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1 An Evaluation of the Management of the Information Systems (IS) and Technologies (IT) in Hospitals (GESITI-Hospitals): North-Eastern Planning Region in Bulgaria assoc.prof. Dr. Bistra Vassileva, University of Economics-Varna assist.prof. Nadezhda Kalinova, University of Economics-Varna Toni Avramov, Ph.D., MD, Saint Marina University Hospital Rositca Nedeva, MD, Saint Marina University Hospital Adriyana Miteva, Ph.D. student, University of Economics-Varna Prof. Dr. Antonio José Balloni, Projeto GESITI DTSD Abstract The aim of the report is to present the managerial situation in hospitals in North-Eastern Planning Region in Bulgaria with a focus on IT implementation. Our intention was to assess the penetration level and the key management issues during the process of information systems and technologies (IST) implementation in hospitals. To meet these goals we conducted a study using prospective questionnaire provided by GESITI project. The results helped us to summarise the challenges in IST management as well as to identify the critical points during the IST implementation in Bulgarian hospitals. Several recommendations and implications for future research were defined at the end of the study. I. Introduction The hospital sector in Bulgaria has undergone a series of structural, regulatory and financial changes over the last decade of dramatic political and economic transition. Although hospital reform has lagged behind the reform of primary health care, it has been intensified since Periodicidade da Publicação: Irregular. 1

2 Figure 1. Current healthcare ependiture 1, 2009 As shown in Figure 1, in 2009 the share of current healthcare ependiture as percentage of GDP in Bulgaria was still below European countries average. Health establishments for hospital aid by end-2012 constitute 339 hospitals with a total of beds (Table 1). Table 1. Health establishments as of , number Establishments Number Beds Health establishments for hospital aid Hospitals of which: Multi profile hospitals Specialized hospitals Dermato-venereological centres 8 80 Comple oncological centres Mental health centres Outpatient health establishments Diagnostic and consulting centres Medical centres Dental centres 49 7 Medical-dental centres _%281%29_YB2013.png&filetimestamp= Periodicidade da Publicação: Irregular. 2

3 Establishments Number Beds Medical-diagnostical and medical-technical laboratories Other health establishments of which: Centres for urgent medical aid 28 - Hospices Homes for medico-social care for children Regional health inspections 28 - National centres without beds 7 Source: National Statistical Institute, posted on Compared to the average number of hospital beds per 100 thousands inhabitants for EU-27, Bulgaria eceeds this indicator with more than 100 beds per 100 thousands inhabitants (Figure 2 and Table 2). Of them, private clinics were 92, with a total of 6915 beds. Figure 2. Number of hospital beds, EU-27, (per inhabitants) Source: 27,_ _%28per_100_000_inhabitants%29.png&filetimestamp= Table 2. Healthcare indicators, 2000, 2009 and 2010 (per inhabitants) Practising physicians Hospital beds Nospital discharges of inpatients (ecluding new born babies) EU Bulgaria Czech Republic Estonia Hungary Poland Romania Periodicidade da Publicação: Irregular. 3

4 Source: _2010_%28per_100_000_inhabitants%29.png&filetimestamp= NHIF 2 contract partners in 2011 are as follows: 4030 GP practices; 4700 doctors; 3050 specialists practices; doctors; 5432 dental practices; 5775 dentists; 650 laboratories; 330 hospitals; 2040 pharmacies. As data shows, Bulgaria's healthcare system is oversaturated with medical specialists and hospitals but yet it is inefficient and corrupt 3. According to the report published on the website of the Bulgarian Ministry of Health Care, bribes amount to around 3.6% of the total public epenses on healthcare and pose a great challenge to politicians. According to the newspaper Sega Daily, a total of BGN B have been earmarked for the sector in 2013, meaning that, following calculations of the Ministry of Health Care, around BGN M are circulating in the system in the form of donations and fees for certain services. According to the document and data provided above, Bulgaria's healthcare system has substantially more resources than average European standards. In 2012, for instance, there were 393 doctors per people, compared to the EU average of 333. Despite the promising figures for Bulgaria, however, regional disproportions cause inequalities in access to medical assistance (Table 3). Table 3. Health establishments as of , statistical regions Bulgaria and North-Eastern Planning Region Statistical region: Bulgaria North-Eastern Planning Region Establishments Number Beds Number Share, % Beds Share, % Health establishments for hospital aid of which: Multi profile hospitals Specialized hospitals Outpatient health establishments NHIF - National Health Insured Fund 3 According to a project for a national health strategy for the period Periodicidade da Publicação: Irregular. 4

