Human Resources Management Decision Making Process in King Saud Medical City

TABLE OF CONTENT

ACKNOWLEDGEMENT

EXECUTIVE SUMMARY

CHAPTER 1: INTRODUCTION
Needs and Challenges in the healthcare sector

CHAPTER 2.0 BACKGROUND
King Saud Medical City (KSMC)
The Health Care Workforce in Saudi Arabia
Human Resources Management in the Saudi Ministry of Health
Aim of this Study
Framing the Research
Scope and Limitations of the Study
Organization of the Study

CHAPTER 3.0 LITERATURE REVIEW
Human Resources Management versus Personnel Management
Informed decision making in Human Resources Management
Tools for Better Human Resources Management
Policies
Organizational Structures and Job Descriptions
Human Resources Information System (HRIS)
Human resources indicators (HRIs)
Human Resources Management Training

CHAPTER 4.0 METHODOLOGY
Introduction
Sampling strategy and population size
Data collection
Data analysis
Data reliability and Validity
Ethical Considerations
Summary

CHAPTER 5.0 RESULTS
Interview Transcripts and Coding

CHAPTER 6.0 ANALYSIS AND DISCUSSION
The emerging concepts and outcomes
Themes
Organizational culture and structure
Communication gap
Knowledge gap
Having authority
Self-confidence in decision making
Theory development

CHAPTER 7.0 RECOMMENDATIONS

CHAPTER 8.0 STUDY LIMITATIONS

CHAPTER 9.0 CONCLUSION

REFERENCES

APPENDIX

TABLE OF FIGURES

Figure 1 Flowchart showing the HRIS process (Capacity Plus , 2011)

Figure 2 From codes to theory model in qualitative investigation

Figure 3 Framing the grounded Theory

Figure 4 Coding and analysis flow chart

Figure 5 Illustration of emerging categories

Figure 6 Comparison of Categories

Figure 7 Schematic view of Decision making

Figure 8 Theory Development model

CHAPTER 1: INTRODUCTION

The health workforce is defined as “all people engaged in actions whose primary intent is to enhance health” (WHO world health report, 2006, p.29). The health workforce plays a major role in the health systems of all countries. They have been described as “the heart of the health system in any country” (Global Health Trust, cited by Hongoro & McPake, 2004, p.1451), “the most important aspect of health care systems” (Narasimhan & Brown, 2004, cited in Hongoro & McPake, 2004, p.1451), and “a critical component in health policies” (Dussault & Dubois, 2003, cited in Hongoro & McPake, 2004, p. 1451).

Shared decision making has evolved from a traditionally paternalistic model of decision making to an approach that has been developed on a platform based on a patient-centered approach. After the development of a professional approach to medical practice in the 18th century, decision making has, to a large extent, been dominated by a paternalistic approach by which clinicians assume authority and decision-making power, oftentimes without consulting individuals about their personal preferences. Since the 1980s, individuals’ right to be informed and to participate in medical care decisions has been increasingly advocated. It has also been postulated that clinical decisions (treatments, screening or diagnostic tests) should be justified by available clinical and scientific evidence and not by a clinician's assumed authority or knowledge—this development has become known as evidence-based medicine.

Buchan (2004) believes that good human resources management (HRM) has become instrumental to the success or failure of a health system, and that better HRM has become a priority on national, provincial and institutional levels. Yet, according to Buchan, “the focus on structural change, cost containment, the introduction of market mechanisms and consumer choice, had little direct attempt to address HR aspects” (2004, pp.1-2). In its World Health Report of 2006, the World Health Organization (WHO) found that there are currently 57 countries with critical shortages, equivalent to a global deficit of 2.4 million doctors, nurses and midwives (p. xviii overview).

In its 16th report, the Council on Graduate Medical Education estimates that by 2020 there will be a shortage of up to 200,000 physicians and 1 million nurses in The United States alone (cited by Derksen & Whalen, 2009, p.1). Uneven distribution of the health workforce is another major challenge both locally and internationally. All counties have also reported to have a geographical imbalance in the distribution of health workers, such as the imbalance between urban and rural areas (Dussault & Franceschini, 2006).

