The importance of internal communication in hospital management

Aim: Th e aim of the research was to describe the status and importance of internal communications in a hospital and recommend proposals for its improvement. Methods: Th ere is analysis of internal communication according own methodology – key assumptions of eff ective internal communication. Qualitative research through depth interviews with top management of the hospital identifi ed the main factors aff ecting internal communication, its eff ect and meaning was tested by quantitative research – questionnaire survey of employee’s views. Results: Th e hypotheses the importance of internal communication and its impact on work behaviour and performance were confi rmed. Internal communication was evaluated by the basic assumptions of internal communication were evaluated and recommended its improvement. Conclusion: Workers perceive internal communication as an important and agree that aff ects their job performance and work behaviour. Th e hospital did not properly set some of main assumptions for the functioning of internal communication. Management adopted proposals of improvement. KLÍČOVÁ SLOVA interní komunikace, management, nemocnice


INTRODUCTION
Th e latest survey of the European Agency for Safety and Protection of Health at Work generated a list of the most common sources of work-related stress.In the overall score, which included not only the EU countries (31 in total), the leading stressors were both communication between the management and employees and insuffi cient communication among employees.In the Czech Republic, poor communication appears in the top three rankings, much more signifi cantly than in other countries.As many as 62% of employees agree that their work performance suff ers due to the poor communication among colleagues, while for 65 % employees, the main stressor is poor communication between the management and employees.Th e top rank (79%) as the greatest source of stress belongs to communication with clients, customers, patients, students.In other countries, the list is dominated by other stressors, e. g. lack of time, inadequate security, overtime, discrimination, etc.No other country records such a strong dissatisfaction with communication, according to the survey.(EASHW, 2010) Th e results of the study Communication ROI Study, conducted by the consulting firm Watson Wayatt Worldwide, verifi ed that companies with highly eff ective internal communications achieve better fi nancial results and signifi cantly higher organizational stability that enhances results.In his article, Yates (2006, p 73) transforms the results in best practices in communication, the setting of which demonstrably improves the employee engagement and reduces turnover.Fig. 1 illustrates the impact that eff ective communication practices have on dedication and hence on the performance of the organization.
Both of the above studies show that the state of internal communications in an organization can be a powerful motivator or demotivator.Few Czech companies focus on internal communications in a systematic manner.(Holá, 2006, p 45) Th e concept of communication is discussed in various contexts and approaches; specifi c internal communications remain an unclear concept for organizations.Communication in general is characterized as a process of sharing certain information in order to eliminate or reduce uncertainty for both parties to the communication.Communication is also a two-way process aimed at shared understanding and collaboration.Table 1 shows diverse approaches to communication.
Although approaches vary, they share the belief that we build the social world through communication interactions.Th e infl uence of communication on conduct and behaviour is summed up by Miller in his Th eory of Planned Behavior (2009, p 127).Organizations, however, prefer the fl ow of information from outside, and the management, oft en out of ignorance, underestimates systematic internal communications.(Holá, 2006, p 4) Internal communication that takes place within the organization pervades all processes and is the link in the management process of the entire organization.According to Wright (2009), the elementary management needs in communication are based on human resource management, corporate culture, decision making, confl ict resolution, change management, and use of technologies.A more comprehensive range of internal communication in terms of its objectives, key processes, and methodologies, and its importance for the organization is provided by Holá (2006)

in her
Tab. 1 Diverse approaches to communication and their use in internal communications according to Miller (Miller, 2009, p 13)   monograph.Likewise, the importance of internal communication is mention by the authors of publications on personnel management, e. g.Baron and Armstrong (2008), Koubek (2004), and authors dealing with corporate marketing communications (Horáková et al., 2008, p 124).
Communication between the management of health care centres and their personnel is studied e. g. by Gladkij et al. (2003).
In terms of the contents, internal communication is defi ned as the integration of three main areas representing its main objectives: 1 Providing employees the information they need to perform their jobs, 2 Linking the information and motivation necessary for collaboration, 3 Forming desirable work-related attitudes (professional behaviour and conduct) necessary for stable employees and organization.
Ineffective communication is manifested primarily through insuffi cient, outdated or ambiguous information and a lack of feedback.
Th ese defi ciencies result in distorted information, which, in combination with the lack of space for its clarifi cation, fundamentally aff ects work performance and may even result in its paralysis.
In this respect, internal communication (including communication between the management and employees, team communication, and personal communication during collaboration) forms an important working condition.(Holá, 2011, p 5) Internal communication is a blend of HR work, internal marketing, and management communication.Th e basic prerequisites (elements) that determine its functioning include: corporate culture based on moral and ethical values,  a unifi ed management team of the organization and full responsibility for the communication of the organization,  defi ned division of labour, organizational structure, defi nition of the main processes in the organization,  declared strategy of the organization and the resulting communication strategy, communication plan,  declared social policy supported by HR work in order to fi nd mutual respect between the organization and the employees and the fulfi lment of mutual expectations,  eff ective internal marketing, especially internal public relations that aff ect the relationship employees have to the organization,  communication skills of managers,  open communication that includes feedback,  technology -setting information and communication infrastructures to meet the needs of internal communications.
All these elements determine eff ective communication, infl uence each other, and, together in synergy, build the quality of communication.(Holá, 2011, p 78)

