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Journal of the Academy of Hospital Administration

Job Redesigning - Key To Cost Containment and TQM in Hospitals

Author(s): Sanjay Kumar Arya*, DK Sharma**, Shyama S. Najarajan***, Vipin Kaushal****

Vol. 15, No. 1 (2003-01 - 2003-06)

Key Messages:

  • Understanding the Australian experience in job redesigning as key to cost containment in hospitals is relevant for application in Indian hospitals.
  • Creation of a new generic classification of hospital workers - Patient Care Assistants - increased patient admission and productivity and decreased recurring costs.
  • There is need to create a new generic classification of workers in Indian hospitals called "Trained Hospital Assistant".


Today's consumer driven market has not left the healthcare sector untouched. Patient satisfaction and therefore value for money is the buzzword. However, an eagles eye view of the various causes attributable to lack of quality care in our hospital, brings out one of the factors to the forefront, is the lack of general upkeep of the hospital and the huge investment on the manpower. An Australian study has shown light in this area by successful implantation of the job redesigning programme. The present article aims at understanding the Australian experience vis a vis its implication in the Indian hospital context.

Keywords : Job redesigning, Patient Care Assistant, Trained Hospital Assistant


The hospital is an indispensable part of our health care system, which predominantly provides curative health care service. Although hospitals seem to occupy a very small part in overall health care system in terms of number, but these in fact take a major chunk of expenditure on health care and also marks the reputation of health system. The role of hospitals in the health care system can be fortified by the fact that in the total medical care infrastructure, the Primary Health Centres (PHC) and Subcenters, which predominantly provides preventive care are 1,85,855 in number and the secondary and tertiary level hospitals constitute 18,101 in number. Whereas, the hospitals constitute approximately 1/10th the number of infrastructure in the total health care system it constitutes more than 30times (665, 639 beds) the number of beds as against 24,803 beds in the preventive care setup (CBHI, health info India, 1997-98). Inspite of the larger bed strength the Secondary and tertiary level care pulls only 45% of total public health investment (5.2% of GDP) as against 55% spending on PHC (NHP-02) 1.

Therefore, society looks upon hospitals for their welfare and it is the duty of hospitals to meet this demand. However, with the rising cost of health care service, the hospitals have to carry out their functions effectively and efficiently so that, appropriate quality, of care is provided at a cost acceptable to the Society. Cost effective therapy has further become imperative because, out of the Rs. 86,000 crore health care industry Rs. 69,000 crore is out of pocket spending 2 and with insurance at the corner has made the market consumer driven. This is one of the many factors, which can be attributed to a consumer driven health care industry. The other key factors being-increased consumer awareness, improvement in buying capacity, medical services coming under the ambit of Consumer Protection Act and the introduction of Citizen Charter.

All these factors have made people more aware, demanding value for money and thus putting pressure on hospitals and health care institution to provide health care at reasonable cost. Today's ultimate quality benchmark is patient satisfaction.

Relationship between Quality and Cost

Needless to say that when we strive for quality it automatically brings down the cost of care. The success story of industrial sector has not left the health sector untouched in the era of resource crunch. Limited resource available has to be stretched to meet the unlimited needs. The Darwin's theory of Natural Selection and the Survival of the Fittest has time and again proved itself. Thus even in the health care industry, today quality means not just good service but cost effective and efficient service.

An Observation

Existing Scenario - In our country, scenario is not very encouraging. Our hospitals are not able to keep pace with developments outside and not able to provide services to the satisfaction of population. This is amply demonstrated by frequent adverse report about functioning of hospital in the media and also increasing cost of health care services. This is because of the dual problem- the recipient of care and the provider of care. The population (recipient) does not know as to what they should expect from a hospital. Hospitals (provider) lack system to get feed backs from the patients and their relatives about the services being provided. Many hospitals have no system to record and attend to grievances of the clientele, thereby shutting doors to any further development.

Therefore, to assess the quality of care provided by hospital a randomized study was concluded by a voluntary agency on "working of private, government hospital". Of the various criteria used in the study, a few were:3

  1. How hospitals address patient grievances?
  2. What are the major concerns / problems faced by patients in these hospitals?

