Knowing the current state of the system is important to detect the barriers to overcome in its future projection. To this end, and in coincidence with the proposals of Nogueira Rivera (2002), the procedure to diagnose the situation of the organizational management control, adapted to the characteristics of hospital organizations, is resumed. This phase is completed with the use of anonymous questionnaires and independent interviews with members of the workforce, as well as the collection, analysis and processing of information, to answer the following questions: where are we now? Where do we want to be? What do we need to do to get from here to there?
Introduction
Management Control as an important function of the Administration, has evolved over time, as the organizational problem raises new needs (Blázquez, 2000). Likewise, the tools used for this purpose for decision-making should also do so. Management Control moves in three dimensions: strategic, operational and economic; where the company configures its strategic decisions, through internal and environmental analysis; It evaluates the implementation of decisions operationally, verifies compliance with procedures and processes and performs economic analyzes, based on an efficient, timely and effective information system (SI) that allows the correction of deviations and their monitoring.
In the design of service processes it is important to have an underlying structure. This structure or conceptual framework was suggested by Albrecht and Zemke (1985) (referred to in Schroeder, 1992). This conceptual framework, that is, the services triangle, presupposes that there are four elements that must be taken into account when producing services: the client, the people, the strategy and the system.
The client is, of course, in the center of the triangle because the service must always be centered on the client and the lines that connect it to each of the points indicate that direction towards the client. People are the employees of the service company, they must be aware of the strategies that the organization has outlined. Strategy is the vision or philosophy that is used to guide all aspects of service delivery and the system (on which people depend to provide the service) includes both the physical system and the procedures that are used.
These concepts are a very interesting way of considering service operations, and at the same time, useful for designing service systems and for solving existing problems in them; that's why the service triangle can also be used to diagnose service problems and determine what causes poor service.
The study of different management and control models (Buffa, 1987; Drudis, 1999), De Miguel Fernández, 1991; Nogueira Rivera, 1997 / b /, Royero) and as a function of Management Control (Lorino, 1993), denotes the growing tendency to give diagnosis an important place as a prelude to the control and management of business systems.
Development of the proposed procedure
Stage 1 Diagnosis of Management Control
The analysis begins with the dimensions of management control that includes the following elements:
Strategic dimension
1. Strategic course: It constitutes a premise for the application of the model, therefore, it must be specified if the organization has carried out the strategic exercise adequately. The SWOT analysis could be the reference for this analysis; This constitutes the tool par excellence for the definition of strategies based on the analysis of internal potential and study of the environment. There are other tools such as the SISTRAT methodology (García Falcón & Osorio Acosta, 1998, p.58), easy to use by small companies without the help of consultants, which allows a comprehensive study, since it offers, in addition to the analysis of the general and specific environment of the organization, an internal analysis that includes the value chain, internal resources and capabilities. For hospital institutions it could be of help,as long as it suits their conditions and characteristics.
2. Leadership: It is essential for the success of the changes in the organization, since the involvement of the management team and above all, its top leader, is required to attract and engage all workers in the process of change and implementation of the Proposed tools to improve decision making and organizational control. Management must promote a culture of teamwork, training everyone in modern management practices and a culture of service that allows satisfying customer expectations (both internal and external), for which it must be the most committed in this process. As Krajewski & Ritman (2000, p.109) put it: “… strong leadership from top executives is required to achieve success”.
3. Product / market scope: Understands the essence of the target audience for which the organization is oriented (patients, geography and other segmentation variables). Case mix analysis could be useful in this regard.
4. Identification of the key success factors: They represent a reduced number of key indicators (linked to the mission) such that, if they show satisfactory progress towards the objectives, a positive performance will normally be perceived in the improvement path.
Operational dimension
1. Resources: It comprises the base of the resources that the organization has, unique and specific resources that can be from each organization in particular. These resources include, not only the assets the organization owns, but also what it “knows” (key competencies), the skills and capabilities of human capital as the primary source of value creation.
2. Tendency to decentralize: In the sense of making business units smaller and smaller to achieve greater capacity to adapt to the environment, through not only a rapid response, but also a successful response, because you are much closer to the problem and, consequently, you have a better understanding of it.
3. Identification of key processes: Represents the identification and familiarization of workers with the internal processes of the organization, is what the people of the organization “do” (Hamel, 2000, p.80). This element is deepened in the procedure adapted from Nogueira Rivera (2002) for the management and improvement of hospital processes.
Economic dimension
It includes, not only the periodic calculation of financial ratios from the information provided by the financial statements, but also other indicators, so that they allow the organization to project itself into the future, by analyzing its behavior over time (trend) and the application of benchmarking (internal and / or external), as a necessary requirement for a continuous improvement process. In the Cuban hospital case, although some of these financial ratios are not managed, the cost and activity analysis are relevant to assess and diagnose the efficiency of their actions given by the rational use of their resources, a prevailing need in these systems, due to elements provided in Chapter I.