Needs and Challenges in the healthcare sector

Apparently, there are serious health workforce challenges rising throughout the world due to the acute shortages and uneven distribution within and between countries. According to Bossert, et al (2007), this is leading us to a global health workforce crisis (p.8). The challenge is not only due to workforce shortages and uneven distribution. Bossert, et al (2007) identified issues which have greatly affected the performance of human resources for health worldwide, such as lack of attractiveness of the health care profession, migration, multiple job holding, absenteeism, ghost workers and lack of motivation (pp.17-20).

The lack of attractiveness of the health care profession and/or health work force migration is mainly attributed to low motivation. There are many causes for low motivation, such as chronic staff shortages, low income, working conditions, better career opportunities and much more. On the other hand, having income-generating opportunities elsewhere and personal problems have been identified as the main reasons for absenteeism and multiple job holding as well (Dieleman& Harnmeijer, 2006).

Absenteeism in the public sector might expand and cause a "ghost worker" phenomenon where personnel exist on paper but not in practice (Bossert, et al, 2007, p.19). Ghost workers in the Saudi public sector might be attributed to the very high level of job security public workers enjoy. In its 2006 World Health Report, the WHO set a goal to try and tackle the crisis. The goal was simply “to get the right workers with the right skills in the right place doing the right things!” (p. xx).

CHAPTER 2.0 BACKGROUND

King Saud Medical City (KSMC)

King Saud Medical City (KSMC) is the largest health facility operated by the Saudi Ministry of Health (MOH). It is situated in Riyadh, the Capital of Saudi Arabia. KSMC (also known as Shumaisi Hospital due to its location) is a 1446-bed teaching hospital delivering primary, secondary, and tertiary care, under the government of the Saudi Ministry of Health (WHO, 2010). It consists of three hospitals, a general, pediatric, maternity hospital. It also has two separate independent facilities, King Fahd kidney center and Riyadh dental center. KSMC provides a long list of secondary and tertiary health care services to Riyadh residents. Its emergency and outpatient departments are among the busiest in Saudi Arabia. That is why it is known for its great diversity of human resources.

The Health Care Workforce in Saudi Arabia

The Saudi ministry of health (MOH) provides services to about 60% of the population. Other health services providers separate from MOH, such as referral hospitals (e.g. King Faisal Specialist Hospital and Research Centre), security forces medical services, armed forces medical services, National Guard health affairs, Ministry of Higher Education hospitals (teaching hospitals), ARAMCO hospitals, Royal Commission for Jubail and Yanbu health services, school health units of the Ministry of Education, the Red Crescent Society (Almalki, et al, 2011, p. 786) and the private sector. According to MOH statistical book for the year 1430H (MOH, 2009), which is equivalent to the year 2009, The Saudi health system employed a total of 373979 health care professionals. Table 1 sheds some light on the workforce employed by the Saudi health system.

Table 1 shows Statistics on the Saudi health system workers. Source of data: MOH statistical book for the year 1430H

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The biggest challenge currently facing the Saudi health system is its reliance on foreign workers to cover its needs for professional health care workers. Today, more than 55% of health care professionals working in Saudi Arabia are non-Saudi. The government sector have achieved some success in reducing its reliance on foreigners by using the Saudization scheme (a scheme meant to increase the number of Saudi workers through using many different methods). Why is Saudi Arabia still suffering from lack of local health care workers? Is a weak and underperforming human resources management to be blamed?

Another issue to consider is the number of non-health care professionals working in the Saudi health system. Over 61% are professionals (service providers), while still lower than the global average of 67%, in high income countries the health management and support workers slightly outnumber health care professionals (WHO, 2006, p. 6). Bad management and weak support services could indeed be the cause for many of the challenges facing the Saudi Health care system.

Gender imbalance is another issue to investigate. Only around 40% of health care workers are female, in many countries women comprise over 75% of the workforce (WHO, 2006, p. 4). What is keeping women away from the Saudi Health care sector? Does this have a harmful effect on the quality of health care services being provided?