Some of the findings of this study were as follows:

I. Patient Grievances Redressal System

  1. 57% Hospitals claimed to have complaint box while actually only 27% hospitals had these in position.
  2. Only 15% hospitals had a proper manual describing how a complaint is to be received and dealt with.
  3. Only 6% hospitals had boards displaying to the general public as to how they can lodge their complaint or get their grievances redressed.

II. Nature of Complaints

A. Private Hospitals: Percentage wise, top three complaints were as :

  1. Poor Sanitation 43%
  2. Inadequate Hospital Utilities 41%
  3. Improper Billing 8 28%
    (* only 17% of hospitals had displayed their price list)

B. Public Hospitals : Percentage wise, top three complaints were as:

  1. Poor sanitation 41%
  2. Inadequate hospital utilities 30%
  3. Complaints related to inadequacy of medical care 26%

Another study by Srilatha in Public Hospital in India revealed that poorly maintained toilets and lack of general cleanliness in the hospital was one of the major causes of patient dissatisfaction, with no major difference across the category of patients old / young, gender, education and economic status 4.

Another patient satisfaction survey by Institute of Health Systems in Dec. 2001 on 30 hospitals managed by Andhra Pradesh Vaidya Vid Parishad (APVVP), with a sample sizes of 1382 inpatients revealed similar results. Although composite scores of patient satisfaction level was at 71%, 36% of respondents did make adverse comments on the general cleanliness, shortage of drug supply and toilet maintenance 5.

From the above studies it is evident that, people in general are dissatisfied with the services of both govt and private hospitals i.e. utilities being provided and general upkeep of the hospitals. Hospitals at present are not responsive to patient's basic need. Patients are paying, but they are not satisfied with the returns i.e. they are not getting value for their money.


Experience of Australian Hospitals
Few of hospitals in Australia experimented with a new approach to achieve the objectives of quality and cost containment. This approach was based on observation that the patient care units in hospitals are staffed with many categories of health care workers doing different jobs like Cleaning staff, Ward attendant, Catering staff, Porter etc.

This arrangement typically results in:

  • Overstaffing
  • Inflexibility in deployment of staff
  • Overlapping of authority
  • Difficulty in coordination
  • Lack of sense of responsibility and involvement in patient's care

This organizational scheme (fig. 1.) was found to be responsible for increased cost, inefficient management system resulting in poor quality patient care. It was felt that rigid demarcation of work creating different categories of staff akin to the patterns of manufacturing industry sector was responsible for this.

Therefore, there was a consensus that the hospitals have to redefine the job design of these categories health care workers in hospitals. It was further envisaged that, by replacing the various categories of workers with only one generic classification of multiskilled workers, the patient care processes can be managed effectively and efficiently resulting in improved patient satisfaction.

Figure 1: Organisational Structure before redesigning

missing image

To achieve this, a detailed job analysis was carried out and assessment of skills and training required to impart these skills were worked out. Proper selection and multiskilling of manpower was carried out by giving appropriate training, thus promulgating the creation of a new generic classification of hospital workers, called as 'Patient Care Assistants'. The new category of personnel was redeployed on a unit basis (Fig.2).

Figure 2: Organisation Structure after redesigning

image missing

This experiment had shown very encouraging results in the form of

  1. Increased patient admission
  2. Improved productivity in terms of revenue generated
  3. Decreased number of staff over the period
  4. Decreased recurring cost over the period

Experience in our country - Multipurpose Health worker Scheme

In our country too the reforms on the similar lines were done. The most pioneering and successful rural health care model in India has been that of Dr.Arole in Jamkhed, Maharashtra which started in 1970 on a Comprehensive Rural Health Care Project (CRHP) 6. In order to achieve effective health care, a local women in every village was identified as a "village Health worker" and was trained to be the first point of contact for the community equipped with knowledge of all preventive and promotive health related issues. A mobile team of doctors and nurses backed her for further assistance and referrals. This model was an enhancement in the health indicators of a Jamkhed at a low and affordable cost as evidenced in the Table - 1.