In parallel, a procedure for diagnosing the service system is proposed, based on the triangle of services. As discussed above, it provides an important tool for the diagnosis and design of service operations. In this case, a procedure is proposed (Figure 1) with the aim of diagnosing the situation of any service organization.
Stage 2. Determine the degree of customer satisfaction with the service offered.
Step 1
The center of the triangle is the customer, all organizational efforts are aimed at achieving their satisfaction, determined by the fulfillment of their expectations and can be measured using different tools.
In health, this important issue of quality attributes has been studied and there is consensus with the attributes that tools such as SERVQUAL proposes, Elias, J. and Alvarez, J. (1998) state that, the satisfaction of a patient is given by the perceptions you have in each of the sections of a tube known as satisfaction. These sections are:
- Reliability: it is the level of effectiveness that the client user expects to find, based on the explicit and implicit promises made previously about the service provided by the organization (from a hospital it is expected to treat patients but if it also has a reputation as a good hospital, it is expected that do it with high effectiveness). Relative weight granted 32%. Sensitivity: it is the expectation that the service will be received at the appropriate times. Valuation of time as a scarce resource, quota of respect for the time of customers. Relative weight 22%. This attribute measures in the servqual through the response capacity or accessibility. Tangibles: it is the assessment that the client will make of the physical appearance of the people; the installations; cleanliness and order are also considered “tangible”. Relative weight 11%. Assurance:it is the perception of courtesy and professionalism transmitted by professionals (by everyone, not just those who directly serve). Relative weight 19%. In the servqual this attribute is appreciated under the name of Security. Empathy: it is the client's perception of the accessibility, communication and understanding of all the personnel of the organization. Relative weight 16%.
This could be a reference tool that, together with SERVQUAL, would allow determining the satisfaction of patients and professional and support staff.
Step 2. Determine the causes of dissatisfaction, linked to the vertices of the triangle of services.
Once the degree of customer satisfaction is known, the measured differences will reveal where the problems are, what quality attributes fall short of customer expectations.
It will be known what is wrong, if the effectiveness, the comfort of the facilities, the professionalism of the staff, the hygiene of the place, the response time, etc. and therefore carry out a system diagnosis.
Furthermore, if there are problems with gap 1 of the SERVQUAL tool, this means that managers are unaware of customer expectations and, therefore, the organizational strategy is not geared towards it.
On the other hand, if there is no good standardization, it means that the strategy has not been deployed based on service processes, by defining operations objectives with their corresponding policies and system of indicators that allow measuring the results achieved and based on this, establish feedback.
If there is no good compliance with the standards, it may be because there is no adequate control, because there is no good compensation and recognition system, and therefore the staff does not feel committed to the results or motivated by their activity.
As a way to make a more accurate diagnosis it will be necessary to implement the following steps.
Step 3 Determine the existence of problems regarding the strategy.
The operations strategy must be derived from the organizational one and result in a consistent pattern in decision making. For the analysis of this aspect, the following questions should be followed:
1. Is the strategy defined in the organization?
This defines where the organization is headed. It is important that the system strategy is defined before formulating the operations strategy, that is, of the different services: clinical, healthcare.
2. Was the involvement of the internal and external environment taken into account in the formulation of the strategy?
To formulate a global as well as an operations strategy, it is necessary to make an analysis of the internal and external environment (clients / patients based on the typology of cases (case mix), economy, technology, conditions of society. In the external case These may occur: an increase in health problems, changes in the demand for the workforce, customer needs, the emergence of new technologies or new scientific knowledge that may vary clinical practices. Internally, this is seen in the availability of resources, the culture of the organization, the capacities and abilities of the workforce, the types of control used The operations strategy seeks to resolve weaknesses and increase existing strengths.
3. Is the mission of the operations strategy defined?
The mission defines the purpose of the operations function in relation to the organizational strategy. You must declare the priority among the operational objectives: costs, quality, delivery time and flexibility. It will often be a restatement of the organizational strategy in terms of operations and derived from it directly.
4. Are the key result areas defined?
Those that contribute the most to the successful fulfillment of the mission and strategies of the organization. They must concentrate the greatest efforts, analysis and use of resources available to the system.
5. Are the objectives of the different services and processes established?
Schroeder (1992) states that there are four possible objectives in operations: cost, quality, delivery time, and flexibility. These should be expressed in specific and measurable quantitative terms. They should be viewed as a refinement of mission in measurable terms. Costs must be those necessary to ensure a previously planned level of service, quality measures must contribute to patient satisfaction according to studies of expectations and needs. Delivery time refers to the ability to deliver the service at the place and time that the client / patient needs it. It can be flexible through the innovation of new health products or in a quick response to changes in technology, clinical practices or the environment in general.