METHODS
This survey was based on methodology verified on a long-term basis by the author (Holá, 2011, p 92).It includes: 1 An analytical part of the monitored centre using standard analyses (SLEPT, SWOT) and an analysis of the prerequisites of a functioning internal communication, which generate the most important factors that affect internal communication.The basic sources of the analysis include internal documents of the organization that regulate the internal communication within the organization, and structured (evaluation of the basic elements of internal communication) and in-depth interviews (on functioning and malfunctioning communication) with top management (deputies).In consequence, the potential causes of the ineffi cient internal communications were identifi ed. 2 Identifi ed defi ciencies in the internal elements of communication, ie modifi able factors were validated with a quantitative questionnaire-based survey of the employees.Th e questionnaire therefore focused on the individual elements of internal communications and on its importance for the employees.Th e questionnaire was anonymous; employees completed the questionnaire online (the application was installed on the server of the University of Pardubice).Only fully completed questionnaires qualifi ed for the assessment; anonymous, randomly assigned passwords prevented multiple forms completed by one person.Selected results were tested for statistical signifi cance using frequency distribution statistics, a signifi cance level of α = 0.05 according to Pecáková (1998).3 Statistically validated results were submitted to the hospital management based on the resulting document Hospital's Internal Communications.Studies of available literature (Holá, 2011) in combination with the author's experience facilitated proposals for streamlining internal communication.2. Findings confi rming the importance of communication and employee satisfaction, which should motivate the management to improvements, are as follows: Th e majority of employees (84%) are satisfi ed, believe their work is meaningful and the hospital care adequate (60%), and are loyal to the hospital (94%).Whole 80% of employees surveyed agree that a sufficiently effective communication (functioning communication in the work team, suffi cient updat-ed information, room for clarifi cations, etc.) has an impact on their work behaviour and performance.For the majority (85%) workers, communication with the hospital management is very important.

RESULTS OF A SURVEY OF INTERNAL COMMUNICATION
Each of the above majorities was tested for statistical signifi cance with a frequency distribution test, significance level of 5%.(Pecáková, 1998, p 87) An analysis based on basic prerequisites and interviews with managers identifi ed the main barriers to communication.Th ese were subsequently verifi ed with a questionnaire.Based on the summary of the current internal communication in the hospital, the following measures were proposed: In organizational culture: Reinforce the corporate culture -e. g. by declaring a code of ethics, punishing misconducts, and building an open atmosphere; create a fair environment; promote cooperation.Showcase the work of each team to improve cooperation.Furthermore, introduce public awarding of the best employees of the time period (for a project or based on ratings) which will engage all employees or teams.Introduce uniform standards -support for regular staff evaluation and remuneration.Create a feedback system (suggestion boxes, intranet discussions).Create a higher authority status (ombudsman) for building a fair environment.
In managerial communication: Develop managerial communication skills.Specify the powers and responsibilities, the competency and conditions for the performance of functions (create job descriptions for managers).Declare mutual understanding and willingness to cooperate among managers (support each other and encourage cooperation among subordinates).Establish clear rules for management meetings (provide participants with the schedule and materials in advance; fi rm direction of the discussion; room for discussion; suppression of adverse behaviour and clear declaration of mutual respect), adopt uniform conclusions, and transfer information from the meetings.
In specifi c activities of internal communication: Assign an individual/s responsible for internal communication, preferably from senior management; equip them with competencies and create room for their work.Develop a communication strategy, a plan, and set up channels of communication (meetings, intranet, evaluation).Improve the concept of the hospital newspaper, consider a similar format for internal communications or target a section of the newspaper to the staff .Introduce controlled internal (personnel) marketing; make better use of electronic means of communication, e. g. for regular e-mail news; use the printed news and notice boards.Transform the intranet from an electronic bulletin board to a communication portal.Generally the most frequent reason that managers give as the cause of malfunctioning communication is the lack of time (oft en, however, it is also ignorance of the issue).On the other hand, most common investments in internal communications are reported to be made into information and communication technologies, which may be credited with too much importance despite the fact they certainly improve communication when used correctly.(Holá, 2006, p 46) In health care, the lack of time of the management combines with the lack of funding for information and communication technologies, a fact that severely complicates internal communication.However, in this hospital, it is primarily the management's will to improve which is the key for any amelioration.

