Health workforce management

Dr. Rizwan S A, M.D.,

Health workforce management‘The problem with people is that they're

only human’

Dr. Rizwan S A 3

Take home messages

• People are not ‘things’• One person can’t do everything, team work is best• Good leadership helps a team perform better• Staff should be trained to attain highest standards• Good communication will solve most problems• Supervision is indispensable• Conflicts will always arise, the trick is not to let them

interfere with work

CRHSP, AIIMS

1. Introduction

3. Leading a health team

2. Health team

Leadership

Motivating

Sharing objectives

4. Organizing health team activities

Delegating

Supervising

Job descriptions

Norms & standards

Coordinating

Communicating

Meetings

Training

5. Controlling & assessing work

Controlling

Assessing

Managing performance

Records & reports

Conflict resolution

Health workforce management

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References

• On being in charge - WHO• RCH manual for medical officer - NIHFW• Epidemiology and management for health care for all

- P V Sathe• World health report 2006 - WHO• Contemporary public health: policy, planning,

management - J. P. Gupta• Managing health services - Nick Goodwin

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Introduction - 1

• Public health workforce: people whose job is to protect and improve the health of their communities

• 80% of health budget is spent on salaries and staff benefits, hence people matter more than things

• Managing people is more complex than managing things• Things don’t think, answer back, are insensitive• People like to feel useful and appreciated and become

discouraged when ignored or unjustly criticised

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Introduction - 2

• To keep people satisfied at work, the work must be interesting and stimulating

• Working conditions, relations among team members and between the community determine work satisfaction

• Person in-charge of a health team should be sympathetic and helpful to the workers and maintain a relaxed and happy working atmosphere

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Introduction - 3

• Better health care depends on efficient management, but management depends on people and good management can help a team work together harmoniously and efficiently

• Five ways of achieving this – Setting and sharing objectives– Encouraging good personal relations– Distributing tasks– Coordinating activities of the team– Applying sound organizational principles

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Health team - 1

• Health team: group of people sharing a common health goal and objectives determined by community needs, to the achievement of which each member contributes according to her competence and skill and in coordination with others

• The team includes all those working together, even clerks, drivers, cleaners in addition to the technical staff

• Health team exists for the community

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Health team - 2

• No one person can acquire all the necessary skills and so people have to work together to get the work done

• To work well as a team, the leader and other members need skills of leadership and organization

• Characteristics of teamwork– Common binding purpose/goal– Clear understanding of each other’s functions– Pooling of knowledge– Joint responsibility for the outcome

‘Behind an able man there are always other able men.’- Chinese proverb

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Leading a health team

Leadership

Setting and sharing objectives

Motivating the team

Delegating

Supervision

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Leadership

• Ability of a manager to influence and induce subordinates to work with confidence and zeal for the achievement of organizational goals

• Theories of leadership– Trait theory: Leaders are born, not made– Behavioural theory: Leadership depends on behaviour of the

leader– Contingency theory: Leadership depends also on subordinates,

the task, the workplace situation‘Management is doing things right; leadership is doing the right things.’

- Anon

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Hersey and Blanchard's situational leadership theory

13

Meri Marji- E.g. Government

servant

Mein hoon na!!

Kya? Kaise? Kab? Kyun?…

Bhagwan barose!

E.g. Intern

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Team & Leader

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Example - 1

Problem Category Solution

Intern keeps reading during peak OPD hours,he is not interested,manages patients badly.

Unable and Unwilling

Be firm and strictly monitor

New lab tech in PHC,willing to work but does not know things

Unable but Willing

Pair up with an experienced tech for few days, check progress, show support

Bhagwan barose!

E.g. Intern

Kya? Kaise? Kab? Kyun?

…

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Example - 2Problem Category Solution

You are a new medical officer, you find that a senior PHN does not do any work. Sulks at you. Upon enquiry you find that….

