Management

What is Management ?
- it’s a dynamic process to get things effectively done to achieve desired goal or objectives through:
- Management is both a Science and Art
As a SCIENCE, management has basic rules and principles.
As an ART, successful managers learn through experience to
fulfill objectives via Management functions:-
1-Proper planning,
2-Efficient implementation
3-Evaluation to assess achievements and identify the need for
re-planning

N.B Management require identify the needs for re-planning. So is a dynamic process.

Effectiveness is the degree to which a stated objective is being achieved Well

Efficiency is the optimized(balanced) use of resources (humans, equipments, supplies, money, space, information and time)

- PRINCIPLES OF MANAGEMENT :
1. Management by objectives: Management is getting things done.
2. Learning from experience: If the objectives not completely fulfilled, management analyses why?
What are the obstacles? and try to address them.
3. Division of labor: Management is getting things done through people.; it needs TEAM WORK.
4. Convergence of work: should be planned, assigned to team members (division of labor), and coordinated to achieve.
5. Substitution & proper use of resources: is efficient use of resources.
6. Delegation: means that someone with authority gives another person the authority to take responsibility for a specific
activity when the need arises. /The delegate cannot re-delegate the authority
7. Setting priorities: This means two things:
• Be selective. Do not become overloaded with routine and unnecessary information.
• Make big decisions first (prioritization of decisions).

Planning
is the process of determining the objectives and steps that will be employed in achiving them.
A plan includes goals, objectives and outputs, and describe action and resources necessary to achieve them.
Types of planning:
A. Strategic planning for long period from 5-15 years and for large organizations, e.g. Ministry of health.
B. Action Plan describes all the activities that have to be carried within a year. This plan also includes the budget needed.
- Time for prepration for one week or even one dayto 3 months.
- are done for can be done for a small unit or even for an individual e.g. a PHC center, Department of Public Health,
N.B The planning process starts by identifying where we are now (the present situation),
and where we want to be the objectives / the desired situation).
The planning function includes:
1.Situation analysis.
2. Problem identification and priority setting.
3. Objective setting.
4. Selection of alternative solutions/interventions.
5. Planning for resources.
6. Planning for monitoring and evaluation.
7. Planning for sustainability.

1. SITUATION ANALYSIS depends on the level of planning.

The situation analysis for population/community-based planning includes
→ Demographic and socio-economic situation analysis: includes the population size, age and sex composition of the
population, average family size, per capita income, major economic
activities, educational levels and illiteracy rates, etc.
→ Epidemiologic situation analysis includes identification of the main health problems and their causes and factors, vital
rates for morbidity and mortality defined as age, sex, and cause specific.
→ Health and other resources analysis would cover the health system in the country and other related sectors including
educational resources, mass media activities; women and youth programs / projects; non-governmental organizations
(NGO's and cooperatives roles, social services in general; agriculture development activities, etc...
Sources of data :
Documents and records / Reports and surveys interviews
1. PROBLEM IDENTIFICATION AND PRIORITY SETTING The problem may be an acute disease, a chronic
disease, affecting all population groups, or a specific group . e.g: High infant mortality rate, diarrhea among under-five
children, malnutrition among under-five, TB, obesity, CHD, adolescent's health problems, smoking, etc.
- Problem Definition Each problem should be clearly describedand cover:
(i) The nature, extent of the problem, including who is affected, which age group, social class, and geographic area;
(ii) The trend of the problem, whether increasing, decreasing or stationary;
(iii) Causes of the problem including the health related factors affecting the problem;
(iv) Consequences of the problem.
e.g Diarrhea is of a high incidence rate among children in the first two years of life. It is especially high among lower
social classes and in rural areas. The incidence is almost stationary over the past years. It increases with lack of
environmental sanitation, and lack of healthy practices. It causes high death rate, and is also related to malnutrition

- Analysis of the problem Community health problems can be analyzed by the problem tree indicating the problem,
causes and contributing factors. This is done by asking yourself 5 times why?