5 Statistical region: Bulgaria North-Eastern Planning Region Establishments Number Beds Number Share, % Beds Share, % Diagnostic and consulting centres Medical centres Dental centres Medical-dental centres Medical-diagnostical and medical-technical laboratories Other helth establishments Source: Adapted by The supply of doctors by regions varies from 25.6 to 50.2 per people and is highest in the districts with functioning medical universities and university hospitals. According to the Ministry of Health Care, over the net 10 years, the situation is epected to change significantly as a result of the growing scarcity of medical eperts. The deficit of specialists in certain areas has the potential to destabilize the whole healthcare system and to increase the outflow of medical personnel. II. Methodology Both qualitative and quantitative methods were employed in this research. Five hospitals located in town of Varna, North-Eastern Planning Region in Bulgaria were included in the study. Two of them (coded as B1 and B2 ) are independent clinics within the organisational structure of a hospital which is registered as JSC. Qualitative stage. The qualitative study involved in-depth interviews with IT eperts, medical doctors and health care managers, as well as content analysis of secondary sources of information. Four in-depth interviews were conducted with IT eperts working in the field of health care organisations. Five in-depth interviews with medical doctors and health care managers were conducted followed by two sessions of brainstorming after the field work. Content analysis was performed for specialised reports about situation in Bulgarian hospitals and Bulgaria's healthcare system and for the customer opinion and attitudes shared in online forums. Quantitative stage. Periodicidade da Publicação: Irregular. 5

6 The prospective questionnaire provided by GESITI project was used as a tool for collecting primary information from respondents. The questionnaire was translated into English language and then to Bulgarian language. Data were collected by a combination of self-administered surveys and face-to-face interviews. The interviews were conducted by an assistant professor and a Ph.D. student. III. Results and Analysis. Results are presented following the structure of the questionnaire. Table 4. Profile of the hospitals, participated in the survey A B1 B2 C D Foundation date г.* Company s nominal capital, BGN Company s capital composition National National National National Amount of employees Total bed capacity 60 35** Annual amount of appointments that include internment Annual amount of lab appointments Annual hospital morbidity 34: Interviewed persons in the Board of Directors Interviewed persons in IT sector 1 Other interviewed persons * The hospital has been established in the 60s but the actual status was officially registered in ** Total bed capacity of hospital B equls to 1017 beds. Respondents positions in analysed hospitals are as follows: Hospital A - Medical Director; Hospital B1 - Medical Director; Hospital B2 - Assistant professor, Ph.D.; Hospital C - Medical Director; Hospital D - HR Manager. Table 5. Type of analysed hospitals Type of hospital Public Private University Municipal Periodicidade da Publicação: Irregular. 6

7 Hospitals are selected purposely to cover the whole range of different types of their ownership in order to conduct a comparative analysis later on. According to the answers, all respondents agree that their hospitals meet costumer needs and satisfy consumer wants and requirements. Unfortunately, we found out that there are a lot of negative opinions and attitudes shared in online forums about service quality provided in respective hospitals. Table 6. Health services scope of the hospitals Health services scope of the hospital A B1 B2 C D City 20% Region 70% State 10% International HUMAN RESOURCES Situation with human resources in respective hospitals are analysed based on data presented in Tables 7 to 13. Table 7. Profile of hospital s directors Number of directors General Director, President/ Eecutive 2 3 Clinical/Medical Director 1 20 Administrative-Financial Director 10 HR and IT Director 2 Hospital B is university hospital and its form of ownership is joint-stock company. The hospital includes several clinics which are managed by directors. That is why, the number of directors is much higher compared to the other hospitals participated in the survey. Table 8. Hospital s employees profile Number of employees with basic education 0 <5% 11 Number of employees with secondary 15 40% 6 82 education Number of employees with high education: 30% Business managers 4 5% 1 Doctors 37 30% 6 46 System analists 0 0 Periodicidade da Publicação: Irregular. 7

