OUTSOURCING IN HOSPITALS: Accountability cannot be outsourced

Ahmad Ayaz

Hospitals are unlike ordinary workplaces. They are places where people arrive when they are unwell, worried, anxious and often emotionally vulnerable. Patients may be in pain, while attendants may be struggling to understand procedures, locate wards, obtain medicines, complete formalities or simply find someone who can guide them. In such an environment, every interaction matters.

A polite word can provide reassurance. A helpful response can reduce anxiety. Conversely, rude behaviour, unnecessary confrontation, indifference or an inability to guide a patient or attendant can turn an already difficult experience into a distressing one.

This is why the growing practice of outsourcing certain hospital services deserves closer attention—not because outsourcing is inherently wrong, but because outsourcing must never become an outsourcing of responsibility.

Many hospitals outsource administrative, operational, housekeeping, security and other support functions for legitimate financial and managerial reasons. Such arrangements can help institutions manage manpower and certain non-core functions efficiently.

But once an outsourced worker is deployed inside a hospital and interacts with patients and attendants, the institution cannot divest itself of responsibility for maintaining appropriate standards of conduct.

From the perspective of a patient or attendant, there is often no meaningful distinction between a regular employee and an outsourced employee. Both are encountered inside the hospital and both are perceived as part of its institutional environment. A patient does not necessarily know which agency has employed the person standing before him or her, nor should a patient be expected to understand contractual arrangements between the hospital and an outside agency.

The basic question for a patient is much simpler: Is this person authorised to be here, what is his or her role, and can the hospital ensure that the person behaves appropriately?

That is where institutional accountability becomes important.

Training Cannot Be an Afterthought

Anyone deployed inside a hospital should receive appropriate orientation before being assigned duties. This is particularly important for outsourced personnel who may have direct interaction with patients and attendants.

Working in a hospital requires a different level of sensitivity from working in many other environments. Personnel need to understand basic patient etiquette, communication, professional boundaries, confidentiality, hygiene, emergency situations, escalation procedures and the importance of treating people with dignity.

An employee recruited for a particular support function cannot simply be placed inside a ward and expected to learn everything through experience.

Training should clearly explain what an employee is authorised to do, what he or she is not authorised to do, whom to approach when a problem arises and how to communicate appropriately with patients and attendants.

There should also be clear instructions that no employee, regardless of employment status, should unnecessarily confront, intimidate, insult or argue with patients or attendants.

If an attendant is prohibited from sitting in a particular area, for example, the rule can be communicated politely. If a chair is reserved for a particular purpose, the attendant can be informed courteously. Rules are necessary in hospitals, but the manner in which those rules are implemented is equally important.

A hospital cannot expect patients and attendants to remain calm and respectful if its own representatives communicate with them in an aggressive or humiliating manner.

Outsourcing Must Not Create an Accountability Gap

One of the greatest concerns with outsourcing is the possibility of an accountability gap.

When something goes wrong, the hospital may point towards the contractor, while the contractor may point towards the individual employee. The patient or attendant is then left wondering where to complain and who will actually take responsibility.

That cannot be an acceptable system.

The contractual arrangement between a hospital and an outsourcing agency may determine who recruits, pays or administratively controls an employee. But when that employee is deployed inside a hospital, the institution must retain effective supervisory control over the standards expected within its premises.

Contracts should contain clear provisions regarding conduct, qualifications, training, identification, duties, attendance, discipline and complaint handling. Hospitals should also have the authority, subject to applicable rules and due process, to require the removal or replacement of personnel who repeatedly violate institutional standards.

Most importantly, there should be someone within the hospital administration who is clearly responsible for supervising outsourced manpower.

A patient should not have to move from one office to another simply to determine whether the person who behaved improperly was a hospital employee or an outsourced worker.

Uniforms and Identity Cards Matter

Another issue deserving attention is compliance with prescribed uniforms, professional attire and visible identity cards or designation badges.

This applies not only to outsourced personnel but, wherever prescribed, to doctors, nurses, paramedics, technicians and other hospital staff.

A hospital is a complex institution. A patient entering a ward may encounter doctors, nurses, technicians, pharmacists, attendants, housekeeping personnel, security staff and administrative employees. For someone unfamiliar with the hospital, distinguishing between different categories of staff is not always easy.

Visible identification therefore serves a practical purpose.

A doctor should be identifiable as a doctor. A nurse should be identifiable as a nurse. A technician, paramedic, attendant or other employee should similarly be identifiable according to his or her designated role.

Prescribed uniforms and visible identity cards provide patients and attendants with a basic understanding of who is performing what function. This becomes particularly important in busy government hospitals, where large numbers of patients and attendants may be present.

There may be legitimate professional or practical reasons for variations in attire, and an instance of non-compliance should not automatically be treated as misconduct. However, where a hospital has prescribed a uniform, dress code or identification requirement, it should be implemented consistently and sensibly.

The objective is not unnecessary formality. It is professional identification, accountability and order.

The Same Standards Must Apply to Everyone

There should also be no perception that standards apply only to outsourced workers.

If hospital authorities expect outsourced employees to wear identification cards, maintain discipline and behave courteously, the same institutional culture should be visible among regular employees, contractual workers, doctors and paramedical staff, according to the requirements of their respective roles.