Another big cause for alarm is the nurse/doctor ratio, which currently stands at 2 to 1 (MOH, 2009). While the exact nurse/doctor ratio necessary for a health system to run efficiently and effectively remains unclear, some of the more established and successful health systems, such as in Canada and the United States have a ratio of around 4 nurses per 1 doctor. According to its 2007 Health Statistics Book (MOH, 2007), the Saudi Ministry of Health spent about 48% of its budget on salaries alone, while the typical country spends just over 42% of its health care budget on its workforce(WHO, 2006, p. 6).

The statistics on the Saudi health workforce available for public view is mainly about its general demographics. Sadly, there is no mention of other human resources indicators of significant importance, such as workforce productivity, retention, motivation, training, etc. No major studies were found either. Only one study was found which can be connected to an important HR performance indicator (HRI), which is HR motivation level. In a job satisfaction survey done by Al-Ahmadi (2002) in Ministry of Health hospitals in Riyadh, overall job satisfaction was found to be moderate (from abstract).

Lack of statistics and studies about the health workforce in Saudi Arabia does not give us a clear picture on how well they are being managed, but the few key indicators previously mentioned in this study gives us the impression that there are some serious defects in human resources management in the Saudi health sector.

Human Resources Management in the Saudi Ministry of Health

As mentioned above, the Saudi Ministry of Health (MOH) manages about 60% of the Saudi health care system. The way it manages its human resources is by using a chain of personnel management departments starting with the General Directory for Personnel Affairs. Almost all hospitals have one as well. Almost all its workers are hired directly by a unified body responsible for hiring most civilian public sector workers in Saudi Arabia. This body is called the ministry of civil services (MOCS).

Looking at the way the personnel management system in the Saudi health system works, it mainly provide some basic services using a pre-determined pay scale, and a set of rules used to manage civilian public workers set by the ministry of civil services (MOCS).

These services include:

- Asking MOCS for employees needed by the health facility they serve.
- Recording vacation leaves.
- Punishing employees who did not follow MOCS rules (e.g. absenteeism), mainly by deducting from their salaries (They cannot fire an employee without MOCS's consent)
- Processing retirements, transfers and resignations.
- Sending requests for education and training to MOCS for employees chosen by the health facility's management.

The current personnel management system in the Saudi health system does not (and may not even want to) have much influence over planning, developing and managing human resources. This centralized method of hiring government workers might be one of the reasons for the difficulties facing human resources management in MOH. The sheer number of hospital and primary health centers it management surely doesn't make this task any easier.

With its workforce of more than 200 thousand, distributed among over 2400 health facilities including 244 hospitals, coupled with the current centralized hiring method the Saudi government deploys, makes human resources management a daunting task. Trying to uncover the flaws within the human resources decision making process of this huge organization, and with very little statistics and references to work with, forced me to narrow my view and choose to study only a small yet very important part of this organization. King Saud Medical City (KSMC).

The way human resources are managed in KSMC is similar to most other MOH hospitals. A personnel management department (PMD) is responsible for hiring, firing, promoting, demoting, transferring, retiring, compensating and giving vacations to most of the workforce in coordination with the MOH, who then coordinates with MOCS. This is the method KSMC uses to obtain most of its human resources.

However, the personnel affairs department does not make independent HR decisions, other than for its own employees. Instead, it relies on the feedback it receives from department heads that in turn, coordinate with KSMC's top management, which in turn coordinates with MOH before making important HR decisions. In Addition, There are human resources who are not managed by PMD. Those include workers directly hired by KSMC through its limited self-operating budget and from companies contracted to operate some of its services. These human resources are the responsibility of the self-operations department or the companies who employed them.

Certain departments are directly contacted by MOH, such as the Nursing department, which coordinates with the Nursing General Directorate in HRM of nurses. Hence, it is possible that MOH has direct influence over KSMC's human resources. Currently, HR management responsibilities are mostly in the hands of department heads and the facility administration, but they have limited powers over the management of human resources hired by MOH, as they are public workers who adhere to a set of rules determined by the ministry of civil services (MOCS).

