In no other public activity is the outcome as dependent on efficient management as it is in healthcare delivery. It is therefore completely astounding to note the sparse attention that has been accorded to the crucial discipline of hospital management. Only in the last two decades has the specialty been extended the legitimate attention that is its due.
This apathy has been historically global. Hospital administrators were looked upon with a degree of disdain. Most of the hospital superintendents in my medical school days (more than four decades ago) had gravitated to that position after a prolonged clinical career when it was presumed that they had acquired all the skills necessary to function effectively as administrators. The need for specialized training was completely unappreciated. In fairness some of them did demonstrate efficiency but for most it was a welcome sabbatical from years of clinical overload.
Some of the top hospitals in the country had taken to appointing retired senior services personnel in the belief that their stint with the armed forces equipped them with the requisite know-how to run a hospital. Brigadier (Dr) Gaind was the Hospital Administrator at the All India Institute of Medical Sciences for years and by all accounts he did an excellent job. He was an ex Army Medical Corpse Man but the interesting part is that he did not have any formal training as a hospital administrator. Brigadier Ghufran who headed the Tirath Ram Shah Hospital was not even medically qualified.
The important question that had remained unaddressed in those days was whether it was necessary to have a medical background to function as a hospital manager and an administrator. To a large extent, that question is still open not just in India but worldwide. The Griffith Report in the United Kingdom encouraged clinicians as well as non-clinicians to take up managerial responsibilities within the National Health Service way back in the late 1970’s and early 80’s. Collating the results from this experience, it is still unclear whether the medically qualified functioned better than the non-medically qualified. Somewhat similar situation exists in North America where in most states health service management has been the domain of qualified nurses and social workers.
Having said that there are some very good Hospital Administration/Management programmes in the US that have been operational for the last four decades. There are more than 50 that have sprung up in the last twenty years. The choice therefore remains with the physician should he/she wish to divert to management or acquire healthcare managerial skills which may come in handy in clinical healthcare delivery. The author of this review did precisely that when he enrolled for a part-time healthcare management MBA while in the US — at a pretty late stage in his career.
Things also seem to have moved on in India though not at the pace needed. With the rapid proliferation of a private nursing home culture in addition to sophisticated multidisciplinary hospitals in the major metropolitan cities, the need for efficient hospital managers is acute.
It is towards this end that Dr Joshi’s book has made a seminal contribution. It has already moved on to a second edition, which is the one I am reviewing. I am at a loss though as I have not had the opportunity to peruse through the first edition as it was released when I was still abroad. But anyone perusing through the second edition with meticulousness would be left in no doubt that hospital management is a skill that has to be formally learned and a medically qualified person has an advantage over the non-medically qualified person as a hospital manager. Dr Joshi, without actually stating this, makes it very clear.
The book is in six parts dealing with the intricacies of every aspect of hospital management. The Part-3, which deals with accreditation, and the Part-4, which elaborates quality management in all its dimensions, are specially noteworthy and I would so far as to say that the erudition evident over there makes this volume score over others available in India on the same subject. Being a historian of medicine, I also found the adumbration of the history of hospital management as a specialty internationally most interesting. Dr Joshi has also included some very useful annexures towards the end, which are very useful.
The techniques of quality management viz. Lean Sigma, Kaizen and Quality Circles (which should be known to every medical practitioner but is not) have been explained in a very simple manner.
All in all, the book is eminently readable and superlatively informative without being tedious.
The major problem that I personally had was the absence of elaboration of quality management skills needed while providing mental healthcare in India. This omission was surprising, as lack of emphasis on mental healthcare has resulted in a national crisis which needs to be addressed very soon. Readers would agree that the quality of mental healthcare available in India leaves a lot to be desired. I would sincerely hope that Dr Joshi would address this shortcoming in the next issue.
I would highly recommend this volume to every medical school/hospital library. I would also like a copy of this book to be available to the Minister for Health. I have been a long-term advocate of including hospital management in the medical curriculum and as a part of internship training. Managerial skills are mostly acquired and do not spring up spontaneously. And with the pace at which healthcare sector is proliferating, need for medical managers is acute.
Dr Joshi needs to be felicitated for commendable service rendered by him through this second edition.
Quality Management In Hospitals (2nd Edition)
Author: S K Joshi
Paperback: 464 pages (Rs 595)
Publisher: Jaypee Brothers (2014)
Reviewer: Dr Ashok Jahnavi Prasad