Able but Unwilling

Call her to your chamber, speak to her gently, discuss about a problem and ask for ideas, gain confidence

A Resident with good public relations, knowledge and skill base, sincere in his work, reliable

AbleandWilling

Appreciate and provide occasional guidance

Meri Marzi- E.g.

Government servant

Mein hoon na!!

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Setting and sharing objectives

• People work well together when they agree with one another and take part in setting the objectives

• People who are not involved in objective setting waste resources

• People who are opposed to set objectives may obstruct work

• Local objectives must be set in consultation with Community members, Health workers, Patients, Ministry of health

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Motivating team members

• Motivation is an inner impulse that induces a person to act in a certain way– Level 1: obtain the necessities of life – food, clothing, shelter,

rest and safety– Level 2: satisfy social needs – companionship, love and position

of respect– Level 3: personal satisfaction and pursue ideals

• A leader should understand what encourages and what dissatisfies people at work‘Leaders must be close enough to relate to others,

but far enough ahead to motivate them.’

- John C. Maxwell

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Maslow’s need hierarchy theory

Self actualisation needs

Esteem needs

Social needs

Security needs

Physiological needs

Comprehensive health care

Awards, promotions

Team work, social events

Job security, retirement benefits

Salary

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Causes of motivation

• Achievement: wise leaders will help their workers achieve by giving clear

instructions, suitable training and facilities

• Recognition: leaders should be willing to praise when praise is due

• The work itself: a good leader will try to keep dull, repetitive tasks to

minimum and assure workers of the value of their work

• Responsibility: a good leader tries to increase worker’s sense of

responsibility rather than diminish it by criticisms

• Advancement: a leader should encourage people to increase their skill and

knowledge and train them for promotion

• Self-improvement: leaders can help workers by challenging them with

questions at work, help them set up research, by giving high quality

supervision

‘Withhold not good from them to whom it is due, when it is in the power of thine hand to do it.’

- Proverbs 3:27

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Causes of dissatisfaction

• Inefficient administration: leaders who fail to pay salaries on time, to distribute supplies on time

• Incompetent supervision: a supervisor who cannot help in a difficult diagnosis will lose respect

• Poor personal relations: workers should be treated fairly, should be consulted about their work.

• Poor leadership qualities: people respond to much better to example than to exhortation, without personal authority that comes from integrity, the authority of the position will not impress others

• Low pay: absolute level is less important than relative level• Bad working conditions: a good leader ensures good working

conditions and in its absence inspires by example

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Delegating authority and responsibility

• Delegation means giving another person the power to make decisions

• Advantages– It saves time for other duties– Workers in the field must be able to make decisions – Saves long delays that occur when awaiting decisions from a

distant authority– Allows workers to enjoy their work and become more skilful

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Cons of delegation

• If wrong decisions are made, work may suffer

• A bad leader may pass on all the work to members with very little for himself to do

• A leader may delegate work to people with insufficient experience

‘As a manager the important thing is not what happens when you are there, but what happens when you are not there.’

- Anon

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Rules for delegation of authority

• Be clear about exactly what is delegated

• Select the right person

• Tell others about the delegation

• Do not interfere unless asked to

• Give support as needed and monitor progress‘Surround yourself with the best people you can find, delegate authority, and don't interfere as long as your policy is being carried out.’

- Ronald Reagan

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Styles of supervision -

• Autocratic: Do as I say! It tends to humiliate people and make them irresponsible

• Anarchic: Do what you like! (jaise chal raha hai, vaise chalne do na! ya tumhari marzi!)

• Democratic: Lets agree on what we are to do – helps people grow, to become responsible and show initiative

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Can you tell?