This very complicated method of human resources management is surely a source of concern. Recently, a drive towards obtaining accreditation from a local hospital accreditation body known as the "Central Board of Accreditation for Healthcare Institutions" (CBAHI), led KSMC to try and create a new human resources department to help with the accreditation requirements (CBAHI standards, 2006, p. 10). So far, this goal has not been achieved. It also has applied for accreditation from the Joint Commission International, which also requires a centralized method for managing human resources (JCI, 2011, p. 209). This surely will impose greater pressure on KSMC to open a human resources department. What is preventing them from doing so?

KSMC usually sends its human resources statistics directly to MOH, which then adds them to the national statistics. No statistics originating from KSMC are available for public view. Though when asked, KSMC employees and even some of its managers gave some alarming observations on the current state of the workforce in their hospital, such as:

1. High dropout and low retention rates, especially among physicians and nurses.
2. Low discipline. Almost all departments complain about high absenteeism and/or low adherence to work hours.
3. Ghost workers.
4. Low job performance. Many employees do not perform all the duties and responsibilities they are assigned to do, or do not do them well enough.
5. Low motivation. Workers complain that they are not given enough incentives to improve their performance.
6. Lots of complaints about issues like workload distribution, promotion, and training.

While these problems appear to be serious, there are no statistics to support or deny them. This gives rise to an important question. If there are no HRIs or even plain statistics, how is it possible for decision makers to make informed HRM decisions?

Aim of this Study

Today, public expectations and demands for health care is increasing worldwide. Health systems all over the world face mounting pressures to provide better services to the communities they serve. With HR playing a major role in every health system, the need for better HR management has become a necessity (Hornby & Forte, 1997, p.1).

Studying the basic Saudi human resources for health statistics available to us show that there are indeed many challenges facing HR managers in the Saudi health system. What are the HR managers doing to deal with these challenges? The fact that no comprehensive human resources indicators are present makes us wonder how HR managers identify possible issues causing underperformance of the HR and how they handle such issues.

The answer might lie in the way HRM decisions are taken. Hence, it would be appropriate to try to identify the tools they use and obstacles they face to develop methods to improve HR performance and take appropriate action. Knowing how informed HRM decisions are, might shed some light on how well human resources are managed in the Saudi health system. With the limited data available to determine the current prevailing methods used to make decisions affecting human resources, how do we know how informed these decisions are?

King Saud Medical City (KSMC) was chosen to be the venue for this study, mainly due to the size of its workforce, and the researcher’s prior experience working in it. While many MOH health care facilities are becoming autonomous due to the de-centralization plan MOH is undergoing (WHO, 2005, p12), KSMC still mostly remains under the direct management of MOH, and hence its type of management is similar to most other Saudi hospitals.

Although this study was only conducted in KSMC, it appeared to be highly representative of other human resources management in the Saudi health system due to the sheer size and diversity of its workforce, and because its management type is similar to most other MOH hospitals, which are in turn, responsible for providing 60% of the health services in Saudi Arabia.

While there might be an underlying utility theory behind the HR decisions made by decision makers in KSMC, what are the sources of information they depend on to maximize the utility of their decisions? Also, when HRM decision makers in KSMC make decisions which affect the workforce they are managing, do they look into the effect of their decisions? Do they try to assess the loss or gain in utility? What are the obstacles they face (if any) when trying to make informed decisions?

The purpose of this study is to try to shed some light on the decision making processes used by decision makers responsible for human resources management in KSMC in order to assess how informed they are. This can be done by exploring the types of decisions they make, the obstacles they face and the sources of information they rely on when making their decisions. This will be done by doing the following:

1. Explore the current prevailing methods used to make decisions pertaining to human resource management.
2. Determine whether these methods are sufficient to make informed decisions.
3. Assess the utilization of newly introduced decision making tools.
4. Discover obstacles (if any) which prevent human resource managers from making informed decisions.

Framing the Research

This study is for HRM decision making done by decision makers in KSMC, and whether it is well informed. This is to determine whether uninformed decision making is a reason for the problems facing human resources in KSMC.

- Field of action research: King Saud Medical City, Riyadh/Saudi Arabia.
- Possible Problem: Uninformed decision making.
- Possible Solution: Better decision making and stricter adherence to these decisions.
- Outcome: Better performance from KSMC human resources.