- Priority Setting With the limited resources we need to address the priority problem areas first.
Priority setting would take into consideration the following:
1.The magnitude / extent of the problem (incidence and prevalence).
2 Seriousness of the problem which has four maincomponents:
- (Urgency) Some problems need a rapid response to prevent the spread or death; e.g contaminated food, radioactive waste
- (Severity). This is measured by immediate effects e.g. high mortality rates.
- (Economic costs) should include the costs of medical expenses, public services and prevention programmes.
- (Impact) on others: communicable disease control remains an important priority;
3.Effect (economy, productivity, socioeconomic)
4.Feasibility of prevention and control

2. GOALS AND OBJECTIVES clarify what need to be done. If you do not have clear Objectives one may end no
where. The first step is to define the general objective of the programme/ project. Thi out in the goal.
Goal: The goal is the intended end-result or achievement of a programme, project of activity
Specific objectives: One of the basic components of planning is to establish realistic objectives and targets.
Objectives must be SMART and: Specific
Measurable: be useful in assessing the degree to which it has been achieved and to allow for monitoring and evaluation.
(achievable, realistic):Objectives should not be too difficult to achieve, or too modest.
Relevant / appropriate: Objectives should help to solve the problems .They should be relevant to the situation.
Time-bound/time specific: Objectives must give clear dates/periods within which the stated objective has to be achieved.

4. SELECTION OF ALTERNATIVE SOLUTIONS Criteria for selecting appropriate solutions:

- Foreseen Effectiveness of proposed solutions
- Technical feasibility (availability of resources, human, equipment and supplies)
- Political and institutional support

H.C managers skills : Healthcare managers direct entire facilities, specific departments, or medical practices and are
required to possess several skills including:
- Analytical Skills: Understanding current regulations, as well as adapting to new laws
- Communication Skills: Effectively communicating to convey policies and procedures to other health professionals and
ensuring compliance with current regulations and laws
- Interpersonal Skills: Discussing staffing problems and patient information with other professionals, such as physicians
and health insurance representatives
Management skills
- Leadership Skills: Hiring, training, motivating, and leading staff, solve staffing and administrative issues
- Technical Skills: Staying current in healthcare technology advancements and data analytics
- Critical Thinking: Identifying strengths and weaknesses, and finding alternative solutions.
- Active Listening :Offering one’s full attention with regard to what others say, asking questions when appropriate
- Coordination: Adjusting one’s actions with regard to another’s actions for effective work collaboration
- Judgment and Decision Making: Examining both benefits and consequences of potential actions to help determine those
most appropriate
ORGANIZATION-BASED PLANNING is the result of combining talents and efforts of organized group of people with a
particular purpose.. Ex: universities, ministries, departments and units ….et
Why we need strategic planning for organizations? - Review ongoing program and take actions to improve performance
and Solve problems / Ensure stability and sustainability.
- Strategic Planning is a 35 years plan that would go into several steps to reach preset goals that the organization would like
to achieve in the future.
The steps to be followed in strategic planning include the following:
1. Organization vision and mission
A-Vision describes what the organization hopes to be in the future. It spells out the highest ideas and wishes and is a drive
for continuous improvement
Ex: We believe that we are on the face of the earth to make great products and that's not changing. Apple’s vision
B-Mission: statement of purpose and main services of the organization and how it will be offered
Ex: to bringing the best user experience to its customers through hardware, software, and services. Apple’s mission
2.Organization situation analysis Strengths, Weaknesses, Opportunities, and Threats Challenges (SWOT/SWOC)
3.Problem solving
a. Identify the problems (the difference between the present and the desired situation)
b. Prioritize the problems
c. Establish goals and objectives
d. Select solutions
4. Put an action plan (consider organization stability)
5. Implement, monitor and evaluate
6. Update your plans

* THE IMPLEMENTATION FUNCTION

Organizing / Staffing/ Directing &leadership / Coordination &team build / Recording & reporting / Monitoring /Supervision
1. Organizing Structure: The framework in which the organization defines how tasks are divided, resources are deployed,
and departments and staff are coordinated.assigning tasks, grouping tasks into departments,delegating authority,
and allocating resources across the organization.
During the organizing process, managers coordinate employees, resources, policies, and procedures to facilitate the goals
identified in the plan.
2. Staffing helps in placing right men at the right job. It can be done effectively through proper recruitment procedures and
then finally selecting the most suitable candidate as per the job requirements.
3. Directing & leadership a process in which the managers instruct, guide and oversee the performance of the workers to
achieve specific goals
- Leadership The art of influencing people so they will strive willingly to achieve the group goals)
- Characteristics of a leader: Personal Honesty - Ability to delegate - Communication- Sense of humor - Confidence
Commitment - Positive attitude - Creativity- Ability to inspire - Intuition - Courage - Caring - Optimism - Self-control
- Leader vs Manger
Manger Leader
Do things right Does right things right
Relies on system Relies on people
Manatins work Develops work
Count on control Count on trust