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Choice of supervision

• Choice of supervision depends on

– Job factorsComplexity, difficulty of job, need for quick decisions,

consistent results, creative work

– Personnel factorsSkill, reliability, experience of the workers, willingness to

accept responsibility and make decisions

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Adapting supervision styles

• Good supervisors adapt styles according to needs• Democratic style

– For work that requires creativity– With competent, reliable, experienced people and those who are willing to take

responsibility

• Authoritative style– For tasks that require coordination and consistency (dealing with large

numbers of people)– For tasks such as emergency or controlling epidemic– Workers who have little understanding of the goals, have limited

experience/skills and unreliable– Where staff can be closely supervised and controlled– Not suitable in rural health work where workers work in isolated health posts

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Organising health-team activities

Job descriptions

Norms and standards

Coordinating activities

Communication

Conducting meetings

Training staff

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• Distribution of tasks among members of the team is an important function

• Work should be arranged in such a way that members use their individual skills and talents and there is no ‘overwork’ or ‘underwork’

• Job description is a means of helping to distribute tasks

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Using job descriptions

• A job description states– Objectives, activities and programmes of the post– Authority of the worker– Responsibilities of the worker

• The purpose of job description is to define exactly to all members their work

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Uses of clear job description

• Clearly explains what each workers is expected to achieve

• Prevents arguments between people, prevents gaps and overlaps

• Can identify areas for training• Serve as a basis for evaluation

• However they should be used flexibly, guidelines rather than too strictly or literally

• Thus workers should be ready to help with one another’s work when necessary

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Contents of job description

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How to outline duties?

• Training and tradition

• Interpretation by the person who holds the job – it is very useful to ask workers to list their duties and discuss with them

• Requirements of programme and services

• Since rural health work keeps changing, supervisors should keep job description under constant review

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Example of a job description

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Using norms and standards

• A job description does not say how much a health worker must do or how well

• Norms and standards translate health objectives and targets of health teams to amounts of work and quality of care expected

• They can be applied to work, performance, productivity and behaviour. E.g. no. of deliveries conducted by the ANM, birth complications rate, performance over time

• Can be used to compare workers• However, workers cannot be regarded as machines with

predetermined production mechanisms, they can set their own standards

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Coordinating activities

• It means bringing activities into proper relation with each other so as to ensure that everything is being done and no two people are trying to do the same job

• Components– Distributing authority– Channels of communication– Arranging work so that right things are done in the right place, time,

way and by the right people

• A coordinated activity is orderly, harmonious, efficient and successful

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Organizational principles to achieve coordination

• Objective: group objective must contribute to overall objective

• Definition: clearly defined tasks for groups

• Command: clearly identified person in charge

• Responsibility: person in charge

• Authority: each person should have authority equal to responsibility

• Span of control: person in charge should control not more than 6-10 people

• Balance: activities of the groups should balance out

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Checklist for coordination

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Communication

• Why is communication important?– Personal relations within a team are important and can be made

worse by poor communication

• Principles to maintain good communication– All members should be free to express their views– A message should be expressed clearly– The leader should ensure that the communication sent was

received and executed– Conflict or disagreement should be managed in a way that will

achieve constructive results‘The single biggest problem in communication is the illusion that it has taken place.’

– G B Shaw

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Managing space to assist communication

• A big group is better divided into small groups of 6-7

• Table may hinder communication, esp. avoid long or U-shaped tables

• Do not place tables in a way that emphasizes rank order unless there is a reason

• Seating arrangements should reflect the purpose of meetings

• Adapt seating arrangements to the purpose, not the purpose to the seating arrangements

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Two people or one person & small group

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Small group (5-10)

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Large group (10-50)

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Conducting meetings

• Regular meetings of health teams are necessary, to make decisions on a new project, or educational activities

• Preparing for a meeting

– Purpose: Brief summary of what is to be achieved, agenda– Subject: Each person should have as much information as possible

about the subject to be discussed– Type and size: Small or large, invited only or open, formal or informal– Place, time and duration– Who is convening and organizing– Announcements about the meeting

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Excuse me Mr. Chairman, but before we close may we know why

we came here?

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A good meeting is successful communication

• The success of a meeting depends on quality of communication

• If the purpose was to pass on information or explain something, the speakers should ensure whether this has been successful (by questions and discussion)

• It the purpose was to seek views, the chairman should summarize the views and obtain agreement

• Quarrels and shouting are often due to poor communication, they can be minimised when people understand each other clearly

‘The most important thing in communication is to hear what isn't being said.’