Accountability loses credibility when it is selective.

An outsourced employee should not be excused simply because he or she works through a contractor. At the same time, a regular employee should not be permitted to disregard institutional rules merely because of permanent employment status.

Every person working within a hospital contributes to the environment experienced by patients.

The standard should therefore be consistent: competence, discipline, courtesy, identification and responsibility.

Complaints Need a Proper Mechanism

Hospitals should also examine whether their complaint mechanisms are sufficiently accessible to patients and attendants.

A person who faces rude or inappropriate behaviour should know where to report it. There should be a clearly identified help desk, grievance mechanism or designated officer who can receive such complaints.

Complaints should be recorded and examined rather than dismissed merely because the person involved is outsourced.

At the same time, a complaint should not automatically be treated as proof of wrongdoing. Hospitals deal with large numbers of people every day, and misunderstandings can occur. An employee may have been enforcing a legitimate rule but communicated it poorly. A patient or attendant may also have misunderstood a situation.

Complaints should therefore be investigated fairly, with an opportunity for all concerned to explain what happened.

Where inappropriate conduct is established, corrective action should follow. Where a complaint is found to have arisen from a misunderstanding or circumstances beyond the employee’s control, that should also be appropriately recorded.

The objective should be correction and accountability—not humiliation or arbitrary punishment.

Outsourced Workers Also Deserve Respect

There is another side to this issue that should not be ignored.

Outsourced employees often work in demanding environments and may themselves face difficult working conditions. They should not be stereotyped or treated as inferior simply because they are employed through an outside agency.

Many outsourced workers perform essential functions every day and carry out their responsibilities sincerely and respectfully.

Therefore, raising concerns about outsourcing should never become an attack on outsourced employees as a category.

The real question is whether the system through which they are recruited, trained, deployed and supervised is adequate.

A responsible hospital should ensure that outsourced personnel are properly briefed, adequately trained and treated fairly while also being held accountable for their conduct.

The hospital must also ensure that outsourcing agencies do not merely supply manpower but meet the standards specified in the contract.

Hospitals Need an Institutional Culture of Courtesy

Ultimately, this issue is bigger than uniforms, identity cards or outsourcing contracts.

It concerns the culture of the hospital.

A well-managed hospital should create an environment in which a patient knows whom to approach, an attendant knows where to seek information, employees understand their responsibilities and supervisors are available when problems arise.

Courtesy should not depend on whether the hospital happens to be crowded that day. Discipline should not depend on whether a senior officer is visiting. Uniform requirements should not exist merely on paper. Identity cards should not be worn only when an inspection is expected.

Rules become meaningful only when they are consistently implemented.

Hospital administrations should periodically review their arrangements for outsourced personnel and ask some basic questions:

• Are employees properly verified and selected?
• Have they received orientation before deployment?
• Do they understand their duties and limitations?
• Are they trained in dealing with patients and attendants?
• Do supervisors regularly monitor their performance?
• Are identity cards and prescribed uniforms being used?
• Are doctors and paramedical personnel also complying with applicable identification and dress requirements?
• Is there a simple mechanism for lodging complaints?
• Are complaints investigated fairly?
• Is responsibility clearly fixed when violations are established?

These are not unreasonable demands. They are basic elements of responsible institutional management.

The Patient Must Remain at the Centre

Healthcare is ultimately about the patient.

Administrative convenience, contractual arrangements and manpower management are important, but none should overshadow the experience and dignity of the person seeking medical care.

A patient arriving at a hospital should not have to worry about whether the person dealing with him or her is regular, contractual or outsourced. The expectation should be the same: professionalism, courtesy, appropriate conduct and accountability.

Similarly, attendants should not be treated as an inconvenience merely because they ask questions or seek assistance. They too have a legitimate need for information and guidance, subject to hospital rules and the requirements of patient care.

The solution is not to eliminate outsourcing. Nor is it to blame every outsourced employee for the conduct of a few.

The solution is to strengthen the system.

There must be proper selection, mandatory orientation, adequate training, clearly defined duties, effective supervision, appropriate uniforms or professional attire, visible identification, consistent discipline and an accessible grievance mechanism.

These standards should apply across the hospital according to the responsibilities of each category of staff.

A hospital’s responsibility does not end with the employment contract. Once personnel are deployed within its premises and interact with patients and attendants, the institution has a responsibility to ensure that the environment remains safe, orderly, respectful and professional.

Outsourcing may transfer an employment arrangement to a contractor. It cannot transfer institutional accountability.

Patients come to hospitals seeking treatment, care and reassurance. They should not leave with an additional grievance simply because basic standards of courtesy, identification and supervision were missing.

The measure of a hospital is not only the quality of its medical infrastructure or the expertise of its doctors. It is also reflected in how every person entering its premises is treated—from the moment a patient walks through the gate until the time he or she leaves.

Professionalism cannot be outsourced. Courtesy cannot be outsourced. Discipline cannot be outsourced. And, above all, accountability cannot be outsourced.

(STRAIGHT TALK COMMUNICATIONS EXCLUSIVE. The author is a Columnist. He can be reached at ahmadayaz@gmail.com.)

_{(Disclaimer: The views are of the author and not of the Straight Talk Communications)}