Health Service Management
Subtopic:
Leadership in Healthcare Delivery
Leadership in Healthcare Delivery
Introduction
- Leadership, according to WHO, is one of the six building blocks of health systems – (what the other five?- service delivery, human resources for health, health information systems, pharmaceuticals,
- health financing). For the case of Uganda, available literature suggests that leadership is lacking at all levels in the health care system ((Accordia Global Health Foundation [AGHF], (2009, p.16))
- And where there are leaders, they generally lack skills – (Uganda Human Resources for Health Policy 2006.p.g 4). And so as we discuss health services management, it is essential to be aware that HRH are few, and only a few of the few are health managers – many of whom may not have the required leadership and management skills.- More will talked about in HRH and the critical shortage.
- Leadership does not mean dominating the subordinates as it is the case with leadership; however, the leader’s job is to get work done by other people, and make people willingly want to accomplish something. So effective leadership means effective and productive group performance.
Definitions
Leadership – 1
It is the ability to influence and secure the cooperation of others to work to achieve certain goals. It implies:
- Influencing others to willingly carry out ones wishes
- Accept ones advice and direction Leadership – 2
- The art of mobilizing others to want to struggle for shared aspirations
- The ability to inspire others to struggle to achieve shared objectives and Fulfill shared aspirations
- The ability of gaining commitment rather than commanding obedience, enlisting support rather than giving orders.
Leadership – 3
- A relationship through which one person influences the behaviour of other people
- A social process in which one individual influences the behaviour of others without the use or the threat of violence (of any kind)
Leadership -4
- There are leaders who also have high positions
- There are those who can influence but have low positions
- Managers who can influence have an edge over those who cannot
Leadership styles
A leadership style is a leader’s way of providing direction, implementing plans, and motivating people.
There are many different leadership styles but commonly used are;
- Autocratic/authoritarian leadership:
- Democratic leadership/participative/consultative
- Laissez-faire style/free- rein/ultraliberal/delegative
- Bureaucratic style
Autocratic/authoritarian leadership:
The autocratic leadership style allows managers to make decisions alone without the input of others or consultation of their team member’s even if their input would be useful. Managers possess total authority and impose their will on employees. No one challenges the decisions of autocratic leaders. This leadership style is found in large bureaucracies like police, army and prisons.
Characteristics of autocratic leaders
- Have high concern for work than for the people who perform the
- Set rigid standards and methods of performance and expect the subordinates to obey the rules and follow them subordinate/followers are motivated by coercion
- Decision making is basically for the manager with no subordinate involvement
- Emphasis is on difference in status that is I and
- Information must always flow from top to bottom
- Should never be criticized nor their action
Advantages of autocratic style
- Quick Decisions: An autocratic style of leadership can be effective in work environments where decisions need to be made quickly. The sole responsibility rests with the leader, and she makes the decision without the need to consult others.
- Close Oversight: In an autocratic work environment, the leader typically keeps a close watch on the activities of the workers. This eliminates the tendency for workers to relax at work that may occur with more lenient management styles. The result can be increased productivity and speed, as workers who fall behind are quickly identified and corrective measures are taken. Quality may improve, as the employees’ work is monitored constantly. Time wasting and the need to waste resources is also reduced.
- It’s Easier to Set Policy: This is because in autocratic leadership style, there are no opposing political ideologies to stand in the way of policy making.
- Less time consuming especially in decision making and taking
- Very efficient especially in times of crisis
Disadvantages of Autocratic or dictatorial leadership
- One way communication without feedback leads to misunderstanding, and communications
- An autocratic leader makes his own decisions which can be very dangerous in this age of technological and sociological complexity.
- It fails to develop the worker’s commitment to the objectives of the
- It creates problems both with employee morale and production in the long-run; due to their
- It is unsuitable when the workforce is knowledgeable about their jobs and the job calls for team work and cooperative spirit.
- Limited Freedoms and Access to Information especially for the employees/subordinates.
- Motivation of employees is compromised since they do not exercise their
- Employees are less
Democratic leadership/participative/consultative Definition
Is a type of leadership style in which members of the group take a more participative role in the decision-making process. There is redistribution of power and authority between employees and managers to provide employee involvement in decision-making. Democratic leadership attempts to manage with democratic principles, such as self-determination, inclusiveness, equal participation and deliberation.
