David Dean Ellis LL.M MBA BA

Chapter 1

Introduction

Barbados is a 167 square mile sovereign island state located in the Lesser Antilles of the Caribbean. The island is a former colony of the British colonial Empire and is home to 285,000 inhabitants most of whom are of African descent. The island formally gained its independence in 1966.

Background

The history of healthcare in the Barbados dates back to 18^th century where solitary physicians operated within the parishes of the island and provided basic primary health services. Since that time there has been a slow but steady development of the health services spanning several decades and constitutes a continuous revision of practice and structure for the health agencies of that nation. The financial structure of Barbados’ medical services prior to its 1966 independence from Britain was patterned along the lines of the mother country in that medical services were funded and supported by grants from Britain as well as private funds from charities and private citizens.  (Downes, 2001)

The island first started its training and education of doctors in 1967. At that time, there was no formal infrastructure for the education of Medical personnel in place. It was not until after the establishment of an independent government that the island received its first official health body. The Ministry of health became the sole

“…executing agency for the delivery of health care in the public sector and has responsibility for planning, regulation and evaluation across the public, private and NGO sectors. A Minister who has overall responsibility for policy-making and political direction heads it. Decision-making is centralized and there are no local authorities.” (Barbados Health Services Act. 1969).

At present the island’s public health infrastructure comprises one hospital providing secondary/tertiary health care with a capacity of 623 beds, and 8 supporting free polyclinics. This from the island having opened its first public health center in 1953. Since that time access to emergency services especially in the private health care sector has been greatly increased including a greater number of regionally trained physicians from the University of the West Indies. (Walrond, 2001)

Policy development

Historically, Barbados’ economic strategies included five main goals;

1.The redefining of productivity in the country.

2.The creation of employment and employment opportunity for the citizens,

3.The provision of public services.

4. Economic development. 

5. Developing the countries human resource in order to expand the existing economy. (Downes, 2001)

These goals were heavily influenced by the social and economic conditions of the time and reflected a society more interested in the provision of access to services than a structured plan of social and economic development.

The first goal attempted to restructure the production of sugar as a cash crop. Since the 17^th Century, the island had been producing sugar as its principle form of foreign exchange, a process started by colonial settlers since the discovery of the island. The development of alternative sweeteners however and the removal of preferential trade agreements by the European market made the production of sugar less sustainable as a form of economic production.

The second developmental policy goal was the creation of new employment opportunities in order to reduce unemployment as most of the island’s population was involved primarily in the sugar industry, which was failing due to the macroeconomics of the time.

The third goal concerned the provision of public services such as education, sanitation, housing and most important for this study has been the provision of social services such as health facilities and the eradication of poverty in the country. Recent iterations of this objective are incorporated within the concept of enhancing human development, that is, the widening of the choices available to the population and the enhancing of the citizens ability to take advantage of these new services. Human development therefore in this context, includes social and economic development.

The fourth goal included the achievement of balanced and sustainable economic growth and development as determined in regional or physical and sectorial.

The fifth goal concerned the development of the people as a factor in increasing the island’s competitiveness in the regional and global market. Development here was seen as the creation of a human resource trained in technological advances and educated enough to contribute to the development of the island. The advancement of national productivity therefore was seen through the development of Barbadians students and scholars and the inclusion of civil institutions for a more regulated society.

Post Independence

The early post-independence development strategy was to focus on increasing economic growth through diversification of the economy. The Government hoped that the other objectives of employment creation, poverty alleviation and social equity would be achieved through the ‘trickle down’ mechanism (Howard, 1989). Early development planning was influenced by the economic thinking of the period, which emphasized the promotion of economic growth by increasing the national saving ratio (i.e., savings to national income ratio). (Downes, 2001)

Recently however, due to global economic patterns such as the 2008 financial crash, small island economies like Barbados which rely heavily on tourism and external investment have seen many adverse effects and in particular on healthcare. The Ministry’s current budget for all “non-essential” spending is $258,945,232.00 BBD, which represents the majority of its total estimated $342,381,895 annual budget for the same period.  This figure represents a drastic reduction from its actual expenditure in 2012-2013 period of $347,808,351. (Barbados Estimates 2013-2014)

Recent Economic Challenges to Barbados’ Health Services

In 2013, the Barbadian government affected a drastic reduction to public health spending as well as the Barbados drug service in the amounts of 35 million and 3 million barbadian dollars respectively creating a serious challenge for the public health services and devastating to many existing public sector programs. (Barbados Approved estimates: revenues and Expenditures. 2013-2014). The National Commission on Chronic Non-communicable Diseases is an example of such an initiative, which was seriously affected by these budget cuts with expected results. In an article titled “Health cuts may prove costly”, the local Nation newspaper quoted the former Minister of Health Dr. Jerome Walcott as saying that the cuts came with cost,

“…to human life and morbidity” (The Nation Newspaper Tuesday March 25th 2014)

This opinion has become a reality for the quality of care at the island’s only secondary care hospital. With systemic inefficiencies being reported in many departments and day-to-day hospital processes. (Reflections on Past and future directions, 2011)

In this report I will explore the effects of changes in the economic climate of Barbados with respect to their effects on both the public and private health care facilities on the island. I will also examine the impact of decreased funding on the areas of performance management, quality control and innovation in Healthcare in Barbados. In order to develop this analysis a number of health facilities on the island have been selected for review. The Sandy Crest Medical Centre established in 2006, the Heart and Stroke Foundation of Barbados established in 1985, the Wellness Centre Established in 2002, the Barbados Fertility Centre established in 2002, the FMH emergency medical clinic (Frank, Michael and Harold), which are all privately owned facilities and the Queen Elizabeth hospital the island’s only secondary public health care facility which has been in operation since 1964.

Chapter 2

Review of Literature

Key Aim

Information concerning the business of healthcare in the Caribbean is scarce due to the lack of academic research in the area. Healthcare economics in the region, like most of the developing world has always been a struggle of improving cost efficiency without compromising the quality and innovation of health care services (Alert, 2014).  In researching this topic a number of sources were examined in order to create a picture of how healthcare economics in the Caribbean and in particular Barbados operate and how processes within the system could be improved. As a result literature concerning the management techniques used in developing countries were examined in order to provide a starting point for possible frameworks, which have been used successfully to improve quality, efficiency and promote innovation.

Sources

To this end over 130 peer-reviewed articles were consulted on these topics from The West Indian Medical Journal, Emerald Insight, PubMed, Biomed and JStor.Org.  The study also incorporated 18 texts on management theory.

Key Search terms

Key search terms included “Healthcare management”, “Innovation in Health Care Systems”, “Quality care delivery” and “Cost reduction in Health care”.

Inclusion Criteria

Sources were included based on their relevance to the managing of health systems specifically in the area of quality and innovation as well as their ability to be translated into the context of a developing nation and in particular fit into to the current structure of the Barbadian healthcare System. For this reason, only frameworks and methodologies researched in the last 15-20 years were included in the study as any information or statistics preceding this time frame would have predated the first Strategic plan for Health document published by the Ministry of Education (2002). This document restructured the healthcare environment and reshaped the direction of policy in the country. Studies prior to this new restructured healthcare environment would bear little relevance except in the way of background information. Exceptions to this would be the relevant laws, which predated this period as well as any academic literature containing theories relating to the development of hypotheses concerning management approaches to health care environments. A total of 13 papers were excluded based on this chronological criterion.

Using this chronological filter it became clear that the major theories which have been driving forces within healthcare globally of the specified time period have been “Lean Philosophy” as well as it’s predecessor “Total Quality Management” (Smith et al 2001, Macintosh et.al 2014, Jarlier and Protat, 2000). These management philosophies have dominated the literature with respect to their focus on quality and their process based view of operations, which provide fertile ground for innovation within many industries. Of the 130 articles reviewed for this study, a total of 80 articles contained references to these management techniques as viable means of improving organizational quality and efficiency. The applicability of these philosophies in developing nations with limited budgets however remains an area, which has not received a lot of attention and scrutiny. Assessing the relevance of such philosophies in a context such as Barbados’ health system may allow insight into the effectiveness of these philosophies in that environment.

Lean Philosophy

Lean Philosophy encompasses several “process-based” approaches that included an emphasis on systems producing exactly what the customer wants at the lowest cost and with as little waste as possible. Lean philosophy’s underlying assumption is that organizations are a concatenation of processes working towards customer satisfaction for maximum profit.