- Peter Drucker

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Role of chairman

• Keeps the meeting to its main purpose, gives everyone fair chance, controls timing, keeps order

• 3 simple rules

– No rudeness or personal remarks– Chairman must have absolute right to control the discussion, rule

out irrelevant remarks and bring an end if necessary– Everyone should be stimulated to take equal part, discouraging

talkative persons and stimulating hesitant persons

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Controlling time in meetings

• Questions and discussions should be kept to definite time limit

• If decision cannot be reached within time limit, it is advisable to postpone the attempt, which gives more time to think and prepare

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Committee meetings

• A special type, a committee is a group of people appointed by another person or group for a special function

• 2 types – Advisory committee: Advises somebody who has the power of decision– Executive committee: Has certain powers of decision on its own

• Reasons for appointing a committee– Responsibility is shared– Reasonable range of knowledge and opinion consulted before decision

is reached– Eliminate self-interest, bias and prejudice in decisions

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Committee rules & procedures - 1

• Powers and duties: What are the responsibilities and what is their authority

• Membership: Rules for appointing members, filling vacancies, co-opting members

• Voting rights

• Arrangements for meetings: how often, who may call, advance notice

• Procedure (how to conduct business): how decisions are reached, by majority or two-thirds or unanimously

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Committee rules & procedures - 2

• Chairman– Appointed or elected– Convenes meeting, decides agenda, leads meeting, signs the

‘minutes’, calls members to speak, puts motions for voting and passes them as rejected or accepted

• Secretary– Appointed or elected– Records main events, names of members present, visitors, those

absent and their messages, exact wordings of decisions, summaries of discussions, date of next meeting

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Committee rules & procedures - 3

• Order of business

– Chairman calls meeting to order (announces names of absentees and their apologies, introduces new members, recognises guests)

– Secretary reads previous meeting’s minutes– Members propose additions/corrections to minutes– After all modifications, chairman moves to approve minutes,

voting takes place and approved– Discussion proceeds according to agenda items and decision

made on each item

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Training staff

• Human resources are the most expensive form of health resource, hence they should have high standards of performance

• Purpose of training – To improve competence– Maintain a positive attitude towards work– To reduce sense of inadequacy – To ensure that community gets quality care

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Training strategies

• Continuing education– A system that gives opportunity to continue learning, both for personal

career and benefit of health services– Help to adapt performance to new developments– Still inadequate in many countries, carried out in piecemeal

• In-service training– Is associated with supervision, service and problem related– Concerned with local needs– Deals with training needs as they arise– Deals with problem solving in health care– Training focussed on priority health problems

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Training need analysis

Training objectives

Training delivery

Training evaluation

What are the training needs for this person and/or job?

Objective should be measurable and observable

Techniques include on-the-job-training, action learning

Measure reaction, learning, behavior, and results

Training process

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• Task analysis

A detailed analysis of a job to identify the skills required, so that an appropriate training program can be instituted

• Competency analysis

Careful study of competency level to identify a deficiency and then correct it with a training program, or some other development intervention.

Assessing training needs

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Required competency

level for certain position

Competency Gap

Competency Assessment

Current competency level of the employee

Training and Development

Program

Competency analysis

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Assuring competence of health teams

• Selection and recruitment

• Assessing competence and performance

• In service training approaches

• Relating the training system to health care

‘A good manager is a man who isn’t worried about his own career but rather the careers of subordinates’

– H.S.M. Burns

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The educational process

• Defining learning objectives• Setting criteria and designing methods for assessing

achievement• Selecting learning methods• Organizing learning experiences• Providing conditions in which active learning can take place• Developing and using training resources• Reinforcing learning experience with supportive supervision• Evaluation

‘Good management consists of showing average people how to do the work of superior people’

– John D. Rockefeller

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Steps in educational process

‘The art of choosing men is not nearly so difficult as the art of enabling the chosen ones to attain their full worth.’