Characteristics
- Leader is people oriented
- Togetherness is emphasized
- Delegation of tasks to other employees and subordinates along with full responsibility makes them accountable for their actions and tasks as well empowered.
- Openness to feedback (initiatives and otherwise) from the managers and
- Members’ suggestions and guidance direct the effective management of the
- Emphasis is on ‘we ‘rather than ‘I’ and ‘You’.
- Communication flows in all directions that is from up and bottom Advantages:
- All the people involved use their skills together for the completion of a certain task and hence, almost all ideas are taken into consideration and carefully debated.
- Communication gap is reduced. Tension between the leader and team members is decreased as a result of which fear of rejection and denial also reduces – this makes all sorts of issues addressable. An autocratic leader, on the other hand, would have certain demands and expectations from his subordinates which make the employees fear the leader.
- A positive work environment is This means that a culture of junior workers getting a fair amount of responsibility and challenges is encouraged. When there are the right vibes among employees, work becomes more pleasurable.
- Promotes cooperation and team worker among the members of the
- Employee turnover reduction. A democratic leadership makes people feel empowered at work as it is essentially performance based. A majority of the workers appreciate this method of management as it secures them a safe future with the company.
- Delegation of Responsibility is achieved whereby a democratic leader will delegate responsibility among members of his or her team to facilitate member participation in making decision.
Disadvantages:
- Some managers adopt democratic leadership to please their subordinates but fail to follow the technique in its entirety. They might simply take in all the ideas and end up never implementing them.
- The decision making process might be delayed which may affect organizational
- May create a feeling of frustration and ill-will especially among some employees whose decisions/suggestions are undermined.
Laissez-faire style/free- rein/ultraliberal/delegative
Definition
Is a type of leadership style in which leaders are hands-off and allow group members to make the decisions. This type of leadership involves little direction and lots of freedom for workers. The leaders sit back and watch the activity or results take effect.
Characteristics of Laissez-Faire Leadership
Laissez-faire leadership is characterized by:
- Very little guidance from leaders
- Complete freedom for followers to make decisions
- Leaders provide the tools and resources needed
- Group members are expected to solve problems on their
Advantages:
- Allows visionary workers the opportunity to do work they want to do free from
- No work for the leader
- Instills a sense of responsibility among team members especially those who are self
- Best leadership style where employees are highly motivated and achievement
Disadvantages
- less group satisfaction
- Less group/work productivity since workers may not possess the necessary skills to complete a job.
- Poor quality of work since workers lack direction from leaders and also lack the guidance and support of the leader
- Jobs fall back on someone else or are not completed since there is lack of clear job description
Bureaucratic style
- Emphasizes rules and routine
- You must use “appropriate” forum or channels
- It is red-tape leadership Basis of leadership style
Ultimately, the leadership style one adopts springs from one’s ideas and feelings about human nature.
Factors that influence the leadership style to use
- Manager’s personal background: that is his/her personality, knowledge, values, ethics and experiences the manager has or what she/he thinks will work.
- Staff being supervised: the style varies depending upon the individual staff and what will best respond to.
- Organization: that is the traditions, values and concerns of the organization highly influence the manager on which style to use.
Leadership Theories
There are many different ideas about how a person becomes a good leader. Despite years of research on this subject, no one idea has emerged as the clear winner. The reason for this may be that different qualities and behaviors are most important in different situations. In nursing, for example, some situations require quick thinking and fast action. Others require time to figure out the best solution to a complicated problem. Different leadership qualities and behaviors are needed in these two instances. The result is that there is not yet a single best answer to the question, “What makes a person a leader?”
Consider some of the best-known leadership theories and the many qualities and behaviors that have been identified as those of the effective nurse leader (Pavitt, 1999; Tappen, 2001).
Trait Theories
At one time or another, you have probably heard someone say, “Leaders are born, not made.” In other words, some people are natural leaders, and others are not. In reality, leadership may come more easily to some than to others, but everyone can be a leader, given the necessary knowledge and skill.
Behavioral Theories
The behavioral theories are concerned with what the leader does. One of the most influential theories is concerned with leadership style (White & Lippitt, 1960).