Improvements made in a Lean context should therefore concentrate on optimizing customer satisfaction. This perspective, which is widely applied in many organizations, has been termed “the process-based view”. Raab et al, (2006) suggest that “lean” should be seen as an ideal to be pursued. , Lean might include any operational improvement that includes waste reduction, flow improvement and improved customer satisfaction. This non-structured view however has negative implications in a healthcare environment with non-linear and sometimes unpredictable process combinations, where the alteration of one process may inevitably have serious effects on other systems. For instance, the altering of a hospital’s triage protocol has implications for their billing processes though the connections between the two departments may not be immediately obvious. In developing countries especially arbitrary process improvements are subject to cost restrictions depending on the scope of changes being made to a facility as a single alteration may have unintended consequences for the system as a whole.

In most health care settings the implementation of lean processes presents a challenge to even the most proficient organization.  Bryant Et al (2006) argues that the most successful lean operations seem to occur when employees manage the steps that produce value as a whole, rather than in bits or silos. In a health care setting this whole systems approach can prove quite daunting as the healthcare environments represents situations of many moveable and flexible parts. This view also poses a challenge in public sector organizations where employee feedback and value creation are not viewed as subjects of necessity because of pre-planned budget restrictions made by the government (Barbados Strategic Plan for Health 2003).

The principle challenges however which lean practitioners face in implementing lean principles in public sector health care environments involve the following:

1. Identifying and removing processes, which can truly be classified as waste.
2. Identifying what users of the system truly consider as being value in a health care setting.
3. Fostering a culture among staff which can be considered as continual improvement

Identifying wastes in a healthcare environment

Professor Domingo of the Asian Institute of management (2013) suggests that the seven types of waste in any process or service industry can be reduced through a five step process which involves;

• making waste visible,
• being conscious of waste,
• being accountable for waste,
• measuring the waste
• eliminating and reducing waste.

This process would naturally involve many sub processes and implications when applied to the public sector, such as; who is ultimately accountable for “waste” in a public sector health Facility, what are the costs involved in the identification process and what are the implications of lean implementation on the culture of the facility. Bouville and Alis (2014) suggest that lean solutions such as delegation of responsibilities, standardization, job rotation, quality management) lead to the worsening of employees’ attitudes (job dissatisfaction, desire to leave one’s employer) and employees’ health at work in many organizations and therefore cannot be seen as being positive in every situation. Their study on these aspects of lean implementation however was restricted to the manufacturing industry and therefore should not be generalized across all industries.

Identifying what constitutes value in a health care system

The idea of value creation is a problematic concept in healthcare when viewed from the perspective of the patient. Porter (2010) states:

“In any field, improving performance and accountability depends on having a shared goal that unites the interests and activities of all stakeholders. In health care, however, stakeholders have myriad, often conflicting goals, including access to services, profitability, high quality, cost containment, safety, convenience, patient-centeredness, and satisfaction.”

From the patient perspective however it is easy to generalize and relate quality to positive outcomes of intervention however Berg and Ikkersheim (2013) report includes several indicators which can be described as patient centered value-adding including speed of delivery, and response of clinical staff.

Value creation in healthcare therefore is as subjective as value creation in product manufacturing and not easily measured.  Whereas Porter (2010) postulates that value in healthcare should always be measured from a patient centered approach, he adopts an “outcome-focused” measurement scale to assess value. This scale however does not necessarily provide a useful tool when measuring chronic and Palliative care as outcomes are of less importance than the day-to-day care and treatment of the patient in these instances. Both Porter (2010) and Berg and Ikkersheim however focus on developed countries and fail to take into consideration that the idea of value in healthcare may differ greatly depending on the economic environment and the geographic location of the facility. It is expected for instance that patients in a highly developed and prosperous society may have different expectations from their healthcare system than patients with little or no access to medical care.

Fostering a culture of continuous improvement and Quality 

In a study of the effects of aspects of lean production on workers attitudes Bouville and Alis (2014) show that Job satisfaction and Employees commitment to the job is directly related to the “version” of lean which is implemented in the organization. In particular standardization (creating repetitive uniform tasks), problem solving demand, and Quality management was proven to have some negative effects on job satisfaction, health at work and intent to stay in the job. Conversely job rotation had a more positive outcome on these indicators. The study did however conclude that Lean production implemented without particular Human Resource practices such as training, resulted in less than desirable effects, a view which is supported by Paracha et.al (2014) in their examination of the high performance work systems framework (HPWS) in the service industry. Though applied to education this study concluded that Human Resource Management engagement and support were integral to creating and maintaining optimum performance in the service industry. These studies however are limited in their application to healthcare environments and assume that human resource training and quality assurance measures are available. Healthcare environments for instance comprise individuals who are expected to be highly trained by the institutions of learning from which they originate; so training here assumes a much different perspective and may involved more quality assurance and monitoring which in itself may prove costly and time consuming.

This top-down approach when implementing change in an organization has been examined by many researchers (Kroeber and Kluckhohn.1952, French and Bell 1990) as a necessary component in fostering an attitude that is in line with lean thinking and continuous improvement. In a health care setting however the challenges posed by an ever-changing environment comprising of diversely trained professionals from differing socio-economic backgrounds does present unique challenges organizational change.

Specifically is the problem of the line supervisor’s interpretation of what constitutes waste and what constitutes improvement. It may not be advisable or efficient therefore to adopt a top down approach to implementing lean in this setting, as management must necessarily rely on the feedback and expertise from the supervisors who actually work on the floor in these settings. Conversely operating from the bottom of the organizational ladder in small incremental changes also presents its challenges to the whole organization especially when budget restrictions are factored in to the equation.

TQM in the field of healthcare

Total Quality Management (TQM) is a comprehensive and structured approach to organizational management that seeks to improve the quality of products and services through ongoing refinements in response to continuous feedback from customers and staff. Using this management framework, I will examine some of the decisions and strategies, of the private and public Barbados’ health services with respect to their attempts to improve the quality of their service in the face of funding restrictions. TQM works by measurement and finding the right criteria to assess and track quality levels. In health care settings, excellence is usually measured in terms of health outcomes and patient satisfaction.

TQM focuses on five major concepts (Deming. 1982; Juran, 1989). They are

1. Focus on customers
2. Continuous improvement and learning
3. Participation and teamwork by all employees
4. Measuring outcomes of initiatives through surveys etc.
5. A process approach to improvement

In a private sector health facility however, business performance is important to the sustainability of Quality improvement programs. Commitment of top management is essential. Substantial inflow of resources, adequate training, workforce participation and effective measurement techniques are some of the key components of success. O’Riordan (2012) for instance explores the financial effect of TQM implementation from a managerial accounting perspective and argues that return on investment may not be the most relevant or immediate priority in such an initiative and that the actual measurement of the success of a TQM program in itself makes for a rather costly endeavor.

Jarlier and Charvet-Protat (2000) make a convincing argument for quality improvement in Public sector healthcare environments by suggesting that whereas quality comes with a cost to implement, the failure to provide quality can be even more costly as the cost of correcting failure may be greater than the original cost of quality improvement. The research based on collected data from quality programs in hospitals published between 1992- 1998 reveal substantive evidence that there was a decrease in overall long term cost to institutions which concentrated on quality improvement.

Al Rashdi (2011) however makes the point that quality improvement comes with its particular challenges not least of which is the complexity of the healthcare environment and the fact that many healthcare processes contain a wide range of costs, a lot of which are intangible and hidden. He also makes the point that public healthcare providers tend to separate finance considerations from quality control because of the perception that they are external to a competitive market environment. This perception is particularly relevant in small island economies where there is little or no substantive competition to the central health care authority.

The Barbadian context

The Barbadian Health Service has undergone an interesting developmental process much like that of health services in the United Kingdom. E. R Walrond (2001) describes this process:

“At the beginning of the 20th century, Barbados was described as the unhealthiest place in the British Empire; at the end of the century, it is considered amongst the healthiest of developing countries.”

This statement however has not been substantiated by factual data, as very little data is available on the implementation of quality control initiatives in the Barbadian health services. Indeed there is a marked absence of what Alert (2014) describes as “hard data” to support this claim. In his essay Alert asserts that the hard data available pertains to mortality statistics, which show Barbados has the lowest mortality rates from strokes, but comes in behind its regional island neighbors St. Lucia and Bahamas in terms of the mortality rates from heart disease. Jamaica, Grenada and St. Vincent have lower death rates from hypertension than Barbados; Jamaica and Bahamas have lower death rates from diabetes than Barbados. These statistics however do not provide conclusive evidence on the efficiency of a health system or the innovation present within it as a number of factors, which are external to the health organizations such as socio economic conditions, genetics, and public infrastructure such as sanitation; water supply and safe roads affect it.