8 Engineers Economists Nurses Others The economic situation of hospital D is quite unstable. Although it is a specialised hospital (incl. provision of special vaccinations) which serves the whole North-Eastern Region in Bulgaria there are a lot of problems with financing and management. The staff was on strike several times during the last year though active strikes of medical personnel are not permitted by the law. Table 9. Training and qualification courses, provided by the hospitals to their personnel Hospital provides qualification courses to their employees. Formal programme or training guideline for top leadership, medium managers and technical staff. A B1 B2 C D A B1 B2 C D Don t know According to the data, hospitals do not provide systematic (if any) training and qualification courses to their personnel. Usually medical doctors invest their own money for qualification, participate in projects or apply for grants in order to finance their carrer development or to participate in international conferences. The most recent courses attended by the respondents are as follows: Hospital A - Medical imaging; Hospital B2 - Specialist Hospital Care. Table 10. How the courses are conducted? How are the employees training and development conducted (personal training inside or outside the hospital, e-learning, streaming (via internal or eternal video) From the efficiency and effectiveness results of each process From the search of needs by the leadership Internal training modules with outsourced trainers E-learning or presence courses in market recognised companies Periodicidade da Publicação: Irregular. 8

9 These results support the above conclusion that training and qualification courses are not planned in advance. Staff development can be considered an ad hoc activity. Table 11. The average staff proportion who have been trained for the last 2 years Top management Intermediate management Professional supervisors Administration professionals Main processes professionals ne Above 20% Above 50% ne Above 20% Above 50% ne Above 20% Above 50% ne Above 20% Above 50% ne Above 20% Above 50% A B1 B2 C D Number of collaborative doctors working in the respective hospitals are as follows: Hospital A 11 +; Hospital B1 7 to 10; Hospital B2-1; Hospital C - 1; Hospital D - 1. It is typical for private hospitals to have many collaborative doctors who work there, that is why the number for hospital A is more than 11 persons. Table 12. Methods adopted to promote people training in the hospital Free internet access Restricted internet access Purchase of specialized publications Subscription of specialized journals Remote learning Incentive to Master degree Incentive to Post Graduate degree Participation in national events Participation in international events Periodicidade da Publicação: Irregular. 9

10 Others Doesn t adopt any Hospital B performs better than other hospitals and provides a variety of methods to promote training and further education because it is university hospital. Other hospitals rely only on free internet access and epect that their staff will be prone to self-education. According to the performance evaluation implemented on site to the staff we can conclude that hospitals do that occasionally instead of planning it (Table 10). Table 13. Performance evaluation of the personnel A B1 B2 C D, in a systematic manner, occasionally such evaluation is implemented The final conclusion is that ecept hospital B (univesrity hospital) training and qualification courses are not planned in advance and it is epected that medical doctors and nurses will self-educate themselves. Such lack of investment in human resources development combined with the low level of wages result in low quality of medical services and increase of the outflow of medical personnel. STRATEGIC HOSPITAL MANAGEMENT According to previous research (Tsolova et al., 2007, p.6) it is not very common for the clinics and hospitals in Bulgaria to be enabled to manage the funds in a fully autonomous manner. There is a salient attitude among health care professionals that clinics and hospitals have no financial autonomy which affects directly strategic hospital management. Our results confirm that conclusion. Only hospital A doesn t have a formally defined strategic plan. One of the reasons could be the intensive training of the management staff of the state hospitals years ago in conformity to the new legal regulations which required a master degree in economics for the management staff. Unfortunately, operational staff doesn t now anything about the strategic intentions of the hospitals (Table 14). Plans are revised annually or once in a two-year period. Periodicidade da Publicação: Irregular. 10