The three styles are:
- Autocratic leadership: (also called directive, controlling, or authoritarian). The autocratic leader gives orders and makes decisions for the group. For example, when a decision needs to be made, an autocratic leader says, “I’ve decided that this is the way we’re going to solve our problem.” Although this is an efficient way to run things, it usually dampens creativity and may inhibit motivation.
- Democratic leadership: (also called participative).
Democratic leaders share leadership. Important plans and decisions are made with the team (Chrispeels, 2004). Although this is often a less efficient way to run things, it is more flexible and usually increases motivation and creativity. Democratic leadership is characterized by guidance from rather than control by the leader.
- Laissez-faire leadership: (also called permissive or nondirective). The laissez-faire (“let someone do”) leader does very little planning or decision making and fails to encourage others to do so.
It is really a lack of leadership. For example, when a decision needs to be made, a laissez- faire leader may postpone making the decision or never make the decision. In most instances, the laissez-faire leader leaves people feeling confused and frustrated because there is no goal, no guidance, and no direction. Some very mature individuals thrive under laissez-faire leadership because they need little guidance. Most people, however, flounder under this kind of leadership.
Characteristics of effective leaders
- They display honesty and integrity: consistency between words and
- They are never destructive: they never back-stab
- They have clarity of vision and direction: leaders must know where they are going for others to willingly join them.
- They are able to inspire: ability to communicate the vision with enthusiasm, energy and a positive attitude about the future
- They are competent: leaders must be capable and effective; they must have a record of
- They display commitment and produce quality work: they see their work as a reflection of
- They are supportive and service oriented rather than bossing oriented: genuinely interested in their collaborators, ready to listen and able to inspire, promote and support their continuous development.
- They treat people as individuals and equals: Never See value in everyone.
- They believe in people: those who don’t trust anybody end up not being trusted by anybody
- They are able of treating people in terms of their potential
- “Treat a man as he is and he will remain as he Treat a man as he can and should be and he will become as he can and should be”. (Wolfgang Goethe)
- They are continuously learning: the more they learn and know, the more they realize they don’t know.
- They inspire others to continuously learn and
- They are flexible and pragmatic: they grasp and adopt new
- They are change oriented, able and ready to take
- They are able, ready and quick in recognising their own
- They are able to accept, without blaming them, their collaborators mistakes: to them, the only real failures are the mistakes (the experiences) not learned from.
- They listen to others: they know and accept their own Pursue others’ ideas
- They give credit to others: constantly and
- They have sense of humour, irony and self-irony: these are signs of intelligence and can protect against dogma, arrogance and self-righteousness.
- Humour can help to change
- Being able of laughing at ourselves preserves us from becoming too boring; from being too full of ourselves and from taking ourselves too seriously.
Differences between the Leader and the Manager

FUNCTIONS OF MANAGEMENT IN DETAILS PLANNING
Planning is the first step in the management process and every manager is expected to understand its essence in order to be successful in their managerial role. Planning is particularly important because of scarce resources and uncertain environment with competition for those resources.
Definition:
Planning is a decision making activity requiring the process of ascertaining objectives and deciding on activities to attain those objectives.
Or: is the process of preparing for change and coping with uncertainty by formulating future courses of action.
Or: is ensuring that the important organizational objectives are accomplished as and when desired. Or: is having a specific aim/purpose and coming up with ways/methods for the achievement of the goals.
Reasons for planning/purpose of planning
- To successfully achieve the organizational goals and objectives through the set
- To ensure effective resource utilization including human resource so as to prevent resource
- To better cope with situational crisis since this was anticipated and hence planned
- To ensure effective control of the resources especially human
- To guide decision making since it specifies the action and steps to be taken in order to achieve the organizational By enabling the managers to make decisions on current and future activities.
- To enable anticipation of problems and thus facilitating smooth flow of organizational
- To identify gaps and areas requiring change; this will be addressed for the better of the organization. This can be achieved through periodic review of the organizational activities.
- To give meaning to work since employees will work towards a well defined
Characteristics of a good plan
- Should be simple and comprehensive so that all the employees can grasp its significance and thus easily put into action. It should as well be detailed enough so that it can cover all aspects of the operation necessary to achieve the objectives.