Also Alert found no data available to allow a comparison between fee-for-service private healthcare versus free public care, but suggested that public perception tended to favor private fee for service healthcare as being superior to public healthcare in the island.

The reality of healthcare in Barbados

There are limited data on the efficiency and quality of healthcare on the island.”              

Mason (1998), reports a number of successful lawsuits brought against the Queen Elizabeth hospital for carelessness for amounts exceeding $350,000 in malpractice litigation and punitive damages.

The private sector

Barbados’ private health care sector includes one private hospital, Bayview Hospital, as well as pharmaceutical, laboratory, diagnostic, dental, reproductive and physical therapy services (Canadian Trade Commissioner Service, 2010).

Like the public sector there is a marked absence of data on the performance and quality provisions, innovation and efficiency of the private sector in the country. The data that is available however, shows a marked increase in the number of private clinics established on the island (Snyder et. al 2013). What is interesting about the growth of private health care in Barbados is that the large majority of these facilities specialize mainly in one field of medicine, which is an indicator that the private facilities on the island have adapted their service offerings to become more specialized and in line with the demands of the market in which they operate. The Barbados Fertility Clinic established in 2002 for instance specializes in Fertility treatments for both local and international clients and advertises that their treatments offer a savings of over 50% off international prices whereas the FMH (Frank, Michael and Harold) clinic established in 1997 specializes only in emergency medical care and offers a 24 hour service to their clientele. (Johnston, 2012)

These marketing strategies along with the highly specialized nature of these facilities indicate the competitive nature of the private health services in the island. These facilities basically exploit the opportunities created by an overburdened health service, which is incapable or is unwilling to provide these specialized services (Mitchell, 2008).  In addition the advent of “medical tourism” has changed the focus of the business of healthcare in the island. Private health care clinics such as the Sparman Clinic has been noted as a medical tourism destination in news reports and government policy documents as it has used online advertising to attract international patients to undergo cardiac surgeries at its facility (Invest Barbados, 2010; Ministry of Health 2009; Online Medical Tourism, 2012).

The level of care in terms of quality provided however has not been researched and there is no available evidence to support the claim that private health care in Barbados is superior to public healthcare in terms of efficiency. The level of innovation demonstrated by a business strategy which is exploitative in nature as well as the streamlining of their services however indicates that these organizations are at least familiar with the concept that increased quality and a lighter more agile organization are necessary components to the survival of business organizations and in particular healthcare enterprises. This is regardless of the fact that these organizations offer far less services to the public, primarily because they are profit driven business entities which are   more sensitive to market demand than the utility of their facilities in servicing the public as a whole. (Johnston, 2015)

Hsu (2010) for instance discusses the argument of the duality of profit maximization and efficiency as evidence of the utility of the private healthcare facilities worldwide. In this “competitive market model”, the possibility of greater profits is a significant motivator for increased quality, efficiency, consumer choice and responsiveness. This is of particular importance in developing countries where the limited financial resources of the population means that private facilities must constantly be able to provide legitimate competition to government run facilities in order to survive.

Also of note here is the relative flexibility of such facilities and their ability to adapt to change. Public health services generally tend to have complicated bureaucratic structures and processes, which hinder change processes and management (McHugh and Bennett 1999, Butler 1991, Drucker 1999). Private organizations with flatter organizational structures are therefore able to implement quality and efficiency improvement schemes with greater speed Jacques (1990).

This is certainly the case in Barbados with private sector facilities, which are largely partnerships or sole proprietorships. Many of these facilities have already mobilized to take advantage of the possibilities afforded by Medical Tourism due to their lean structures and uncomplicated bureaucratic process. The Sparman Clinic, the Barbados Fertility Clinic and The Bayview Hospital for instance now actively pursue international clients both on their websites and through international advertisement. This business tactic is aimed at broadening their market reach to increase profits and allowing the public service to provide for the non-paying local clientele.

Chapter 3

Aims of this Study

Formalized public healthcare was initiated by the Barbados Health Services Act of 1969 (CAP.44) and has been controlled since that time by several iterations on this original act. The Ministry of Health, which maintains control of the island’s public health policy and strategy, has published several documents in which the Queen Elizabeth hospital has been a critical factor of many policy standards. Special note here must be made of the Queen Elizabeth ACT of 2002. This Law was passed as a means of creating legislation surrounding the management and direction of the hospital. This act established a board of directors, which was responsible for the management of the hospitals finances and the day to day running of the hospital, thus bringing a “private sector approach” to hospital management; an innovative way of bridging the two sectors.

The concepts of quality and efficiency therefore is relative when comparing private and public health services in Barbados as the objectives of these facilities differ with regard to their outlook on health care. The concepts of utility for a large population, which the public sector employs, and a market sensitive, profit maximization approach, which defines private enterprises, would necessarily approach quality and efficiency from different perspectives.

Study Aim 1: Describe the quality of care management in Public and Private Health Care in Barbados.

Study Aim 2: Describe efficiencies and inefficiencies of the Public and Private Health care in Barbados

Study aim 3:  To what extent does lean theory and TQM explain the results of the study?

Chapter 4

Research methodology

Design

The original intention was to conduct a single cross sectional survey in the form of a structured interview as a means of providing a comparison between the private and public health care facilities. Additionally, the possibility of online response interviews was offered to the potential respondents to accommodate their busy schedules. However, I was refused access to the public sector to conduct a survey and therefore had to rely on secondary sources of data to gain an understanding of the development of public health services in the country.

Sample

The questionnaire was distributed to 32 of the members in senior management positions in the six private health care facilities on the island after ethical permissions were secured from Senior Directors for data collection. (See figure 2) These individuals were identified based on their seniority and their experience (over 4 years) in a supervisory management position.

The first rationale for this approach lay in the fact that whereas effective change management is an all-encompassing process involving all sections of the organization; for effective organization-wide change to occur, it must necessarily first be sanctioned by top-level management. The power dynamics in an organization are very important to the success of change management since only top level management are able to affect system wide change. (Morgan, 1997, p. 170)

The second rationale involves the more informal aspects of change management which include attention being paid to the complexity of the change involved, the organizational culture and most importantly its leadership which have a direct impact on the organization’s ability to adapt. (Fayol 1949, Naylor 2004, Mintzberg 1979).

In total, a convenience sample of 19 senior managers were taken for data collection, With 8 members refusing to participate and four candidates who were identified but failed to respond to the contact.

The rationale for the inclusion of only senior management in the survey deployment stems from the possibility of them having a  “bird’s eye view” of the health industry.

These staff members were first contacted via the telephone and an introduction letter sent to their organization. An interview time was set up for candidates who responded to the introduction letter and a “follow up” phone contact was used for individuals who had not responded within a week. A policy of two follow up calls was employed before candidates were considered non-responsive. Of the population approached, 24 candidates responded to the introduction letter whereas 8 candidates required a follow up contact. Three of the candidates identified were not in a position to respond to the study due to logistical reasons such as being on vacation.

The following private institutions were contacted and a request was made for respondents from all senior management positions both clinical and administrative. The request was left up to the discretion of the company to nominate a respondent:

• The Sparman Clinic
• Sandy Crest Medical Centre
• The Wellness Clinic
• The Barbados Fertility Centre
• The Heart and Stroke Foundation of Barbados
• The Bayview Hospital

Of the institutions contacted, the only private secondary institution, the Bay View Hospital declined to participate in the study. The final sample size included 20 respondents that fit the criteria of senior management positions including Clinical and Administrative staff members. One of the these candidates however was in the process of retiring from their position and asked not to be included as a substantive contributor to this study.

The Structure of the Queen Elizabeth Hospital, the island’s public secondary facility represents a highly bureaucratic public structure with a 12 member board and an executive branch containing the directors of the six divisions of the hospital which are medical services, nursing services, financial services, human resources, support services and engineering services. The directors coordinate the day-to-day activities of the hospital and communicate Board objectives whilst collecting information from staff and the public to advise the Board. They also facilitate teamwork and monitor performance.

The facility was initially contacted, via the secretary of the Board of Directors. The facility maintains a protocol for individuals who wish to conduct research on their premises, which involves a submission of a research outline as well as a proposal. Both of these documents were submitted and reviewed by the facility directors.  After several weeks and three additional follow up contact attempts the facility returned no response to the proposal and a decision was made to utilize secondary sources which were more readily available as a means of exploring the methods used by the hospital in approaching the areas of quality research and efficiency explored in this report.