4. Monitoring - Maintenance of regular checking of ongoing activities or programs with respect to defined objectives.
Record actual activities and detect possible deviations /The purpose is to record what the system is actually doing at
present
Monitoring includes: 1-work process / 2-staff performance,/ 3- service achievement
3. Supervision To Make sure that staff performs their duties effectively via :-
- Helps, guides and trains
- Make them competent
- Keep standard of work having the necessary ability, knowledge, or skill to do something successfully.
EVALUATION
- Judgment of values based on measuring or assessing the achievements of program activities and Measure program
effectiveness and efficiency
Conducting evaluation
- Describe the program,
- Determine the overall goals and specific objectives of the programme/project.
- Identify the indicators to be used.
- Develop the evaluation design.
- Collect data Analyze and interpret these data
- Utilize the evaluation results in decision making for corrective actions.

Evaluation uses Indicators

- Indicators Measuring Efficiency includes: input, process, and output indicators.
- Indicators Measuring Effectiveness include: impact and outcome indicators. The sources of data are vital statistics and
programmatic community-based surveys.
- The sources of data are service statistics at the health organization level e.g. MOH and its facilities.

Input indicators:
• Measure the resources of the organization (e.g. MOH).
• Measure whether the used resources are satisfactory or not .
- Examples: number of health units /100,000 population and number of MOH physicians /10,000 population.
Sources of data are MOH documents.

Process Indicators:
. Measure the ability of the health organization in management of the resources.
. Measure the efficiency at which the resources are managed, how the work is performed
Examples: percent of physicians trained in maternal care, percent of MOH-PHC facilities that fulfill the quality standards
according to the checklist.
Sources of data: MOH statistics and reports derived from supervision visits.

Output indicators:
• Measure the efficiency of the health facilities in management of the resources
(e.g. providing quality services) to increase the utilization/caseload at the health facility.
- Examples: average number of ANC visits per mother

Outcome Indicators:
• Measure the effectiveness of the program in achieving its strategic/ programmatic objectives.
• Measure the population knowledge, attitude and practice/behavior related to the health program
• Measure the direct effect of the health services on the community. - Influenced by the ability of the health system in
covering the population with health services.
- Examples: percent of children 24 months old who are fully immunized.
Sources of data :community based surveys.

Impact Indicators:
• Measure the effectiveness of the health program in achieving its goal. - Reflect the health status of the community
(morbidity and mortality) and fertility
• Measure the indirect effects of health services in achieving the goal - Reflect the role of both the health sector and other
health-related sectors in achieving the health goals which need multisectoralapproach.
• Influenced by socioeconomic and cultural characteristics of the community
- Examples: Maternal mortality ratio, Infant mortality rate and total fertility rate.
II. QUALITY MANAGEMENT
- The Degree of adherence to pre established criteria or standards
- Doing right thing right first time and every time
- The British standards institute: the totality of features and characteristics of a product or service that bears on its
ability to satisfy stated needs

- Dimensions of Quality in Health Care are aspects that quality of service should be assessed and improved within.
1. Accessibility availability timely financialy and geagraphical and are able to meet the patient's needs
2. Acceptability/patient-centered the preferences, needs and values of patients and the cultures of their communities.
3. Competency ability of provider to produce satisfactory service to customers.
4. Continuity Electronic The coordination of needed services for a patient, as an unbroken sequence of services.
5. Effectiveness: the degree to which the care is provided according to evidence base to achieve desired (objective)
6. Efficiency: cost effective resourcing (optimized use of resources to achieve objective (patient satisfaction)
7. Equity refers to faimess in dealing with the clients.
8. Prevention/Early Detection The degree to which interventions, including the identification of risk factors, promote
health and prevent disease.
9. Safety the provision of services that do not harm the patient or the providers, or expose them to any unnecessary risk.
10. Timeliness The degree to which needed care and services are provided to the patient at the time they are needed.

Customer Satisfaction
is a major component of a quality management system.defined as the meeting of the requirements of the customers.
A customer is any person or organization that affects or is affected by the service/ process.
Customers are:-
• External customers: e.g. patients, contracting companies, suppliers.
• Internal customers: those are people working inside the healthcare e.x doctors, nurses, administrators.