- Napoleon Bonaparte

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Controlling and assessing work

Controlling and maintaining work standards

Assessing performance

Records and reports

Dealing with problems & conflicts

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• After the objectives and duties of a health team have been defined and team members carefully selected, trained and instructed, control measures can be devised to ensure that the team’s work programme proceeds as expected and maintain expected amount and quality of work

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Controlling and maintaining work standards

• Necessity– To ensure that work is done according to the objectives and within the

allotted time and resources – To enable supervisors to identify deficiencies in workers' abilities and

arrange for proper training– To enable supervisors to recognize and reward good work and

recommend for promotion – To ensure that resources are adequate and properly used– To enable identification of causes of work deficiencies

• Good control should be – Timely, Simple, Minimal, Flexible

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Methods of control in a team

• Instructions– Must be clear enough to be understood by all concerned– Must be practicable and within the capacity of those meant to

carry them out– Adequate resources to carry them out– Must be stated in a way that results can be easily assessed

• Work schedule– Shows what a worker/team is to do and when– They let the supervisor know what team is doing what on a

particular day and time and enables individuals to make the best use of time

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How many of you have gone thru this?

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Visits by supervisors

• In supervision nothing beats a direct visit, esp. for rural health• Personal visits assures workers that the team leader is someone to

whom they can turn for help whenever they need • Provides an opportunity for exchange of ideas and in-service training• Each visit should have a definite purpose and long enough to complete

that purpose• Should ask

– What targets they are aiming at and whether they consider them practicable

• It is helpful to have a checklist• Surprise visits are not good practice, it suggests that the supervisor

does not trust the workers, they should be encouraged to prepare for the visit

‘A desk is a dangerous place from which to view the world.’- John Le Caré

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“My supervisor knows that I am here and that what I do is important enough for a regular visit to review my work”

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Assessing work performance

• Based on clear statement of objectives, that are relevant, feasible, measurable and agreed by the workers

• Determine the level of achievement by the team• Purpose of assessment is to help discover the strengths and weaknesses

of workers and the potential for growth and further training needs• Assessment should be continuous• Supervisor must help workers to respond to helpful criticism and

improve performance• The immediate supervisor who sees the health worker most often is the

best person to make the assessment• A checklist is very useful

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Sample checklist for assessment

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Finding work deficiencies

• There are several reasons, many are not workers’ faults– Insufficient training– Insufficient resources – Lack of clear job description, instructions– Lack of reward, promotion – Team members not working well– Supervisor not encouraging enough– Personal worries

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Why performance appraisal?

• Appraisal provide information upon which promotion and salary decision can be made

• Appraisal provide an opportunity for a manager and his/her subordinates to sit down and review the subordinate’s work-related behavior, and then develop a plan for corrective action

• Appraisal provide a good opportunity to review the person’s career plans in light of his/her exhibited strengths and weaknesses

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Performance planning(Setting Performance Targets)

Regular review and Monitoring

Feed back

Corrective Action

Performance appraisal and evaluation

Training & development Plan

Salary/Bonus adjustment

Career development

Performance management cycle - 1

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Defining performance

targets

Appraising performance

Providing feedback for development

Defining the performance standards means making sure that you and your subordinate agree on his/her duties and targets that you expect

Appraising performance means comparing your subordinate’s actual performance to the standard/targets set in step one

Providing feedback means discussing plans for any development that is required

Performance management cycle - 2

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Lack of standard

Irrelevant or subjective standards

Poor measures of performance

Poor feedback to employee

Negative communication

Failure to apply evaluation data

Problems in performance appraisal

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Performance appraisal

elements has two main

categories

Performance Result: Hard or

quantitative aspects of

performance (result)

Competencies: It represents soft

or qualitative aspects of

performance (process)

Performance appraisal element - 1

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Competencies score

Performance score

Overall score

Will determine the employee’s

career movement, and also the

reward to be earned

Performance appraisal element - 2

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Records - 1

• Consist of information kept in the health unit about the work of the unit, health conditions of the community, individual patients and administrative matters

• Records should be accurate, accessible, available when needed and contain useful information

• Records are an administration’s memory, they help supervisor to Learn what is taking place, make effective decisions, assess

progress towards goals

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Records - 2

• Before asking health workers to make records, supervisors should ask themselves following questions

– Will this information be used?– What part will it play decision making and evaluation?– Can this be accurately collected?– Will it be accessible?– Reasonable cost?– Only because of routine?