Limitations

The online response option via the use of VOIP (voice over internet protocol) and telephone interviews offered to these professionals clearly presents the problem of whether these professionals did indeed fill the forms out themselves even though a consent form with a signature field accompanied all forms.  This method also has the limitation of not being able to ensure that the professionals who chose to answer in this manner were made to “think” about their answers and was not responding as a matter of rote, which is a drawback of interviews, which are not conducted face-to-face. To compensate for this, a “follow up” call was made to the respondents to ensure that the information contained in the consent forms and questionnaires were indeed their own responses. Two members of the sample chose this method of responding.

Ethics

Considerations

A consent form was also attached to the questionnaire to be filled out by candidates who wished to participate in the study. (See table 1)

All data collected from Primary sources were stored in an encrypted file system with password protection both at the program level and at the operating system. Digital copies of respondent information were imported into the data analyzing software and the text files were deleted to ensure privacy. Also data are reported in a way that safeguards anonymity, group statistics and non-attributed quotations.  

Identification of respondents

Target facilities were initially contacted by telephone and a sample of the questionnaire along with supporting documentation from the Edinburgh Napier University was sent via email to a senior manager who was identified by querying the receptionist of the facility and asking for the director or manager. The manager was then requested to distribute the information to all senior managerial staff of these facilities specifically senior members of the administration, department heads, and clinical supervisors.

The method of deployment had to be flexible to accommodate the busy schedules of these professionals, so respondents were also allowed the option to fill out a  questionnaire online and return via email pending an interview date.

Survey Instrument

The questionnaire employed was designed to capture both numerical and subjective and open response data from the respondents. The rationale for this approach was to reduce the reliance on purely statistical analysis of a potentially low number of respondents whilst maximizing the richness of the data.

Structure

The instrument comprised 10 questions that were structured into three sections. Questions 1-3 were given to establish the position and role of the healthcare professional within the context of Barbados health system.

Questions 4-8 were given as a means of probing what challenges health care providers operating in the island face and their methods of responding to these challenges. The instrument focused particularly on the challenges posed by financial restrictions however as this is of particular interest given the current budgetary cuts by the Ministry of Health.

Questions 9-10 focused on collecting the opinions and judgments of the experienced professionals in determining what they believe were the solutions to the problems they faced. In particular, there was an emphasis placed on whether improvement techniques adopted from business management theory could be applied to work within the Barbadian Health Service.

Secondary sources

Information concerning the Queen Elizabeth hospital had to be extrapolated from existing publications

The secondary sources of data chosen were based on their relevance to the themes identified for research as well as for their ability to provide insight into the management strategy used by the facility. The search for literature on the hospital included official government publications and articles written by local healthcare workers published in academic forums such as the West Indian Medical Journal as well as any studies conducted on the Barbadian Health Care system by the regional University of the West Indies within the last 20 years. Official Statistics on the Public health Care System from international organizations such as the Pan American Health Organization (PAHO) and the World Health Organization were also included as supporting evidence for the themes explored in this report.

Sources were also chosen based on currency and applicability to present day operation of the facility.  As a result sources more than 10 years old were not included as being relevant to the study. A total of 21 publications out of the 33 reviewed were used as sources for this study. 

Data analysis

All the data both primary and secondary sources was collected and imported into the MAXQDA data analyzing software. The program was coded to search out and isolate such terms and phrases as “Efficiency”, “Quality care”,  “Budget cuts and restrictions” and “business strategy”. This search criterion was used as a means of identifying areas in the text, which related specifically to the business side of healthcare and it’s challenges. The information was then separated by source and color coded to represent the areas, which were of more concern to the respondents and which frequently, occurred in the responses. Further analysis was done by isolating the coded text into a separate data file so that conclusions could be extrapolated as to what business healthcare practitioners believed would be the solutions to improving quality and efficiency in healthcare on the island.

Data from all respondents were then separated and focus was placed in particular on what the respondents regarded first as “challenges” (questions 4-6) and then as solutions (questions 7-10) to healthcare in Barbados.  The answers were then assessed based on the frequency of the occurrence of certain phrases and those formed the basis of the themes, which were explored further.

Likewise the use of secondary sources was filtered in order reveal important themes and concepts, which kept occurring in the text. The analysis revealed similar methods used by both sectors in approaching the challenges of a restricted budget such as the concept of incremental improvements and “innovation through design” which were adaptations of the improvement strategies used on a larger scale by industrialized countries in their healthcare systems

Analytical rationale

All responses collected from the interviews were filtered to preserve the integrity of the data.  Individuals who either were going into retirement or could not for logistical reasons complete the consent form were not included in this study.

Data were then separated into categories of numerical and open-ended answers from which trends pertaining to the research aims were extrapolated. Due to the small sample size all numerical data was converted into percentages to demonstrate the relevance of specific themes explored in the research.

Secondary source of data were collected and sorted based on their value to the research being conducted and in particular with respect to the original purpose of the publications.

Publications were carefully read and key points pertaining to the research aims were noted and extracted in context in a separate document. These notes were then collected and compared to the findings in the primary data collections to form a narrative as to the operation of healthcare in Barbados.

Chapter 5

Findings

Quality Care Management in Barbados

Quality, as defined in a Barbadian, context represents a reactive methodology geared towards meeting the needs of the population in an adequate manner as opposed to improvement strategies aimed at raising the standards of an already existing and functioning system. This is particularly true in the Public service but is also true in the Private sector because of specialization. (Downes, 2001. Walrond, 2001)

The Public Health system

Quality management has traditionally been the sole responsibility of the Barbados government. Recently however, here have been initiatives created for the purpose of improving the standard of quality both in the private and public sector. One such initiative has been the National Initiative for Service Excellence (NISE). This organization was created in 2012 through a social partnership between the government, the private sector and non-profit organizations for the purposes of raising the quality of services within the country. (Barbados Social and Economic Reports.1996- 2013, 2013)

The initiative however represented an inadequate measure of maintaining quality standards in the public sector as the organization’s purview, though very broad, lacked the authoritative power to enforce quality standards or reprimands for failure to provide quality (Tudor, 2011).

The Ministry of Health does maintain a team of Health officers who are charged with the inspection of all public health facilities; however their responsibilities also include the inspection of all private facilities as well. This leaves the issue of quality assurance largely up to those facilities, which serve the public as an in-house affair. (Barbados Social and Economic Reports.1996- 2007, 2008)

Quality and efficiency strategies in Queen Elizabeth Hospital.

Following a ranking of 3^rd in the Barbadian Government’s National Initiative for Service Excellence award scheme in 2010, the Queen Elizabeth hospital conducted its own research into patient satisfaction and the level of service, which the facility was capable of providing. The self-administered survey returned that the facility was underperforming in the areas of the environment of care and interpersonal relations. (Reflections on Past and Future Directions, Queen Elizabeth Hospital, 2011.)

This prompted the executive to initiate the development of its first Service Quality Program to improve the level of service provided to its customers. The program was piloted on 14 health care departments and involved 274 participants. (Queen Elizabeth Hospital, 2011)  A positive first step towards approaching quality care from a Total Quality Management perspective, this measurement phase led to the instituting of such programs such as the refurbishing of the hospital’s reception area in 2012 as well as the decentralization of its emergency response department which has reduced response times to the north and west of the island (Roberts et.al 2012).

Amidst continual increases in cost and demands made on the resources of the hospital, alterations were made to the way the facility approached quality management and improvements by a process of incremental changes made to key departments (Barbados Strategic Plan for Health (2002-2012), 2003). Statistics from the Barbadian government’s budgetary estimates show that there has been a steady increase in cost to the facility from $139,345,000 in 2006 to $182,549,000 in 2011, which has forced the facility to reconsider many of its operating strategies (Barbados Estimates: Revenue and Expenditure 2009-2010, 2010).

The private sector approach to quality management.

The development and proliferation of private sector health services in the island comes as a direct result of the inability and unwillingness of the public sector to provide some specialized services that are in market demand because of a restricted budget and an emphasis on providing essential medical services (Queen Elizabeth Hospital, 2011).