Quality control
- The management system for initiating and coordinating ;quality development, quality maintenance and improvement
in the various aspects of achieving the customer satisfaction and economical production
- Are Operational techniques (measures) aimed at monitoring process and eliminating causes of unsatisfactory performance
- Its preventive rather than detective
Objectives of Quality control Reduce errors & Enhance quality and productivity & Inspire effective teamwork
- Create problem solving capacity & Develop greater safety and awareness environment & Cost reduction

Accreditation is a formal process by which an authorized body, either governmental or nongovernmental, assesses and
determines whether a healthcare organization meets applicable, predetermined, and published standards.

Quality Assurance (QA): Steps for Quality assurance contains all planned and systematic actions required to provide
adequate confidence that a product or service will satisfy given requirements for quality.
Steps for quality assurance cycle:
1. Develop a plan taking into consideration the elements for QA.
2. Set standards include: - practice guidelines - administrative procedure, rules and regulations - specifications -
performance standards;
3. Communicate standards for the people concerned to conform to.
4. Monitoring of implementation; Auditing
5. Identify problems, and put priorities and Define the problems and Choosing a team to solve the problem;
8. Analyze and study the problem to identify the root causes (data collection, analysis and presentation, Fish-bone diagram);
9. Develop solutions and actions for quality improvement;
10. Implement and evaluate the quality improvement efforts.

Auditing is the process of assessment of financial, operational, and strategic goals and processes in organizations to
determine if they are in compliance with the stated principles and regulatory requirements.

Primary prevention is reflected by doing the things right the first time. This is achieved by conforming to STANDARDS.
Secondary prevention is by avoiding repetition of defects This is achieved by AUDITING.
- Auditing is done periodically whether there is defect or not or when something goes wrong (malpractice, adverse event)
- Auditing is a problem solving process. and must involve everyone who might have contributed to the problem.
- Auditing involves the whole system. We have to examine the Structure / inputs, Process, and outcome.

Auditing can be Internal : auditing by the working team , usually the quality team of the organization
External: auditing by a team from outside the organization, usually as a part of accreditation
Total quality management: Managing a service or process to ensure complete customer satisfaction at every stage,
internal and external, first time and every time
- Its preventive (not to detect problems) and proactive (not reactive)
Continuous quality improvement It’s a management system for quality management system
Is the process that evaluate how an organization works and ways to improve its processes to meet standards

III. PATIENT SAFETY (Protect Patients from Harm)

- It is the reduction of risk of unnecessary harm associated with health care to an acceptable minimum
- it applies safety science methods to achieve a trustworthy system of health care delivery
- It minimizes the incidence of and maximize recovery from adverse effect(medical errors) Finally to achieve the vision of
“safety and quality to every person every where”
Patient safety risks in health care
Infection & Communication & Diagnosis & Management & Medications, Medical devices & Equipment Care &Accidents
Hazards of health care
- In 1990s many countries reported increasing numbers of patients harmed and killed due to health care errors estimated by
1 in every 10 patients around the world .44000 to 98000 preventable deaths annually due to medical errors
- 7000 of them related to medication errors alone
- In 2004 the WHO called patient safety as an endemic concern; it identified six action areas and developed solutions to
improve patient safety by achieving six important goals for patient safety.
International Patient Safety Goals:
Goal one: Identify patient correctly:
- use 2 identifier (not by room or bed) before receiving any medical products or procedures
E.g bracelet with a bar code and full name
- Do not use the patient room or bed number to identify the patient
Goal two: Improve effective communication among health care team:
- Verbal or telephone orders verify the complete order (have the person read back the complete order)
- Don’t use abbreviations and symbols that can cause confusion (list them)
Goal Three: Improve the safety of using medication:
- Enlist look-alike drugs to prevent interchange of these drugs
- Label medications and containers in all procedure settings and prevent error involving the interchange of these drugs. .
Goal Four: Eliminate wrong site, wrong-Patient, and wrong
- Preoperative verification (documents)
- Surgical site marking (patient involved) before anesthesia.
Goal Five: Reduce the risk of health care --acquired infections
- Hand hygiene guidelines & Prevent Central line infection & Prevent Surgical site infection
Goal Six: Reduce the risk of patient harm resulting from falls:
-Fall reduction program implementation and evaluation