Research questions:

How informed are the decisions being made by HRM decision makers in KRMC?

Cycle Questions: Can you give examples of human resources management decisions you’ve taken recently? How did you assess the effect your decisions have on the performance of your employees? Please give examples. Can you give me examples of how your decisions influence discipline? Have you ever tried to improve employee motivation? Please give examples. Human resources managers use different tools to help them make informed decisions, such as HR policies, organizational structure and job descriptions, an HR information system, and HR performance indicators. Which tools have you used recently? Can you give me examples of decisions which you needed more information for but could not find any? What did you do? What problems did you have to overcome to make informed decisions? Finally, to what extent do you think that other decision makers in KSMC use information available to them to make informed decisions?

Scope and Limitations of the Study

The study will explore the current prevailing methods used to make informed decisions in the field of human resources management in KSMC by determining the tools decision makers have, and whether they use them or not. The study will try to answer questions about the effectiveness of these tools, what tools are missing, why they are missing and if they do have the right tools, why are they not using them. In general, the study is meant to identify the challenges decision makers in KSMC face when trying to make informed decisions.

The study is limited to a single (but large) health facility. While the researcher believes that it will help form a theory about how informed HRM decision making in the Saudi health system is, and what challenges it faces, this does not mean that the theory can be easily applied to all HRM decisions made by all health service providers in the Saudi health system. There are no doubt some exceptions, but it will be difficult to determine what or where they are. That is why this study cannot be considered representative of the whole Saudi health system.

Organization of the Study

- Chapter 1 of this study introduced the problem statement and described the specific problem addressed in the study.
- Chapter 2: Background study of the current health administration, practice, and HR challenges in King Saud Medical City, and the Saudi health system in general as well as the design and components of the study.
- Chapter 3 presents a review of literature and relevant research associated with the problem addressed in this study.
- Chapter 4 presents the methodology and procedures used for data collection and analysis.
- Chapter 5 contains an analysis of the data and presentation of the results.
- Chapter 6 offers a discussion of the researcher's findings.
- Chapter 7 contains recommendation on how to solve the problems this study has identified.
- Chapter 8 specifies the limitations of this study.
- Chapter 9 contains a summary of the study results, implications for practice and recommendations for future research.

CHAPTER 3.0 LITERATURE REVIEW

Human Resources Management versus Personnel Management

When the concept of human resources management (HRM) started to appear, it gained wide acceptability. Within a few years, many HRM journals and lots of HRM college courses became available. But what is so special about it? Or is it just a re-labeling of what everybody calls a personnel management department? (Blyton & Turnbull, 1992). Blyton & Turnbull (1992) stated that the HRM is "hindered by a number of critical problems, mainly stemming from the central question of what exactly is HRM?"(p. 2). In fact, some believe that the name itself is repulsive, and degrades humans, making them just another expendable resource. They argue that when Henry Ford created his car manufacturing empire a century ago, he didn't treat his workers as just another resource. In fact, he was criticized for doubling the wages of his workers as well as adopting progressive labor provisions such as the 40 hour work week. It was seen as a wasteful loss of profit (Lewis, 1976).

Many human resource academics believe that the differences between HRM and personnel management models are rather philosophical than practical (Koster, 2002, p. 4). However, Sisson (1990) that the new terminology may at least rid personnel management from its unfavorable welfare image and other "negative connotations" (cited by Koster, 2002, P. 4). On the other hand, Authors like Storey (1989) Regard HRM as a "radically different philosophy and approach to the management of people at work" (cited in Koster, 2002, p. 5).

Armstrong (1987) maintains that "although the procedures and techniques of strongly resemble those of personnel management, the strategic and philosophical context of HRM makes them appear more purposeful, relevant, and consequently, more effective" (cited by Koster, 2002, p.5). Blyton & Turnbull (1992) state that "HRM is proactive rather reactive, system-wide rather than piecemeal, treats labor as social capital rather than as a variable cost, is goal-oriented rather than relationship-oriented, and ultimately is based on commitment rather than compliance"(p.5).

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