In their overview of Barbados’ Medical Tourism Industry, Johnston et. al 2012 state,

“The quality of care at the Queen Elizabeth Hospital is well regarded in the Caribbean and is a point of pride for Barbadians. Despite this, the hospital infrastructure is in need of significant renovation and investment” (pages 7-8)

These facilities therefore have sought to exploit the gaps in service created by the inefficiencies of the public sector (Hsu, 2010). Eighteen out of the 19 respondents interviewed in this study (94.7 %) saw their facilities as providing direct competition with the rest of the private sector but in particular the public health service was seen as the major source of competition. As one respondent explains,

“The Government offers free primary care, which competes with a medical facility such as my clinic, a pay-for-service clinic. In spite of government cut-backs to the public health facilities, the private medical facilities such as mine cannot compete on the basis of price, nor can we compete with some free medications, for example cholesterol-lowering medications to patients under the age of 65 years, offered in the government clinics”

In response there has been a major effort made on the part of the private sector to upgrade their service beyond client expectation in order to recruit and maintain a client base. (Johnston, 2012)  Of the 7 clinics contacted for this study, only two of them did not possess an active up to date website, three facilities offered private emergency ambulatory facilities to their patients and one facility offered free wireless internet in office to patients in the waiting room. These add-on feature services represent an attempt on the part of these facilities to add value to their offerings in order to be perceived as more appealing to customers and as a result become more competitive in the market. Competition therefore is managed both from the functional aspect as well as the value-added perspective as these facilities continue to approach the business side of healthcare from a customer-oriented perspective.  Another respondent described the strategy of his facility,

“The quality of care offered in-house is an important part of trying to hold on to a shrinking patient base, so particular attention is paid to taking as best care as possible to all patients coming in through the door. Attending Continuing Medical Education (CME) activities helps the physicians to keep up to date in terms of what is available locally, and stressing the importance of good customer care to the non-physician staff allows the establishment of a friendly yet professional, patient-centered environment within the office.”

Quality management therefore in Barbadian private facilities is seen as a strategy aimed at attracting clientele and maintaining a stable customer base, which in essence is good business acumen. Value-added services such as an online help presence and updated waiting rooms with free Internet are seen as upgrades to the quality of service provided by these facilities by their patient/clients.

In providing these facilities, the private sector has sought to improve the quality of their services and efficiency of delivery. This marketing strategy is based on the failure of the Queen Elizabeth hospital to provide prompt medical attention at its accident and emergency ward (Johnston et al 2012). The average times recorded at the Queen Elizabeth from “door to doctor” during the years 2009-2011 was four hours. (See table 2) This inefficiency as compared to the waiting times offered by private clinics has created the opportunity for facilities like the FMH to exploit the market for emergency patients on the island. (Reflections on the past and future directions, 2011)

	Standards	2009	2010	2011
Total Number of Patients		38,806	40,432	41,711
Leaving Without treatment		4959	4884	4758
Door to Triage (mins) mean/median		45	44	40
45	44	25
Door to Doctor (Hours:mins) Mean/median		5.15	5.18	5.20
3.24	3.25	3.00
Door to Door (Hours:mins) Mean/median		9.07	9.17	9.14
6.47	6.58	6.22
Average number of 2B patients per month		711	646	809

Table 2. Showing efficiency rates at the Queen Elizabeth hospital between 2009-2011.

This exploit of opportunities provided by the gaps in public health services provides growth opportunities for other private facilities. Of the private facilities taking part in this study, only the Barbados fertility Centre did not offer Chronic Non Communicable disease management, as an add-on service in order to increase their income which is a major health concern to the island at present. This is largely because the facility is highly specialized in providing in vitro fertilization services and at present has no competition on the island.

Additionally, these organizations have also embraced the concept of preventative care and rehabilitative services. Both the Sparman Clinic and the Heart and Stroke foundation of Barbados have added exercises and rehabilitative facilities to their services. These add-on services give these facilities access to other target markets within the population as well as adding perceived value to their service package. (Snyder, 2013. Johnston, 2012)

An Explanation of the inefficiencies of the Public and Private Health System in Barbados

One of the more troubling aspects of Public Sector health care in the island is the relative inflexibility to changing conditions and the heavy bureaucracy, which still plagues the system. (Deane et. al 2008) The Ministry of Health still maintains control over the public primary and secondary care facilities on the island despite instituting a board of Directors to run the Queen Elizabeth hospital in 2002. The existing structure now has three layers of Bureaucracy with the Minister of Health as the final authority. Also of importance is that primary and secondary health care services are not placed under the same portfolio with the permanent secretary being the officer in charge of secondary health care services and the Chief Medical officer holding the portfolio of all primary service facilities in the island. (See figure 1) This division of Authority between the primary and secondary services in the country complicates the process of implementing improvement strategies as these services are separated not only by different authority structures but different financing allocations as well. (Barbados Health Systems Profile 2008) As an illustration, the Health Systems profile 2008 declares;

“The pattern of the Ministry’s funding for different activities showed that the most outlays of public health funds corresponded to the provision of hospital-based services. It also underlined the small percentage of funds destined to primary health care services. This suggests that the trend is to focus mainly on secondary and tertiary services (institutionalized care) rather than on prevention, treatment, and management of illnesses (primary health care).”

Figure 1. Showing Public Sector Organizational Chart as of 2015

This concentration on Secondary health care services has created a burden to the health system with patients seeking treatment at the island’s only secondary care facility for conditions, which could effectively be treated at the primary health care centers (Alert, 2011). The phenomenon has created a bottleneck in services at the facility with average waiting times between arrivals and actually seeing a clinician ranging from 3-4 hours. A statistic, which is well below the average waiting times of 163 minutes of the emergency hospitals in, developed countries such as the United Kingdom. (http://www.nidirect.gov.uk/emergency-department-average-waiting-times)

The funding structure of public health services in the island also places a barrier to the efficiency of the system. The island maintains a system of budgetary allotments for each Ministry in which projections are made as to the costing of social programs and the efficacy of these programs are debated in Parliament. The ministries are then granted their annual financial allocations and in Barbados, a large portion of the allocation made to the Ministry is reserved for the development of secondary care services.

This however creates a situation where the entire health system becomes “locked in” to certain policies and directions for one year and adaptability is sacrificed for the maintenance of a stable policy direction within the system. (Health Systems Profile Barbados, 2008 pg. 20)

A very recent example of how this system can be counterproductive to the public health system was demonstrated during the 2008- 2009 global economic contraction that saw the island’s gross domestic product shrink by 3.6%. Government allocation to Health at the start of the crisis was $458,773,151 but the real expenditure at the start of the global economic crisis was recorded at $406,510,095. (Ministry of Finance, 2009-2010 pg.4).

The shortfall in government expenditure to the health profile brought subsequent negative effects on all aspects of health services. The Queen Elizabeth Hospital reported an ever widening gap between the Ministry of Finances budget allocations for the facility and the facilities recurrent expenses in the years 2009-2011 in the amounts of $1,574,000, -$23,678,000 and -$28,455,000 respectively.

This gap in available resources was addressed by the Executive of the facility in their annual publication in 2011;

“The existing package of services currently available at the QEH is under-funded and the hospital is not in a position to sustain the current package of services to which the population has become accustomed and enjoyed.’ (Queen Elizabeth Hospital, 2011)

Lack of funding therefore is a direct impairment to efficiency in the public service as most of the integral service offered by the system and it’s only functioning secondary healthcare system is funded by the government and is therefore sensitive to changes in regional and global trends (Johnston et. al 2012, Alert, 2014).

The private sector

Unlike the public sector, all the private facilities included in this survey were funded largely from private sources and as such were able to provide levels of quality which are commensurate with the amount of capital raised either through bank loans or through private donations (Johnston, 2012)

The Barbados Medical Professionals Act passed in parliament in 2010 was instrumental in standardizing the professional responsibility and conduct of medical staff on the island. The act however limited medical specialists from advertising themselves as health care professionals except under the following conditions;

• In public notices where the announcement of his professional status is required and authorized by law
• In reports and announcements of a bona fide commercial, civic, professional, social or political organization in which he serves as a director or officer
• In connections with medical journals, articles and medical publications and the dignified advertisements of these texts
• In announcements of any public lecture, address or publication by him on medical topics

The Act went on to state that any Medical Practitioner or specialist whose advertisement breaches the rules of the council is guilty of professional misconduct.

This severely restricted the kinds and amount of marketing strategies to which Physicians were capable and suppressed direct competition among private physicians in the island. (Barbados Medical Professionals Act, 2010)

The proliferation of private practices and facilities was a direct response to this legal barrier as physicians found methods of subverting the legal restrictions of the Barbados Medical Professionals Act. A loophole to the act was that Physicians could legally be expected to market themselves as being part of a commercial enterprise, which provided health services. In addition, physicians who were attached to non-profit organizations could receive indirect advertising as a result of media attention on these organizations (Johnston et.al, 2015).