• Supervisors should make sure that the workers understand the reasons for collecting the information required

• Special forms are often used to record information in a standardized manner and save time

‘The problem is people don't keep good records. If people kept better records, they'd save money.’

- David Mellem

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Reports

• The information communicated to other levels of health service, is an important management tool for influencing future actions

• Reporting forms are often standardized and distributed in advance

• Workers should be trained to prepare reports according to instructions

• Copies should be made and one retained as record

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Dealing with problems and conflicts

• Solving staff’s personal problems

– Personal worries are varied and may interfere with work, a good supervisor tries to understand those problems

– A worker who feels that a supervisor does not care and is unsympathetic may feel resentful and angry and affect quality of work

‘The quality of our lives depends not on whether or not we have conflicts, but on how we respond to them.’

-Tom Crum

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Dealing with disputes - 1 • The commonest cause of dispute is confusion, caused by people having

different ideas about what is to be done and how it is to be done• It can be minimised by

– Frequent meetings of members– Allowing people to express views openly and letting the whole group decide

what should be done– Sharing agreed objectives– Clear and detailed job descriptions– Clear instructions and procedures to follow– Distributing tasks fairly – Creating work schedules and distribute work fairly

• Common cause of argument is jealousy and favouritism• A supervisor must be just and fair and never criticise staff in public‘People are disturbed not by things,

but by the view they take of them.’ – Epictetus

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Dealing with disputes - 2

• Conflict is simply a recognition of and expression of difference

• Traditional view– All conflicts are harmful – Indication of management failure

• Behavioural school of thought– Conflicts are logical as people differ– Not always detrimental; could be constructive

• Types of conflict– Functional: enhances and benefits the organization's performance– Dysfunctional: harms or hinders the achievement of organizational goals

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‘Conflict is inevitable, but combat is optional.’- Max Lucado

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Settling disputes - 1

• Reasons for dysfunctional conflicts– Unclear job descriptions– Aggressive nature of individuals– Poor communication– Task interdependence

• Conflict resolution – Clear job descriptions– Closely related jobs to be assigned to same group/ individual– Improved inter personal communication– Better understanding of self and others

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‘Every fight is on some level a fight between differing ‘angles of vision’ illuminating the same truth.’

– M K Gandhi

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‘A good manager doesn’t try to eliminate conflict; he tries to keep it from wasting the energies of his people.’

– Robert TownsendCRHSP, AIIMS

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Settling disputes - 2

• A serious argument can affect morale and performance of whole team• Must be stopped quickly and reconciled• People involved should be interviewed separately and all facts made

known• All efforts should be made to discover the true cause of argument• People involved should be asked separately on how to resolve the

argument and whether they are willing to be reconciled• If a solution can be found that is acceptable to all concerned,

productive and friendly relations can be re-established• If not, the best solution is to persuade them to ‘agree to differ’ – to

acknowledge the differences in their views but to stop arguing about them

‘He who has learned to disagree without being disagreeable has discovered the most valuable secret of a diplomat.’

- Robert Estabrook

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Take home messages

• People are not ‘things’• One person can’t do everything, team work is best• Good leadership helps a team perform better• Staff should be trained to attain highest standards• Good communication will solve most problems• Supervision is indispensable• Conflicts will always arise, the trick is not to let them

interfere with work

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Dr. Rizwan S A 88

Thank you!

‘The conventional definition of management is getting work done through people, but real management is developing people through work.’

- Agha AbediCRHSP, AIIMS