11 Table 14. Strategic plan implementation The strategic plan is known by what group of employees? Regularity of plan revision Director level Management and supervising level Operational level Till each 3 months From 3 to 6 months From 6 to 12 months From 12 to 24 months Above 24 months Only hospital B (clinic B2 ) shows full engagement with the strategic planning process. For the rest of the hospitals only the eecutive management is involved in strategic planning process. It remains hidden or invisible for the rest of the staff (Table 15). The level of engagement of the organisation to strategic planning action The elements from which strategies are created Table 15. Engagement in strategic planning process Only the eecutive leadership participates Everyone participates Leadership and processes leaders participate There is a planning group that prepares and the leadership approves They use market, clients, competition and organization data Others Scenarios analysis Competition threats and opportunities Level of customer satisfaction Potential and actual demand Benchmarking Mission and recognized competences Others A B1 B2 C D Scenarios analysis is the most prefered tool for all hospitals included in the survey. Management uses SWOT analysis, analysis of the competencies and demand analysis as well. Customer satisfaction is not included in the scope of analysed elements despite the formally declared concern to customer needs and requirements. Table 16. Attitudes toward strategic focus and methods A B1 B2 C D Periodicidade da Publicação: Irregular. 11

12 The Customer degree of relevance (requirements, satisfaction, etc) during the strategies development. The Resources degree of relevance (requirements, availability, etc) during the strategies development. There is a follow up to the formulated strategies. Tools like Balance Scorecard are used. The hospital is aware of new technologies related to their business. High Medium Low ne High Medium Low ne Don t know Analysed hospitals follow predominantly resource-based strategic management. Such an approach could be eplained by the legal requirements and financial framework which is quite restrictive and doesn t provide a window for the management to develop customer-based management. The ways the hospital become aware of new technologies Table 17. Information sources for new technologies Journals Fairs and conventions ne Travelling abroad Consultancy Benchmarking Internet Others Journals, fairs and conventions are used by hospitals to receive information about technological development of contemporary medicine. Since hospital B is university hospital it is obvious that it will use variety of information sources, incl. guest lectors and interdisciplinary sessions. The way in which technological innovation could help the hospital Table 18. How technological innovation could help the hospital? by increasing productivity by improving quality by improving the hospital s image other forms Table 19. Intensions for future investments in technological innovation Periodicidade da Publicação: Irregular. 12

13 The hospital strategic plan and the hospital business plan foresee investments towards introduction of technological innovation of products and/or processes Don t know Respondents epress clear confidence for future investments in technological innovations which seems too positive when compared with present situation. R&D - RESEARCH AND DEVELOPMENT There is no clear predominant attitude of respondents according to the R&D activities of analysed hospitals. It is a symptom of a lack of targeted and planned in advance continuous R&D activities and efforts. R&D activities are assessed as random with low to high importance (Table 20). Table 20. Basic indicators for R&D activities The R&D activities that took place between 2010 and 2012 were The importance of R&D activity between 2010 and 2012 The importance of other eternal knowledge that took place between 2010 and 2012 Continuous Random High Medium Low Irrelevant High Medium Low Irrelevant A B1 B2 C D TECHNOLOGICAL INNOVATION Attitudes of respondents toward investments and implementation of technological innovation in respective hospitals are quite diverse. High awareness level regarding technological innovation demonstrates university hospital. Table 21. Technological profile of analysed hospitals Statement A B1 B2 C D Top management believes that competitive performance of the hospital would improve with the intensive use of Information Technology. Don t know The use of IT adds value to the services rendered by the hospital. Don t know Top management understands that the use of IT Periodicidade da Publicação: Irregular. 13