The act also created an imbalance in the competition between physicians in private practice and those attached to public health institutions who became virtually insulated from competition because of their status as being part of the public health care system (Johnston et. al, 2015). Fifteen respondents to the survey (78.9%) claimed that they considered public facilities to be their greatest form of competition especially since primary health care services were perceived to be free of cost.

Private physicians therefore have the tasks of surviving in a legally restricted environment as well as competing with a public health service, which offers free care to a limited market.

This situation has made for an environment in which private facilities have to be selective on the kinds of treatments they offer based on the return on investment, which they are likely to receive.  Popular treatments such as inoculations and vaccinations, which offer a relatively low return on investment, are referred to public primary health facilities or to the Queen Elizabeth Hospital. Of the 5 facilities that participated in the study only one (Sandy Crest Medical Center) confirmed that they offered inoculations as part of their service package. The realities of operating in a restricted environment has been a major challenge for the private facilities on the island seeking to expand and improve the level of services offered to the local population. As one respondent explains,

“The Government offers free primary care, which competes with a medical facility such as my clinic, a pay-for-service clinic. In spite of government cut-backs to the public health facilities, the private medical facilities such as mine cannot compete on the basis of price, nor can we compete with some free medications, e.g. cholesterol-lowering medications to patients under the age of 65 years, offered in the government clinics”

Analysis of the business of healthcare in Barbados with respect to how lean theory and Total Quality Management has impacted on the results of the study

In the face of restricted budgets and challenges from the external environment every business system must adapt in their operations if they are to survive. In developing countries like Barbados adaptation can take many forms and in the public service in particular the concept of reducing operating costs while increasing productivity (Lean Thinking) as well as a customer-centered approach to quality (Total Quality Management) represents some of the more popular ideals of any improvements made to the health services.

Lean thinking in Barbados’s public and private health service.

Lean Philosophy encompasses many different aspects and practices. Within a developing country with financial challenges on its health system however, certain aspects of this philosophy become more relevant. Indeed most of the literature on the implementation of Lean practices in developing countries tend to concentrate on continuous improvement to the already existing system (Chrisholm and Evans, 2010, Campbell et.al, 2008, Grimshaw et. al, 2006)

One of the foundation principles contained in Lean thinking is the concept of the elimination of waste as a strategy to reduce costs. This concept however has been approached as a reactionary step through policy adjustments, which seek to reduce what government administrators interpret as waste.

In 2011, the Barbados government reviewed access to its health policies as well as its immigration law and adopted a policy of removing access of healthcare to individuals who were not citizens or permanent residents. The particular wording of this new policy communicated to doctors through their union state:

• No medical services, including diagnostic, clinical or pharmaceutical shall be provided to individuals who are not citizens or lawful permanent residents. However, medical services can be provided in circumstances of genuine emergency, pre-natal care, immunization, conditions of current public health significance and HIV/AIDS treatment; and (ii) Individuals who are neither citizens nor permanent residents shall be advised to seek medical treatment from a private sector provider of his or her choice.  “The above policy is also applicable to individuals residing here on work permits,” the document said. “Within this policy framework, you should note that only patients outlined at Paragraph 1 would have their laboratory tests done at the Winston Scott Polyclinic Public Health Laboratory. Persons will be required to have their identification card and/or other documents on hand to verify their status. “However, should there be any indication of a public health threat/infectious disease, the request for laboratory services will be honoured.

(www.nationnews.com/nationnews/news/49098/-national-health-care-limit#sthash.CiPq8ITw.dpuf.) 

This conservative measure was introduced as a means of alleviating what the Barbadian government saw as wasteful practices and alleviating some of the financial burden on an overly encumbered public service.

In terms of the criteria for a high performing health care organization this policy represented a step backwards in that it immediately restricted access to healthcare for a large percentage of the population as individuals who the government did not consider “regular” within the country had to pay to obtain care which had previously been free. (Snyder et.al , 2013)

Process improvements and continuous improvements (Kaizen)

Yet another foundation in the concept of Lean thinking is process improvement as a means of increasing efficiency in a system. To this end, the Queen Elizabeth Hospital has sought to increase the efficiency of its systems through the institution of programs geared at reforming the way the hospital operates in a functional manner.

One such program was the decentralization of the hospital’s emergency response department, which was an initiative, conceptualized in 2005 but which has reduced response times to the north and west of the island by 30%. (Queen Elizabeth Hospital 2011).

Another program involved the strengthening of the hospital’s collection for service system, which was improved in the financial year 2011-2012 from 39% to 80% by March 2012, which has had a direct impact on the hospital’s revenue stream (Queen Elizabeth Hospital 2011).

These examples of improvements to the hospital did not represent capital-intensive upgrades to service but incremental improvements made to select departments over time. This strategy has allowed the Queen Elizabeth Facility to work within the prevailing budget restrictions and still affect some improvements to the quality of service and the efficiency of the facility. (Reflections on past and future directions, Queen Elizabeth Hospital, 2011)

Total Quality Management and the patient/Customer Centered approach public and private health care.

Quality Management as it pertains to healthcare in general is most difficult without defining what patients and other stakeholders to the system consider to be satisfactory standards for the system.  

Total Quality Management like Lean Theory constitutes different concepts and practices many of which may not be necessary practical in a developing country with financial restrictions applied to its health services.  Also the absence of available literature and research in the context of the developing world makes it impossible to have an in-depth analysis of all the many aspects of this framework especially given the scope of this report.  Most important however to the Barbadian Health system is the aspect of Total Quality Management which promotes a customer driven approach that includes patient engagement in the decision making process to improve service options. This concept was a feature, which was absent from the policy formulation of the Ministry of Health until 2005 when the Ministry held its first Stakeholder symposium at the Savannah Hotel. (Deane et. al, 2008)

To this end, the Queen Elizabeth Hospital has made strides in public engagements through the formulation of regular patient surveys and a 24-hour hotline that was made available to the public in 2012 for the purposes of gathering the feedback of patients and other stakeholders. (Queen Elizabeth Hospital, 2011)

Once again a restricted budget creates barriers to quality improvement. Amidst continual increases in cost and demands made on the resources of the facility, alterations had to be made to the way the facility approached quality management and improvement actions had to be broken down into several manageable steps due to lack of funding. (Reflections on Past and Future Directions, 2011)

The facility however still remains the Centre point of the island’s Health System providing the widest range of services of any facility (Deane et.al, 2008).

Private facilities on the island however survive largely because the patient centered approach is built into their business strategy. (Johnston 2012). It should be understood that these organizations exist largely to exploit the gaps created by the public service in the provision of specialized services and as a result the concept of the patient’s “need” is at the forefront of the way business is done in these facilities (Johnston et. al, 2015).

The taking advantage of opportunities provided by the gaps in the health services offered by the public health sector is part of the foundation of survival of many of these private facilities. The Sparman clinic for instance advertises the ability to book an appointment online and outside normal working hours as a selling point of convenience to the customer for their facility (Johnston et. al, 2012).

Also these organizations have also embraced the concept of preventative care and rehabilitative services. Both the Sparman Clinic and the Heart and Stroke foundation of Barbados have added Exercises and rehabilitative facilities to their services. These developments have arisen from the concept of placing customer needs at the forefront of the business methodology. (Johnston et. al, 2015).

Additionally all respondents interviewed in this study were knowledgeable about the global economic trends pertaining to their businesses and 13 respondents had active plans in place to respond to what was seen as opportunities presented by certain Macro-economic trends. The Barbados fertility Clinic for example at the time of the survey was in the process of developing a smartphone application to advertise their clinic which would allow users to book appointments at their clinic through the interface. (http://www.barbadosivf.com/).

Finally, all five of the private facilities taking part in this study had some form of patient/client feedback method built into their service. These feedback methods were both applied on websites such as the Barbados Fertility Clinic (http://www.barbadosivf.com) and in office via patient feedback forms. This quality assurance strategy through direct customer feedback represents in a rudimentary form, one of the hallmarks of the Total Quality Management theory, which allows companies the ability to tailor their offerings to the market in which they operate.  (Sommer and Merrit, 1989, Kunst and Lemmink, 2005)

In particular, the opportunities created by the rising costs of health care in developing countries and the possibilities offered by Medical tourism on the regional and international level has prompted these facilities to adapt their marketing strategies and their standards of Quality to appeal to a much wider and more selective audience (Johnston et al, 2012).