6. Are the operating policies to be followed in the organization outlined?
Policies define how the objectives of operations will be achieved. They must be developed for each of the five decision-making categories: process, capacity, inventories, workforce, and quality.
7. Are the results measured and do you provide feedback?
Results are measured in terms of objectives, if these are unsatisfactory, management may change tactics or strategy. This information closes the loop and provides feedback on the results of the selected strategy. In this step, it is important to identify global indicators used to evaluate the operation of the hospital, and what are the objectives.
8. Does the strategy respond to the real needs of the client?
Nothing is solved by having everything very well established if it is not effective, that is, if it is not what the client really wants. Therefore, to answer this question, it will be necessary to know the expectations of the clients, and verify their degree of involvement in strategic planning.
9. Is the customer aware of the actual service provided by the entity?
Sometimes clients create false expectations of a certain service due to lack of knowledge of it. For this reason, the organization must communicate its service offers to its clients. What does the organization provide that is unique? Why should the client trust this service? In other words, give distinctive elements to the client that motivate him or her at the same time. Know and do not expect more than what is really provided.
Any problems that arise in the answer to these questions will indicate deviations in the treatment of the strategy.
Step 4 Determination of problems concerning people.
Consideration should be given to involving the employee in the organization's mission and feeling that they are going to be successful and worthwhile for them.
Once these two elements are resolved, the ¨ ship will conduct itself ¨, this implies autonomy, the worker must be free in his actions, he will make the decisions based on the client; while preserving the interests of the organization.. This is in correspondence with the characteristics of the hospital service, where the staff is specialized and empowered to make decisions in the process of patient care and treatment.
For diagnosis, answer the following questions:
1. Are the staff aware of what the customer wants and of the organizational strategy?
Not only the people who provide the service, but all the people in the organization have to have their sights set on the customer, because when they don't have to provide customer service directly, they do it to someone who will. People are the most important element in providing a higher level service.
Often, the people who provide the service are divorced from the strategy and poor service is provided as a result. In order to answer this question, it is proposed to apply surveys to workers where they are asked about elements related to the strategy, strategic planning of the place and thus determine if they know it or not.
2. Are the suitable personnel for each position?
A fundamental element to offer a good service is the professionalism of the staff that provides it, seen through the knowledge that they have of their subject, the ability and dexterity, the ethical-moral qualities, level of education, acquired training, etc. It is recommended to review the job profiles or the profesiograms in case they are elaborated in the organization, with the aim of verifying the correspondence of the requirements demanded by each position and the real characteristics of the personnel that occupies them, to detect the existing nonconformities. In this case, it is important, then, to know the competences that the worker has to exercise the activity and if they correspond and are taxed to the mission of said process.
3. Are the staff motivated by the activity they carry out?
Motivation is a fundamental factor for the good performance of functions. Maslow's hierarchy of needs states: people are motivated to satisfy different types of needs classified in a certain hierarchical order.
To determine the degree of motivation, according to these needs, the application of surveys is recommended.
Step 5 Detection of problems related to the system.
Service systems must be designed simple, fast, people-proof and capable in their operation, as people depend on a good system to provide good service. For a system to be considered good, it must be derived from the customer's needs and the organization's strategy. For example, a bad location of the facilities and equipment or an inappropriate procedure that makes the customer wait too long could lead to dissatisfaction. For this, a plan of the organization or area under study is recommended to determine the distribution of the facilities and therefore the distances the customer has to travel. This together with the flow diagram that allows studying the procedure followed in the delivery of the service, and determines the bottlenecks, the waiting times,and therefore define the deficiencies of the system and possibilities for improvement.
Therefore, the diagnosis of this aspect will be made by answering the following questions:
1. Is the service system adequate?
2. Is it in correspondence or is it derived from the strategy?
3. Is it within the reach of the organization's staff?
4. Is the system designed to be flexible and responsive to change?
Added to the above, the elements contributed by Hernández Torres (1998) are taken up for the diagnosis of Management Control (Table 1), previously analyzed the correspondence of these terms with the services studied and the corresponding adaptations made:
1. Customer focused organization.
2. Leadership.
3. Work environment.
4. Participation of staff.
5. Focus on the process.
6. Continuous improvement.
7. Relationship with suppliers.
8. Information technology.
9. Cost and value analysis.
10. Management control
How to evaluate the questions:
If your answer is positive with respect to what the question questions, it will give you a score of (5), if it is negative, it will give you a score of (1). If what is questioned is met to some extent, relate this level of compliance to any of the values between (1) and (5).