14 is seen as a factor of value adding and prompt dissemination of information that contributes to the enhancement of the hospital s performance. Are there any financial difficulties towards the investment in IT? The hospital understands the level of qualification of their staff (both employees with labor bond and collaborators) as being good enough to start implementing Information Technology. The hospital is qualifying their servers in order to implement IT/Internet. There are monitoring mechanisms of eternal environment (i.e., is the hospital alerted to the new technologies, customer s interests and concurrent hospitals strategies?) Don t know Don t know Don t know Don t know Don t know Based on the data showed in Table 21 we can conclude that only university hospital reached the level which is necessary for a profitable and effective implementation of contemporary information technologies. Top management of the hospital is determined to continue to develop IT services and to invest in medical staff qualification. One of the problems according to the respondents from that hospital is the lack of real market mechanisms which can stimulate hospitals to invest in better services. There is an attitude that health care sector is overregulated and the financial mechanisms are not transperent to the customers and general public. Table 22. Monitoring mechanisms of eternal environment used by the hospitals If the answer is YES, in what manner? Elements of the eternal environment which are monitored using IT Participation in fairs/ congresses/ events/etc IT Staff does monitors the ambiance Participation in Innovation Networks Meetings with representatives of the sector Participation in sectorial committees Other Costumers interests and/or satisfaction level Interesting technologies Competitors performance Others As monitoring mechanisms hospitals apply predominantly participation in fairs, congresses and events, followed by meetings with representatives of the sector and Periodicidade da Publicação: Irregular. 14

15 participation in sectorial committees. Hospitals monitor basically competitors performance and interesting technologies. Customers interests and satisfaction level are neglected. The eception is the university hospital. INVESTMENT IN TECHNOLOGICAL INNOVATION Bulgarian hospitals suffer from insufficient financing, which is seen as a crucial factor for both effective hospital care and penetration of technological innovation. Table 23. Hospitals investment policy in technological innovation Areas which are planned to be a largest investment for the introduction of technological innovation The hospital invests in technological innovation, regarding the billing in the last 3 years The hospital invests in technological innovation, regarding the billing of net year Management Operations Warehouse systems ERP CRM EAD (remote teaching) Telemedicine Others Less than 1% of billing From 1 to 2% From 2 to 3% From 3 to 4% More than 4% Less than 1% of billing From 1 to 2% From 2 to 3% From 3 to 4% More than 4% A B1 B2 C D A target area for future investment in technological innovation are operations for all hospitals participating in the survey. University hospital is planning to invest in warehouse system, CRM and telemedicine. Additional area which is planned to be a largest investment for the introduction of technological innovation for university hospital is the internal hospital RIS/HIS system. From strategic point of view the lack of interest in technological investments in hospital management could be considered as a negative feature. Table 24. Type of providers of innovative products / services A B1 B2 C D Тhe innovative Big national private companies Periodicidade da Publicação: Irregular. 15

16 products/ services providers in the last 3 years are Big foreign companies Small/medium sized national companies Small/medium sized foreign companies Public universities Private universities Research centers Self Development Other University hospital supports a diverse network of providers of innovative products / services while the other hospitals rely mainly on SMEs (national or foreign). Due to its unstable economic and financial situation hospital D do not pay attention on innovation. During the last few years its primary goal is to survive. The main obstacles to technology innovation already eisting in the hospital Table 25. Main obstacles to technology innovation A B1 B2 C D Allocation Low qualification of the employees Top management s view on the subject Others The main obstacles to technology innovation already eisting in the hospitals are as follows: Low qualification of the employees for hospitals C and D ; Allocation and top management attitude for hospital B. These results are easy to be eplain because hospital B is an organisation with more than 3000 employees, several clinics and many depratments which are managed by a director. As a JSC such organisation is quite difficult to be managed especially in a health care sector. Problems with budget allocation and top management decision making process are typical for such kind of organisations. Hospital A is a private hospital with clear subordination of responsibilities and management decision making process which results in other specific obstacles to technology innovation. Table 26. Types of partnership Partnerships with public entities for the development of technological innovation. Periodicidade da Publicação: Irregular. 16