The Barbados fertility clinic for instance offers a free Wi-Fi hotspot in their waiting room as a feature of an enhanced service. This “add-on” feature though not a medical necessity was implemented as a method of bringing their service offerings more in line with developed countries as a premier facility on the island (http://www.barbadosivf.com/).

Lean and TQM therefore have a place in the Barbados health system and there have certainly been a lot of influence of these improvement methods on the system albeit adapted for the situation.

Chapter 6

Conclusion

Healthcare facilities are a social necessity and involve a high degree of cost. To a small island economy like Barbados, which is susceptible to global economic forces, the concept of quality provision in health care becomes a function of available resources.  This study answers the question of the methods, which can and have been implemented by the local health care system in facing these challenges. This study is important in that it sheds light not only on the challenges which are faced by the healthcare system as has been the case in previous reports conducted by other researchers (Johnston, 2015, Alert, 2014, Waldron, 2001) but also examines the responses to these challenges within the context of the prevailing management and quality improvement frameworks used in health care settings today. This report also goes further in examining the distinction made by Johnston (2012) in examining the private and public health services of the country as distinctive in the ways they approach the concepts of financial restrictions.

In terms of the delivery of quality fortunately, both private and public health facilities have found innovative ways of managing quality and efficiency requirements despite the restrictions to their budgets over the last ten years. The private sector in particular has found methods of survival by filling in the gaps to quality care created by a public health system while the public health system has adopted techniques of incremental improvement strategies adapted from Lean methodology in order to adequately manage operations and still delivery quality care with a continuously shrinking budgetary allowance.

These incremental changes however cannot keep pace with the pressure brought to bear by the rising costs of medicines and the upkeep of public facilities. The Queen Elizabeth hospital, the island’s main secondary care facility has sought to meet these challenges by increasing the efficiency of its in house services and in particular its collections department. The facility though funded by the government still has major challenges where quality and efficiency are concerned but has sought to address these issues through the development of its own quality assurance committee, one of the fundamental principles stressed in the theory of total quality management. The creation of this committee has allowed the facility to become more efficient and to exploit opportunities aimed at increasing the quality of service without incurring substantial costs.

The private sector in contrast has over the years sought to capitalize on weaknesses created by gaps in quality offered by the public service by increasing the quality of their own services to create a market perception of superior care at private facilities. These strategies have been enabled due largely to their light and flexible organizational structures as well as their readiness and ability to embrace the Lean concepts of adding value to processes for superior business performance as well as the removal of wasteful practices in processes. This competitive stance has been motivated primarily by the need to survive in what is perceived as an open market economy and has been extended also to international markets with the advent of Medical tourism.

Legislative action however by parliament has seriously curtailed the level of competition to which private practitioners may engage. In response these practitioners have become more business oriented in their approach choosing to create private companies and partnerships to avoid the negative effects of the Medical Professionals Act (2010) on their businesses. The new private facilities on the island therefore have become extremely business-like in their approach to healthcare, actively choosing to embrace moderns concepts such as Lean thinking and Total quality management in their offerings in order to compete with the public health systems for available clientele and investment from private groups and citizens as well.

Total quality Management and Lean Thinking therefore are most relevant to small island economies and in particular those with restricted budgets like Barbados. The ability of these modern theoretical frameworks to adapt to small island environments and be applied across sectors in various ways makes them valuable. Far from just offering some solutions to budgetary problems these systems also offer insight into the inefficiencies of past management practices and highlight the need for transformational changes especially in the public service.

Literature available on the implementation of these frameworks in developed countries however shows that there are some limitations especially when it concerns Total Quality Management.

Despite the more straightforward nature of this approach there is some criticism. Shortell et al. (2005) reported that implementing TQM philosophies and practices were not significantly linked to improved financial performance, which may be a priority in private settings but not necessarily a major priority in a public health care setting where the budget parameters are predetermined. Nonetheless, positive links to perceived patient outcomes, shorter stays and charges were found. Weiner et al. (2006), however found mixed evidence about TQM’s impact on financial performance using data from 1,784 community hospitals. Alexander et al., (2006) suggest that a positive link exists between implementation intensity, quality improvement practices and lower costs per case. However, contrary to expectations, quality improvement was found to be negatively associated with patient safety indicators, such as post-operative complications (Weiner et al., 2006). All of these studies however were conducted within a European context. 

Sommer and Merrit (1994) discuss the necessary requirements for a successful implementation of TQM in an organization, which includes,

“ (1) planned, (2) organization-wide, and (3) managed from the top, to (4) increase organization effectiveness and health through (5) planned interventions in the organization’s “processes”, using behavioral science knowledge.” (Beckhard, 1969, p. 9),

However the authors admit that data concerning the successful implementation of TQM in a healthcare setting lack substantive credibility due largely to the arbitrary nature of the measurement techniques used by researchers which include measuring success based on improved bedside manner of staff which is a subjective indicator (Meyer and Rowan, 2010).

This practical approach to measurement is supported by Kunst and Lemmink (2005). They explored the link between quality management, patient satisfaction and business performance. The study was conducted on 227 hospitals in Spain, the Netherlands and the UK and discovered a positive relation between patient satisfaction and TQM process, however, patients’ quality perceptions, in relation to experience and TQM, are only modestly associated with organizational performance, measured in occupation rate and financial results.

Quality and efficiency in healthcare in Barbados remains a function of finance and available resources. At present the Ministry of Health is incapable of undertaking major quality and improvement changes due to the complexity of its structure as well as the financial restrictions, which preclude any, finance intensive programs. On the other hand private facilities with their lighter organizational structures and flexible capital arrangements are likewise incapable of servicing the majority of the population because of the high degree of specialization of the facilities as opposed to the diversity of interventions which would be required to service the Barbadian population adequately.

This report should however be viewed within the context of the time. Barbados is an ever-evolving society both in terms of development and it’s approach to policy formulation and planning. The health service of the country is also a functioning part of this evolution. Strategic success in this case therefore cannot be judged especially when there is not an established yardstick upon which to measure the effects of actions taken by the Ministry of Health in improving the quality of the health system (Berg and Ikkersheim, 2013). This report however is intended to give the reader an insight into the operation of the health system in Barbados and meant as a critique of the strategies used by the Ministry of Health.

Due to the lack of Primary data from the island’s tertiary institution also this report is limited in its ability to give up to date facts on the present day operation of the facility. Secondary sources however do confirm that the facility is indeed in the process of change and improvements have been made to its operations.

Chapter 7

Recommendations

Barbados’ Health Services remain an integral part of the development of the country. As a result, its health systems are reflective of the development of the nation as a whole. Based on the findings of my study I recommend a three-step guide to improving the quality of service and efficiency of the system as a whole, that is the Public and Private Health Systems.  This three-step process includes,

1. Viewing the health system as a whole and not as individual silos.
2. Assessing all available medical and health resources within a patient centred context with the aim of providing the best possible quality at the lowest cost.
3. Further integration of Lean principles and Total Quality Management to enhance the efficient management of the system.

1. The information gleaned through my research into the private sector reveals that private health care facilities see themselves as separate and distinct from public healthcare. Alliances therefore should be fostered between private and public facilities, as they are already functionally complementary systems. I believe this recommendation would serve the interests of both parties, as it would eliminate redundancies in the provision of services and focus all available resources on the health situation in Barbados.

An example of dual sector co-operation could be affected in the challenges, which the country is now facing with respect to chronic non-communicable diseases. The Queen Elizabeth hospital at the moment has been inundated with the burden of these lifestyle diseases and is unable to cope with the strain on its resources (Hassel 2007, Deane et. al 2008). Conversely the private sector has seen the shrinking of its client base due to the economic crisis, which the country faces. The government should therefore consider incorporating private facilities into its planning for health provision in the country in the form of subsides or incentives. Primary services therefore such as inoculations and other gaps in public service, once privatized and subsidized by the government would not only have greater benefit in terms of the reach of inoculations programs but would also add more utility to private clinics.  Another option would be to ask members of the public who could afford to pay for their healthcare to do so as a means of reducing the cost of delivery to the rest of the population.

The result of such cooperation would be the incorporation of new and diverse techniques geared towards the increasing of efficiency and quality available in both sectors of the economy. It is my belief that both the private and public sector indeed have a lot to learn from each other in terms of management strategies.

At present no such arrangement exists and what transpires is a duplication of services between private facilities, which are fee for service and considered as expensive to a large portion of the population and a public healthcare system, which overburdens the island’s only secondary health care facility with patient cases.