Table - 1 Snap shot of Basic Health Parameters in Jamkhed

Parameters/ Year 1971-project was introduced 1976 1986 1993
IMR 176% 52% 48% 19%
CBR 40% 34% 28% 20%
Children under 5 Immunisation with DPT and Polio 0.5% 81% 91% 92%
Prenatal Care 6.5% 80% 82% 96%
CPR <0.1% 38% 60% 60%

Another such redesigning was observed on the recommendation of Kartar Singh Committee (1973) all the workers under different national programs were put under Multipurpose Health Worker Scheme after being suitably trained 7.

Over the period of time this reform has proved to be a successful one and has resulted in improved efficiency in implementation of different national programmes and containment of cost.

What Should Be Done In Our Hospitals?

Our hospitals are also facing similar problems and the present system of management of hospitals also needs to be reviewed. Our hospitals at present have highly skilled doctors and nurses, but to assist them we do not have suitably qualified and trained manpower. Our hospitals are also staffed with many categories of health care workers who are neither well qualified nor trained to do the job. This situation is to a large extent responsible for inefficiencies of the health care delivery process. These different categories of personnel who come constantly in contact with patients are ill prepared to do the job, lack a sense of pride in their work and are insensitive to the needs of the patient. This present setup of patient care is difficult to manage and problems are quite frequent and difficulty is encountered in effective coordination.

These experiences at home and abroad are an eye opener. We should review the existing job designs in our hospitals and create a model based on our needs. We can also create a new generic classification of multiskilled-trained hospital workers called as 'Trained Hospital Assistant', who can then be reorganized on unit basis in the various patient care areas simulating the model in Australian hospitals. This new arrangement envisages improving coordination, improving quality of hospital services and ensuring cost reduction. This will also provide for improved job satisfaction, boosting the self-esteem of the workers giving considerable flexibility to the hospital in their operation.


Today, our hospitals are not able to provide quality care at reasonable cost. Present organization structure is costing more (more than 60% of hospital budget is spent as salaries) 7 and delivers less than desired level of medical care.

To achieve quality care and reduce cost some Australian hospitals undertook the process of job redesigning and reorganizing work in patient care unit. This experiment resulted in successful replacement of all existing categories of workers with multiskilled-trained workers designated as "Professional Care Assistants". The workers, thus assigned unit wise resulted in improved hospital working, reduced cost and improved patient and employee satisfaction.

Similar job redesigning exercise was also undertaken in our country in a different context, when working under various national programmes were converted in to "Multipurpose Health Worker". They were trained to perform different functions under various National Programs. This experiment gave encouraging results and improved overall working of health care institutions.

Therefore, there is need to under take a similar exercise of job redesigning and reorgansing the existing different categories of manpower employed in our hospital and develop a single generic classification of worker which can be called "Trained Hospital Assistant". This will enable the development of well-qualified and suitably trained manpower to carry out diverse functions. This will not only improve operational efficiency but also cut down on cost by reducing manpower and aid in improved patient satisfaction and employee satisfaction.


  1. health policy 2002
  2. Health Care in India: The Road Ahead, A report by CII-McKinsey and Company, Oct-2002
  3. Pandey Smita M. "Hospitals don't care about you." In TOI New Delhi dated 25.9.2000.
  6. Narayan Jayaprakash, Ensuring a Healthy future : Lok Satta ; Year 2002,
  7. Sakharkar, Principles of Hospital Administration and Planning, Jaypee Publishers, 1998
  8. Che Jie. Management of Medical Quality. Hospital Management International 1994, pages 108-109.
  9. Emilio F Dominguez. Care Quality and risk management. Hospital Management International 1994, pages 118-121.
  10. Tessa Brooks. Quality Improvement and Orgnisational Audit. Hospital Management International 1994, pages 105-107.
  11. William G Lawrence. Patient services assistant scheme. Hospital Management International 1994, pages 115-117.

* Assistant Professor, Department of Hospital Administration, AIIMS, New Delhi
** Additional Professor, Department of Hospital Administration, AIIMS, New Delhi
*** Manager, Investment and Information Credit Rating Agency, New Delhi
**** Dy. Med. Supt., P.G.I., Chandigarh

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