- Should have clear, well-defined and easily understood
- A good plan should also be well balanced and flexible. That is the existing resources are well allocated for proper utilization so that the short term gains are not achieved at the cost of long term gains.
- Should also be flexible enough to incorporate any changes in the
- Time That is should be established for a specific period of time.
- Actionable; a good plan should be have set out strategies for achieving organizational goals which are practical.
- Should incorporate all the departments within the organization to promote unity and focus on the overall objective i.e. involve participation by subordinates.
Principles of effective planning
- Aims of organization in the plan must be clear, reasonable and
- Involve subordinates in the planning This will ensure acceptance of the plans by those who are to implement it.
- Assign planning responsibility to the right people that is those who are involved with the
- Do not be over optimistic with the anticipated results but rather see what is there than what you want to see.
- Keep the plan flexible but putting under constant review and adjustment where
Levels of planning
There are basically three levels of planning associated with the different managerial levels: these are;
Strategic planning/long term planning:
- Conducted by top management like chief executive officers, directors, presidents, vice- presidents
- Involves determining the direction in which the organization should be run
- Long-range/term planning (a period of up to 10years)
- Deals with total assessment of the organization’s capabilities, it’s strengths and Intermediate planning:
- Coves a time frame of about 6months to 2years
- Conducted by middle management which includes department heads
- Middle managers have to refine broad objectives into more workable and realistic Operational planning:
- These plans are responsibilities of lower management like unit
- Short range plans covering a time span from 1week to one year
- These are more specific and determine how a specific job is to be completed in the best way
Planning process/steps in planning Assessment
This involves collecting adequate data about the organization so as to answer questions of:
- Where are we?
- What do we have to work with?
- Where do we want to be?
- How do we get there?
This information is then analyzed and interpreted as a meaningful whole. Assessment will also help the manager to identify needs of the organization as well as its strengths and weaknesses.
Establish and clearly define goals/objectives:
This portion of the planning process should include a detailed overview of each goal, including the reason for its selection and the anticipated outcomes of goal-related projects. For example, the objective of the hospital is to provide quality health care.
Identify resources
Each goal should have financial and human resources attached for its achievement or completion.
Priority setting
There is need to priotise the objectives as well as resources in regard to their importance. The tasks deemed most important will be approached and completed first. The prioritizing process may also reflect steps necessary in completing a task or achieving a goal.
Development of strategies
These are measures set up for the achievement of the organizational objectives. This step also involves assigning timeline for the achievement/accomplishment of a task. However there should also be consideration of the abilities of the staff in assigning them duties or work as a strategy for achievement. It is also necessary to formulate policies, rules and regulations as a way of controlling organizational activities.
Implementation of the plan:
This is the action stage of the planning process where all the identified strategies are implemented/put into action for the attainment of the organizational goals. However, this stage will require a combination of all skills and coordination of all factors.
Evaluation of the plan:
The plan should be re-evaluated periodically so as to measure its progress and effectiveness in order to correct any deviations and make adjustments where necessary. This can also be done through requesting a monthly progress report from department heads.
Benefits of planning
- Planning provides performance standards which assist in the development potential and standards for measuring the progress of the organization are essential in organizational
- Improves the competitive strength of the company since deviations are easily identified basing on the set standards and thus addressed in regard to the expected standard.
- There is reduced risk and uncertainty since these are anticipated early enough and strategies to overcome them are put up accordingly.
- Promotes proper and effective utilization of the organizational resources hence minimizing
- Planning enables manager to focus on the future than the present hence giving them purpose and direction.
- Provides a framework for decision making. Knowing the organizational objectives and methods to achieve them eliminates ambiguity in the decision making process.
- Proper planning motivates the workers especially if they are involved in the planning
ORGANISATION
Introduction:
When two or more people co-operate to perform a task, it is usually convenient to divide responsibility so that each of them takes care of certain aspects of the job. Organization involves grouping people together in a stable yet working pattern.
Definition:
This is the planned design of the corporate structure showing the relationships between employees and the function each should perform to make the organization work effectively towards given objectives.
OR is the process of combining the work, which individuals or groups have to perform with the facilities necessary for its execution using available resources.
Principles of organization
- Scalar principle: The lines of authority should be clearly stated and should run from the top to the bottom of the organization. This line of command is referred to as chain of command. The major decisions are mad and policies formulated at the top and they filter down through various management levels to the workers.