Health Informatics: It is the Collection, Processing, Analysis and Transmission of health information requird for:
organizing and operation of services & research & training
- Developing the HIS is a priority for Egypt in its efforts to achieve UHC
Types of health information
- Demographic data: age and sex population size, marital status
- Vital statistics: morbidity, mortality and fertility rates
- Health status rates: quality of life, risk factors, life style
- Health care statistics resources: facilities, beds and manpower & Utilization of health system & Outcome of medical care
Sources of data
1-Surveillance system: is the analysis of health related data about a clinical syndrome that has a significant impact on
population to timely detect or anticipate diseases outbreaks
Examples: poliomylities & Hepatitis & Malaria & T.B
2-Population ( community) based
- Censuses: (count the population every 10 years)
- Vital registeration system: (health offices of MOH allover the country)
- CAPMAS (central agency for public health mobilization and statestics)
- Household surveys (Egypt demographic health survey EDHS)
3-Institution based
- Institution & hospital statistics & Utilization records & Services records Hospital death & Hospital infection
Benefits of HIS
- Help decision makers to detect and control emerging and endemic health problems ,plan for services, education and
economy ,achieve universal health coverage
- Help improve quality of services
Strengthening evidence base for effective health policies and Research field
HEALTH ECONOMICS is the study of how people and society choose to employ resources, usually scarce / limited
resources. Economics analyze the costs and benefits. is the application of economic principles to the health field.
- It is an important component of health management as :
To formulate health services.
To establish the true costs of delivering health care.
To evaluate the relative costs and benefits of particular policy options.
To estimate the effects of certain economic variables on the utilization of health services.
Maximising the benefits from available resources.

Economic Evaluation
Cost minimization Analysis: It compares the costs of different interventions that are assumed to provide equivalent
benefits. The decision is targeting the least expensive way of obtaining the health benefit.
e.g. : comparison between a generic drug and its branded equivalent.
Advantages: It is easy and simple
Disadvantages: it may be invalid.

Cost Effectiveness Analysis:

(CEA) is designed to compare the costs and benefits of a healthcare intervention to assess whether it is worth doing.
In CEA the benefits are expressed in non-monetary terms related to health effects, such as life-years gained, symptom-free
days, lives saved or cases prevented.
Cost-effectiveness analysis must be conducted with interventions or programs that impact the same health outcome. For
example, you could compare two programs designed to prevent overweight or obesity, where one program focuses on
physical activity and the other focuses on nutrition.
Advantages:
It is used when the programs may have differential success in outcome, as well as differential costs, but the outcome must
be common in both programs.
To find the most efficient treatment option in terms of cost per unit effect.
Disadvantages: It can not be used to assess a single program or to compare interventions which have several different
clinical effects.

Cost Utility Analysis: It can be used to assess costs and benefits of health technologies.
Benefits are measured in terms of QALYs (most common) and DALYs
QALYs = Quality Adjusted Life Years
DALYs = Disability Adjusted Life Years
CUA = COSTS / QALYs gained or DALYs averted
CUA is a method of choice when quality of life is an important outcome.
Also, it is an ideal method when treatment have a wide range of different outcomes and a common unit is required.
- In QALYs, benefits are measured based on impact on length and quality of life to produce an overall index of health gain.
A health state is valued between 0 (worst health) and 1 (best health) combined it with the length of time in that state.
For example, a drug that yields an improvement in health state value of 0.6 over a period of 10 years would yield 6 QALYs.
- DALYs for a disease are the sum of the years of life lost (YLL) due to premature mortality and the years lost due to
disability for incident cases of the health condition.
DALYs = YLL + YLD
Advantages: - Allows comparison across different health programs and policies by using a common unit of measure
(money / QALYs gained).
- Provides more complete analysis of total benefits than simple cost benefit analysis.To evaluate the effect of a nursing
intervention on patient outcomes when one of these outcomes is Quality Of Life.
Disadvantages:- Elderly individuals are assumed to have lower QALYs since they do not have many years to influence the
calculation of the measurement.
- Specific health outcomes may also be difficult to quantify → difficulty to compare all factors that may influence an
individual ‘s QALYs.

Cost Benefit Analysis

-In a Cost Benefit Analysis, attempts are made to value all the costs and consequences of an intervention in monetary terms.
- It seeks to place monetary values on both the inputs and outputs. i.e. treatment costs and consequence costs.
- This allows a direct comparison between the costs of the intervention and the value of the benefits to see which is higher.
e.g.: the impact of a Triptan at a cost of £ 4 per attack in the treatment of migraine found an economic gain in
terms of work absence saved of £ 12.50