CONCLUSION
Th e hospital management adopted the declared importance and infl uence of internal communication as an important work condition that aff ects performance at work and the conduct and behaviour of employees.Quality Manager was assigned with developing a plan to improve internal communications as recommended.Th e project of improving internal communication formed a part of the hospital's policy of quality improvement in 2010.A communication plan was therefore soon developed, together with a code of ethics (including its distribution and propagation) and the position of an ombudsman dedicated to internal and external problems.Over time, periodic evaluation of employees including the management was implemented for all nursing-related jobs.Th e standard, however, could not be implemented in other professional fi elds.
Since the beginning, senior management has strived to maximize awareness and discussion through regular meetings held with employees (including evaluation of the team for an innovative achievement) and adopted a new "supervision" project designed for the evaluation of work conditions and the functioning of each department and of the hospital as an employer from the employee perspective.Th e intranet has been improved to serve the required communication and is also used more.Th e senior and line managements are gradually completing communication training.Based on the feedback within supervisions, communication in the hospital has been improving and the management's eff orts for mutual communication are appreciated.In some cases, interdepartmental cooperation has improved.In conclusion, the effi ciency of internal communication has been improving and mutual trust between the management and employees has gradually been building; proactive staff is increasingly cooperating.Th e hospital management considers the study a successfully implemented project.

Fig. 1
Fig.1Infl uence of internal communication on the performance of the organization(Yates, 2006, p 73) Th e organization where the internal communication survey was held in the summer of 2009 is a type-2 hospital (a health care institution providing acute inpatient care in a minimum of three of the 7 basic disciplines).Of the total of 567 employees of the hospital, 316 (56 %) took part in the survey.Distribution of respondents: 13% doctors, 72% non-physicians, and 15% other employees (administration).The questionnaire survey looked into potential sources of inefficient internal communications.Employees evaluated the setting of the basic prerequisites of eff ective communication and the importance of communication for their professional performance, work-related conduct and behaviour.Th e survey refl ected the fi ndings of previous analyses and interviews with managers.Th e results of the evaluation are summarised in Table

Current evaluation 1
Corporate culture based on moral and ethical values Weak; with elements of injustice, distrust and favoritism 2 Cohesive team of the company management and full responsibility Management is divided, palpable barriers, lack of mutual respect 3 Defi ned organizational structure, processes, and work distribution Inconsistently declared in the management, ambiguities, poorly established communication channels 4 Communication strategy and communication plan Th ere is no strategy or plan 5 Personnel policy and functional personnel work Poorly defi ned and declared; ineffi cient system of remuneration 6 Functioning internal marketing Intuitive, inconsistent, untapped potential 7 Communicative competence of the management Very good; functioning in teams; however, no communication between the senior management and employees 8 Feedback system in open communication System missing; moreover, inhibitions and fears 9 Technologies Obsolete, inadequate trends in information and communication technologies Organize internal training on the use of e-mail and on the use of technology in communication in general.Publish the results of the study and discuss the plan of gradual improvements under new conditions.DISCUSSION Internal communication in an organization is frequently overlooked as a management tool despite the fact that many studies have shown its fundamental impact on the work attitudes and performance of employees and thus the performance of the whole organization.Th e fi ndings of our survey disclose the current situation.The introduction to the article mentions two important studies that show that as one of the work conditions, internal communication strongly influences the engagement and performance of employees.(EASHW 2010, Yates, 2006) Eff ective communication as a stimulator generates a positive social climate, conditions for cooperation, and facilitates task fulfi lment and self-motivation.Malfunctioning communication becomes a stressor that disturbs work relationships, discourages, and paralyzes.Employees of the surveyed hospital confi rmed that eff ective internal communication is important for their work.An analysis of the current internal communication revealed an underestimation of its importance by the management, the misunderstanding and ignorance of the contents of internal communication, but also the will to improve communication.Hospital managements are oft en overwhelmed by changes in the external environment they need to implement in the organization.Th e constant changes in the healthcare system oft en overshadow the internal coordination within the organization, occupying the room for improvements in the management and leadership.Most hospitals also struggle with insuffi cient funds, and solutions associated with internal communication are not a priority to be invested in.