- Unity of command: Each person in the organization should report to only one And each person should know how he reports to and who reports to him. This process eliminates ambiguity and confusion that can be caused, when a person has to report more than one superior.
- The responsibility and authority of each supervisor should be established clearly and in writing. This will clarify the exact role of the supervisor as to limits to his authority. Authority is defined as the formal right to require action from others. Responsibility is the accountability of that authority. With clearly defined authority and responsibilities, it will be easier for the supervisor to trace and handle problems and make quick decisions when
- The higher authorities are responsible for the acts of their subordinates. The executive cannot dissociate himself from the acts of his subordinates. Hence he must be accountable for the acts of his subordinates.
- The authority and responsibility should be delegated as far down the hierarchical line as objectively as possible. This will place the decision making power near the actual operations. This gives the top management more free time to devote into planning and overall policy
- The number of levels of authority should be as few as possible. This would make the communication easier, clear and the decision making faster. A longer chain of command results in ‘run a rounds’.
- The principles of specialization should be applied wherever possible. Precise division of work facilitates specialization which then leads to efficiency and quality. Every person should be assigned a single function whenever possible
- The line functions and staff functions should be kept separate. The line functions are those that are directly involved with the operations that result in the achievement of company objectives. Staff functions are auxiliary to the line functions and offer assistance and advice.
- The span of control should be reasonable and well established. The span of control determines the number of positions that can be coordinated by a single executive. The span of control could be narrow with relatively few individuals who report to the same manager or wide with many subordinates under the supervision of the same manager.
- The organization should be simple and flexible. It should be simple because it is easier to manage and flexible because it can quickly adapt to changing conditions. It should be such that it easily expanded or reduced at times of demand.
Advantages/ benefits of good organization
- Facilitates attainment of organizational objectives through proper coordination of all activities
- A minimal conflict among employees since the chain of command is clear for
- Overlapping and duplication of work is eliminated since work is distributed among employees accordingly
- There is decreased likelihood of run-around. This can occur when we don’t know who is responsible for what. This is avoided since responsibilities are clearly established.
- Facilitates promotions since the organizational chart clearly points the positions of all individuals relative to one another.
- It aids wage and salary administration. Compensation administration policies get easier to apply since there is a clear stipulation on the benefits of certain jobs in the company.
- Communication is simplified sine the lines of communication and flow of authority is quite clear in the organizational chart.
- Good organization provides a basis for effective planning in the short and long run like expansions and contraction of activities.
- There is increased cooperation and sense of pride. The employee has adequate freedom within the domain of his responsibility and authority since they are all clear to him thus boasting morale.
- It encourages creativity. Because of the sense of belonging and high morale and with the help of clear cut accountability, recognition of skill and appreciation for contribution, it encourages resourcefulness, initiative and a spirit of innovation and creativity.
Organisation structure
This is the arrangement and interrelationship of the component parts and positions within the institution.
OR: this is the network of horizontal and vertical relationships among the members of a group designed to accomplish common objectives.
OR: it is a system of formal relationships that govern the activities of people in an organization.
Importance of organization structure
- Is the foundation upon which the whole structure of management is
- It specifies division of work which helps define teams who work closely
- Promotes hierarchy in the organization since it provides a clear chain of command and defines which employees report to which managers.
- It shows different areas of specialization indicating hierarchy and authority
- A structure helps define exactly who the correct decision maker for each employee is. NB: an organization structure is represented by a chart drawing known as the organization
STAFFING
- The managerial function of staffing involves manning the organization structure through proper and effective selection, appraisal and development of the personnel to fill the roles assigned to the employers/workforce.
- According to Theo Haimann, “Staffing pertains to recruitment, selection, development and compensation of subordinates
- Staffing is the management activity that provides for appropriate and adequate personnel to fulfill the organization’s objectives. The nurse manager decides how many and what type of personnel are required to provide care for patients. Usually the overall plan for staffing is determined by nursing administration and the nurse manager is in a position to monitor how successful the staffing pattern is as to provide input into needed change.
- Staffing is a complex activity that involves ensuring that the ratio of nurse to patient provides quality care. The situation of a nursing shortage and the high activity levels of admitted patients to acute care areas complicate this process.
