation, flexibility, and quality service delivery, especially in the context of government hospitals in Nigeria, where they have been associated with corruption, inefficiency, and overstaffing.

Administrative costs

The US stands out among other high-income countries for its high administrative costs, which are reflected in the prices that medical providers charge. A comparison of eight nations revealed that administrative costs in the US accounted for 25% of total hospital spending, more than twice the proportion in Canada and Scotland, which had the lowest administrative costs. US hospital administrative costs rose from 23.5% of total hospital costs in 2000 to 25.3% in 2011, amounting to more than $200 billion. The higher costs in the US are attributed to factors such as higher physician fees, a focus on specialist services, and greater use of advanced technology.

The complexity of the US healthcare system also burdens patients, who must navigate confusing bills and transfer medical records between providers. Studies have found no link between higher administrative costs and better-quality care. In fact, the combination of direct government capital grants and global operating budgets, as seen in Canada and Scotland, was associated with the lowest administrative costs. Reducing US per capita spending on hospital administration to Canadian or Scottish levels could have saved more than $150 billion in 2011.

The administrative burden in the US healthcare system is often cited as a reason for high spending, with the system's complexity leading to waste and inefficiencies. While the US has a private insurance-based, multipayer system, countries with global, lump-sum budgets for hospitals require less administrative work. Per-patient billing, on the other hand, necessitates additional clerical staff, management, and information technology systems, further contributing to administrative costs.

Patient care

Hospitals, like all organisations, build bureaucracy to decrease risk as they grow. Hospitals create communications departments to decrease the likelihood of bad press, as government funding relies on keeping funders happy. This means that bad press about patient care is more important than the care itself. Every element of service creates its own demand for bureaucratic processes, such as forms, checklists, audits, computer passwords, and mandatory sign-offs.

The bureaucratic structure of hospitals can have a detrimental effect on patient care. A hospital's bureaucracy can be so large that it would be just as busy even if there were no patients. This means that managers are often tied up in meetings, and patient care struggles for attention. The high cost and low quality of healthcare in the US are a direct result of a growing hierarchy, which includes case managers, nurses, specialists, administrators, and insurance providers, all working in silos with large amounts of paperwork and increasing regulations. This inhibits collaboration, stifles communication, and undermines participation and teamwork, leaving patients at the bottom of a $3.54 trillion industry.

Bureaucracy can also have a detrimental effect on the staff providing patient care. The administrative workload of managers can obscure their primary role of focusing on patient care. The implementation of quality care is still considered to be costing hospital operations. However, bureaucratic caring has successfully integrated two different parts into a robust strategy in nursing care. Implementation of bureaucratic caring with systematic planning can significantly increase clinical involvement and support patient safety practices. Patient satisfaction is a result of communicating and respect, and it generates revenue.

In some cases, bureaucracy can be beneficial to patient care. A study on the quality of service delivery in government hospitals in Lagos, Nigeria, found that patients' waiting times did not impact the quality of service delivery. This implies that bureaucracy can allow hospitals to provide quality care without having to worry about the time it takes to provide that care.

Total institution

Hospitals have been described as "total institutions" by sociologists such as Irving Goffman. Total institutions are places where people live and work, isolated from the outside world, and perform routine activities, controlled by the rules of the organization. Hospitals, particularly psychiatric hospitals, fit this description as patients are isolated from society for a period of time and led to live an enclosed and formally administered life.

The idea of hospitals as total institutions is further supported by the presence of bureaucracy within the hospital setting. Hospitals have a clear hierarchy, with doctors at the top, followed by nurses, and then food staff and cleaners. This hierarchy contributes to the sense of institutionalization that patients and their families may experience during their stay.

While hospitals have positive social functions, such as providing employment and contributing to the local economy, they also have negative impacts. Hospitals can be major polluters, both directly through the production of clinical waste and indirectly through staff commuting. Additionally, the reliance on hospitals for medical care can lead to institutionalization, making it difficult for individuals to re-integrate into the community after discharge.

The concept of total institutions in hospitals is not limited to a specific geographical location. For example, studies have examined the impact of bureaucratic processes on healthcare service delivery in government hospitals in Nigeria. These studies found that bureaucracy in hospitals can lead to adverse effects, such as impersonality, prolonged waiting times, and hindrance of innovative ideas.

In conclusion, hospitals can be considered total institutions due to their isolating nature, bureaucratic hierarchies, and the potential for institutionalization. While hospitals play an important role in society, it is crucial to be aware of and address the negative impacts they can have on individuals and communities.

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