17 If the answer was negative, would the hospital be willing to participate in a joint effort towards technological innovation coordinated by a public entity Do you know any kind of financing, credit line or eisting governmental incentive for investment in technological innovation? Don t know Don t know Don t know Only university hospital develop a partnership with public entities for the development of technological innovation through donations and financial subsidies. Both university hospital and private hospital participate in EU financed projects through operational programmes in different fields (competitiveness, innovation, scientific research, etc.). University hospital regularly use these tools. In 2013 private hospital applied for financing with a project under EU operational programme Competitiveness of Bulgarian economy, priority field: Implementing innovation in organisations. Table 27. Hospital s priorities concerning technological innovation Automate the hospital management Use of digital mapping from the hospital Use of databases to store customers information Computerizing Others A B1 B2 C D The hospital is holding a quality system based on ISO 9000, ISO or any similar to that. The hospital is already certified. Table 28. Modernisation of medical appliances Don t know Don t know If the answer was positive, since when (year)? 2003 The hospital uses a quality management methodology (such as KANBAN, 5S, Suggestions and Ideas Program, etc.) University hospital is certified and applies quality management methodology. Hospital C is accreditated according to the requirements of the Ministry of Health Periodicidade da Publicação: Irregular. 17

18 Care but there is no certified quality system operating there. According to the respondent from B1 there are difficulties during the quality systems implementation process, especially regarding criteria which are used and which are obligatory. COOPERATION FOR INNOVATION The analysis of hospitals regarding their innovative profile will eclude partly hospital D, because this hospital faces only problems and challenges to overcome when it comes to innovation. Other hospitals are certain about their involvement in cooperative arrangements with other organisations, in order to develop innovative activities during the period (Table 29). The importance of introducing technological innovations in the hospital between 2010 and Between 2010 and 2012 the hospital was involved in cooperative arrangements with other organization(s), in order to develop innovative activities. Table 29. Innovative profile of hospitals If YES, show below the importance of each partner category: Customers or consumers High Medium Low Irrelevant Providers High Medium Low Irrelevant Other hospitals High Medium Low Irrelevant Consultant companies High Medium Low Universities and research institutes Professional competence and technical assistance centers High Medium Low Irrelevant Irrelevant High Medium Low Irrelevant High Medium Low Irrelevant A B1 B2 C D A B1 B2 C D Periodicidade da Publicação: Irregular. 18

19 Hospital C focuses on providers and universities in its endeavours to develop cooperative arrangements for implementation of innovative activities. Hospitals A and B are customer-oriented regarding development of innovative activities while providers are rated as medium important. Unfortunately, consultant companies and other hospitals are considered unimportant or even irrelevant as potential partners for joint activities in the field of innovation. Hospitals are clearly differentiated by their attitudes toward professional competence and technical assistance centers for potential partnership. University hospital rates them as highly important while hospitals A and C consider them as unimportant. The subject or area of established cooperation by partner categories are indicated in Table 30. Table 30. Cooperation area by partner categories Partner Cooperation area A B1 B2 C D Customers or R&D consumers Technical assistance Training Trials for product tests Other cooperation activities Providers R&D Technical assistance Training Trials for product tests Other cooperation activities Other hospitals R&D Technical assistance Training Trials for product tests Other cooperation activities Consultant R&D companies Technical assistance Training Trials for product tests Universities and research institutes Professional competence and technical assistance centers Other cooperation activities R&D Technical assistance Training Trials for product tests Other cooperation activities R&D Technical assistance Training Trials for product tests Other cooperation activities Periodicidade da Publicação: Irregular. 19

20 Most prefered areas for cooperation are technical assistance and training. R&D is a field for coopertion with universities and research institutes, other hospitals and consulting companies. The importance of the factors that harmed innovative activities in the hospitals are presented in Table 31. Table 31. Importance of the factors that harmed innovative activities in the hospitals Factor Importance A B1 B2 C D Ecessive economical risks High Medium Low Irrelevant Lack of qualified personnel High Medium Low Irrelevant Difficulty to adapt to standards, High rules and regulations Medium Low Insufficient of appropriate financing sources Lack of information about the markets Insufficiency of appropriate outsourced technical services Irrelevant High Medium Low Irrelevant Periodicidade da Publicação: Irregular. 20 High Medium Low Irrelevant High Medium Low Irrelevant High costs of the innovation High Medium Low Irrelevant Lack of information about technology Weak response from consumers relating new products High Medium Low Irrelevant High Medium Low Irrelevant Organisation rigidity High Medium Low Irrelevant Insufficient possibilities of cooperation with other companies/institutions High Medium Low

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