- Staffing depends directly on the workload or patient care needs. An ideal staffing plan would provide the appropriate ratio of caregivers for patients’ individual needs based on data that predict the census.
The staffing process
The staffing function consists of the following sequential steps;
- Analyze the job – by preparing job description, job specification and job analysis
- Actual recruitment – This would explore all the internal and external sources from where the required personnel can be recruited.
- Employee selection – This crucial step involves using such techniques as would identify and isolate the suitable people who would eventually be selected.
- Retention – When the right people have been hired, they must be retained so that they stay with the organization for a long time. This step discusses such factors that are influential in maintaining the work force.
- Training and development – This consists of all such programmes that assist in continuous growth and development of employees.
- Performance appraisal and career development – This step involves devising methods that would judge an employee’s performance over a period of time and providing opportunities to employee’s performance over a period of time and providing opportunities to employees to develop their careers and managerial talents.
DIRECTING
Introduction
This is a management function performed but top level management in order to achieve the objectives of an organization. It is considered life-spark of the organization which sets in motion the action of people because planning, organizing and staffing are the mere preparations for doing the work.
Definition
These are the steps a manager takes to get subordinates and others to carry out the organizational plans or to achieve organizational objectives.
OR: Directing means giving instructions, guiding, counseling, motivating and leading the staff in an organization in doing work to achieve organizational goals.
Directing involves:
- Telling people what is to be done and explaining how it is to be done
- Issuing instructions and orders to the subordinates
- Inspiring them towards achievement of the organizational objectives
- Supervising the subordinates’’ activities
- Providing leadership and motivation
Importance of Directing
- It guides and helps the subordinates to accomplish the given tasks as expected
- It provides the necessary motivation to the subordinates to complete the work satisfactorily and striving to do the best
- It helps in maintaining discipline of the workers through the continued supervision of their work
- Helps to integrate the various activities carried out in the
- The leadership involved in directing helps to create an appropriate work environment and build up of team work.
Process of directing/ steps of directing
- Defining the objectives
- Organizing the effort
- Measuring work
- Developing people
Elements of directing
- Communication: Is the process of passing information, experience, opinion etc from one person to another. It is a bridge of understanding. Communication involves exchange of ideas and information in order to create mutual understanding. It is a process of telling, listening and understanding. A manager has to explain the plans and orders to his subordinates and to understand their problems. He must develop a sound two- way communication system so as to be always in touch with his subordinates. Sound communication fosters mutual understanding and coordination among different units of the
- Leadership: This may be defined as a process by which a manager guides and influences the work of subordinates in desired direction. Leadership is the process of guiding and influencing subordinates for the accomplishment of desired goals. It involves the integration of organizational interests with personal goals. A person can be an effective manager when he possesses the qualities of a good leader. It is through leadership that a manager can build up confidence and zeal among his subordinates. In order to guide his subordinates in the desired direction, a manager should adopt an appropriate style of leadership. The pattern and quality of leadership determines the level of motivation. Leadership is always related to a particular situation.
- Motivation: Means inspiring, stimulating or encouraging the subordinates with zeal to work. Positive, negative, monetary, non- monetary incentives may be used for this purpose. Motivation implies inspiring the subordinates to work with zeal and confidence. No administrative action can succeed unless the subordinates are motivated to contribute their best efforts to the common In order to activate and actuate his subordinates to work in the desired manner, a manager has to make use of appropriate incentives. Various financial and non-financial incentives are available to a manager for this purpose. Motivation is a continuous process of understanding and satisfying human needs.
- Supervision: This implies overseeing the work of subordinates by their superiors. It is the act of watching and directing work and workers. This is ensuring that work is being done as planned. Every manager has to supervise the work of his subordinates to see that they do their work as desired. Supervision is one important element of the process of directing. But supervision is particularly important at the operating level management. The supervisor is in direct personal contact with the workers and he acts as the link between workers and management. The communicates the policies, plans and orders of management to the workers he also brings workers’ grievances, suggestions and appeals to the notice of management effective supervision is essential for the accomplishment of desired goals. The purpose of supervision is to ensure that subordinates perform their tasks according to prescribed procedures and as efficiently as possible.
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