• One of the weaknesses of the health systems in Barbados particularly in the private sector is the absence of any assessment apparatus for quantifying the available resources and the efficient use of these resources. While the Barbados government allocates a percentage of its annual budget to the provision of health care, there are no such figures available for contributions made by private citizens and organizations. As a result the competition for funding is unregulated, and there has been no attempt made to control the sources of funding through legislation. The Medical Professionals act of 2010 though thorough in regulating the practice of medicine and the scope of medical practice in the island does not provide any guideline with respect to the acquisition of private funding by any institution.

The negative effects of the present state of affairs is that funding does not necessarily get to the areas which are most in need and not necessarily in the best interest of the public. Private investment and sponsorship therefore should be regulated and quantified in terms of the creation of a registry of donors and sponsors and the amounts donated and to which organizations so that the government is at least aware of what alternative local funding is available and from what sources. This is not however to suggest that the government should control donations made to private facilities but in a situation where funding represents a restriction to quality and efficiency in the public health care system, a knowledge base of the sources of potential funding at the local level is necessary.

A second and more disturbing effect of this is that public health care in Barbados resembles more of a product enterprise rather than a service enterprise. When the priority of a health organization is focused primarily on securing adequate funding and less on the needs of the users of that service, decisions made become out of touch with the needs of the population. This has however begun to change with the embracing of aspects of total quality management, however further steps could be taken in the form of more formal measurement techniques such as bedside and outpatient surveys aimed at gauging customer requirements. This would assist administrators in determining which areas are the most important to users and stakeholders and which are most in need of available funding and resources.

A cataloging of human resource and potential is also necessary to ensure that all staff working within the health system meets certain requirements and that in case of the absence of qualified staff, other individuals are available and qualified to replace them to avoid any interruption in service. It should be considered a necessity that the system has adequately trained personnel if it is to provide the best quality care available to its client/users. At present the government keeps a register of all qualified nurses and physicians in the island but does not keep a record of medical assistants and ancillary staff working in health in Barbados. This is especially important, as all health systems require duly trained and qualified administrative staff to maintain patient records and order within the office environment. A list of qualified persons would be an asset to both sectors as untrained personnel could lead to major inefficiencies and additional costs to the system due to administrator errors.

• No health system is completely efficient or perfect and the Barbadian health system is no exception. The Queen Elizabeth Hospital reporting their performance states that their average length of stay (6.4 days) is above Moody’s International Healthcare standard of 4.9 days. (Queen Elizabeth Hospital, 2011) In addition in 2011 25% of admissions to the Accident and Emergency ward were non-urgent care requiring. These statistics represent flaws in the system, which could be eliminated by encouraging a more thorough and structured incorporation of Lean Management principles especially in the area of front office management.

When observing the whole of the Barbadian health system also, there exist a number of redundancies such as the underutilization of the primary health care centers in favor of secondary or tertiary care facilities. (Reflections on Past and Future Directions, 2011) This trend has been a concern for the Queen Elizabeth hospital as expressed in their annual report in 2011 and constitutes waste, which should be addressed through a more Lean approach to process, which may involve the assistance of change management professionals depending on the budget restrictions of the Ministry of Health.

In this arena Public facilities could learn a lot from their private counterparts whose existence depends on tailoring their services specifically to the needs of the customer and reducing the occurrence of redundant services at their facilities to conserve capital and resources.

Quality Management in Healthcare is a necessity and not an option and requires that every improvement be measured to determine its relevance to the system. In this regard all heath care facilities should consider testing the feasibility of their improvement strategies. This feature of Total quality management should be adopted at every level and in every facility, which operates within the system. Finally any changes to the healthcare system, which would have an impact on quality and efficiency of the system, should be made formal and regularized through legislation. The absence of laws creates inequities and a lack of order in society of which the business of health care forms a significant part. At present for instance, Barbados has no laws pertaining to the protection of patient’s data such as the Data Protection Act of 1998 in the UK, neither does the country have any legislation pertaining to the rights and protection of patients. These legislative measures are important in raising the standard of professionalism and confidentiality to which the healthcare system should subscribe and in a health care system the professionalism of clinical personnel is an indicator of the quality of service offered by that system to the patients.

It is impossible to have a standardized concept of quality if everyone interprets quality of care differently. This is where legislation on these areas becomes very important. Official bodies that regulate quality should theoretically have the power and authority to enforce quality standards on institutions that fall below an acceptable standard.

The fostering of links between Public Healthcare facilities and private organizations also should be regulated to avoid preferential agreements being made at the expense of other providers and legally authorized bodies such as a Care Quality Commission be set up to monitor both private and public facilities. At present the Barbadian Government uses its health inspectors and ministry officials to ensure that minimum standards of hygiene and safety are met at these facilities however more can be done to ensure that all facilities operating on the island conform to minimum standards of quality as well.

Implications for future research.

This study provides some insight into the challenges faced by developing economies with respect to their ability to provide quality healthcare and the methodologies that can be used to alleviate these problems.

Due to the unavailability of both primary and secondary data on vital services in the country however it is impossible to gain the most accurate picture of what actually happens in practice and how far-reaching the effects of theoretical models such as Lean thinking and Total Quality management would have on the Barbadian Health system over the long term.

As a suggestion future research should be concentrated on identifying the aspects of Lean Philosophy and Total Quality Management in operation at select facilities and linking these methods to outcomes in order to determine their effectiveness over a period of time. I would also suggest that a larger sample size of professionals be included to not only incorporate the Physicians and Administrative staff but all stakeholders in order to assess the impact of these methodologies on the wider community. Furthermore parameters for this study could be assessed through a feasibility study or a pilot program conducted on one or more parts of the health system in order to derive possible outcomes and challenges, which may arise with a larger incorporation of these methodologies into the healthcare system. These outcomes could be expanded to incorporate aspects such as patient satisfaction, financial returns and employee readiness and attitude to change.

I believe that this kind of research can yield valuable information in assisting developing nations with strategizing responses to the economical challenges faced by their health systems and more importantly improving the quality of their health services both in the present and in the future.

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Appendix

Figure 1. Showing Public Sector Organizational Chart as of 2015

Health-System-Profile-Barbados-2008

Table 1. Showing Questionnaire

Name: David Dean Ellis                                                                      Student ID: 40138203 Project Title: “A strategic guide to increasing the profitability and reliability of health systems in a small island economy through an expansion of Health Care policy. A Barbados example.”
Questions	Responses
State your name:
State your occupation:
How long have you been in this position/role:
Do you think that the recent budget cuts by the Barbadian Government to Health Programs have affected the effectiveness and efficiency of your facility:
If so in what ways:
In your opinion does quality of service in a health setting relate to the amount of funding a facility receives:
What strategies has your organization implemented to ensure greater quality care delivery, improvements to their operations or service innovation:
Have these strategies been affected by the national budget cuts to health within the last 7 years:
What strategies would you implement a means of improving quality of service and greater overall efficiency within the health system of Barbados:
Do you think that health systems and facilities in Barbados may benefit from modern management strategies in operations such as Lean operations management (which attempts to eliminate waste through reorganization of work related activities) and if so how do you think they should be implemented within a Barbadian context:

Figure 2. Showing Consent form

Study Title: A strategic guide to increasing the profitability and reliability of health systems in a small island economy through an expansion of Health Care policy. A Barbados example.

Researcher: David Dean Ellis

If you have decided to take part in this research study please read and sign this consent form. 

Please initial box (do not tick)

I confirm that I have read and understood the participant information sheet, dated __________­­­­____, version ________, for the above study. I have had the chance to ask questions and I am satisfied with the answers given.

I understand that my involvement in the study is voluntary and that I am free to withdraw at any time, without giving any reason.

I understand that the interview that I participate in for this research may be audio-recorded. I understand that quotations from my interview may also be used, and that my identity will not be revealed.

I understand that the data collected during the study may be looked at by the research examiners, where it is relevant to my taking part in this research. I give permission for these individuals to have access to my data.

I agree to take part in the above study.

………………………………………………………..………….…………………….…

Name of Respondent                               Date                                                    Signature

Table 2 Showing efficiency rates at the Queen Elizabeth hospital between 2009-2011

Reflections on the Past and Future Directions. QEH report.

	Standards	2009	2010	2011
Total Number of Patients		38,806	40,432	41,711
Leaving Without treatment		4959	4884	4758
Door to Triage (mins) mean/median		45	44	40
45	44	25
Door to Doctor (Hours:mins) mean/median		5.15	5.18	5.20
3.24	3.25	3.00
Door to Door (Hours:mins) mean/median		9.07	9.17	9.14
6.47	6.58	6.22
Average number of 2B patients per month		711	646	809