Normal Laboratory Values
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Saturday, November 30, 2013
Skill Development for Health Care Provider
Indian Health sector is now facing serious problem of lack of trained and skill health care provider. A report by CII mentioned that India currently require additional 1,00,000 hospital beds each year and shortage of 1.4 million doctors and 2.8 million nurses. According to CII Techopark Knowlege Report shortage of Paramedics is 261,500.
So a sincere effort is required by all stakeholders to take initiatives to fill up this gap.
Government of West Bengal under State Medical Faculty have designed several paramedical courses .http://www.smfwb.in/
I will regularly post teaching materials for Paramedics.
Indian Health sector is now facing serious problem of lack of trained and skill health care provider. A report by CII mentioned that India currently require additional 1,00,000 hospital beds each year and shortage of 1.4 million doctors and 2.8 million nurses. According to CII Techopark Knowlege Report shortage of Paramedics is 261,500.
So a sincere effort is required by all stakeholders to take initiatives to fill up this gap.
Government of West Bengal under State Medical Faculty have designed several paramedical courses .http://www.smfwb.in/
I will regularly post teaching materials for Paramedics.
Monday, November 4, 2013
EVALUATION OF HOSPITAL SERVICES
Services provided by a
hospital incorporate elements which can be examined objectively, subjectively
or both. Every enterprise is actively concerned with quality assurance by
determining the quality of commodity it produces and keeping in touch with
consumers to secure their maximum satisfaction. As a result of advances in
medical technology, introduction of high technology and other sophisticated elements,
some vital issues are being raised such as : what is the quantum of output and
degree of excellence of hospital
service? What is the cost of operating the hospital? Is the hospital
spending more because of inefficiency of hospital operation? Could the same
quality of medical care be made available at lesser costs? What is the extent
of patient’s satisfaction? What is the final outcome or end result in terms of
indices like recovery rate, partial recovery rate, death rate, complication
rate etc?
However, due to diverse nature of day to
day activities, large number of variables and subjectivity results are
difficult to measure in hospital services. By its very nature, a great part of
hospital output will always be intangible. Therefore, the measurement of
tangible and intangible outcomes must go hand in hand, and no watertight
compartmentalization can be made between them. Because of this the evaluation
process has greatly depended upon qualitative judgments in addition to
quantified data in most instances.
Evaluation of hospital is a challenge
because of the variation in the intensity of care, equipment, personnel, and
facilities in different types of hospitals. One cannot be sure that the
instruments of evaluating services in hospitals could be made as sensitive,
valid , accurate and specific as one finds in industry where accomplishments
can be measured in terms of an accountable unit , viz., rupees and entirely by
financial tools like profit and loss statement and balance sheet. Because of
this multidisciplinary nature, medical care in hospitals does not lend itself
to simple and direct units of measurement .What one can measure are therefore
certain components or characteristics of it from which one can draw inferences
and implications.
WHY EVALUATION
The last stage of management
process, i.e. evaluation is designed to measure efficiency and effectiveness of
the services after planning, organizing, directing and controlling. No organisation
worth its name can survive and progress unless it overcomes its shortcomings
and builds upon its performance. One cannot substitute form for substance and
appearance for reality for all the time.
Sophisticated technology in
high-tech hospitals is equated with high quality care in minds of both public
and the providers, and high costs and quality are considered synonymous. Nothing
can be farther from the truth.
Considered from all aspects,
there are three main reasons which warrant objective evaluation of hospitals.
- It is to safeguard interests of the recipients of
hospital care. A layman cannot possibly judge for himself whether the care
he is receiving is judicious and scientific. He has insufficient
protection against malpractices, exploitation and inefficiencies of
hospital’s medical staff and systems. Hence, it is the moral and legal
obligation of the administrative and professional authorities to ensure
that hospitals render safe and efficient medical services to patients.
Besides, the legal accountability of the hospitals cannot also be
overlooked.
- It is to locate inadequacies and shortcomings of
the hospital staff, its plant and machinery and what is most important,
it’s working systems. Apparently, the hospital’s end results cannot be
good if there are no proper facilities or appropriate technical
environment in which the physicians can work.
- It is to provide the authorities, viz. governing
body, board of trustees or owners a sound appraisal system of evaluating
the effectiveness of managerial staff at various levels , hospital
administrators and individual physicians , and furnish valid facts and
data to regulate their future
development.
Productivity is the relationship between
resources used and results produced, i.e. the input-output ratio. A periodic
assessment of the services will show the existing state of affairs, and
therefore scope for corrective action to quality assurance.
Quality assurance aims at establishing
programme for monitoring and evaluation
the quality of care, but is not synonymous with use of sophisticated procedures
and invasive technology. Quality assurance entails cost-effective approaches
for optimum utilization of resources and establishing ongoing quality control
programme.
WHAT IS EVALUATION?
Evaluation has been defined as the process of determining the degree of
success in achieving predetermined objectives. It is also defined as
“Measurement of action against accepted criteria and interpretation of
relationships amongst them.” Appraisal, assessment ,progress reporting,
progress assessment, and review and analysis are some of the terms which have
been used synonymously with evaluation.
Evaluation one of the final
tasks in the process of management
What to Evaluate ?
In hospitals and healthcare, there
are five indicators through which the quality of medical care and services can
be assessed.
- The organization
- The process
- The content
- The outcome
5.
The impact
Traditionally, these can be
grouped into three categories, viz. the means (structural factors), the
methods(process factors), and the end results(outcome factors).
Evaluation of the “Means”
Evaluation of the “means”
covers the inputs, ascertaining whether the hospital has been provided
With optimum quantity and right quality of
staff and physical facilities as in the shape of buildings, equipment, drugs,
diet and supplies. Evidently, if the means are inadequate, the quality of the
hospital services should be of low standard. Basically, this is an evaluation
of the “organization.” The inputs that
go into the various productions of medical care are the men (various categories of personnel), money, materials and machines. Effective utilization of these
resources determines the organization’s effectiveness.
The quality assurance committee has to
ensure that there has to be a basic minimum infrastructure regarding space,
equipment, physical facilities and staff requirement. The type of organization
needed for each department or service that is the authority-responsibility
relationship, coordination and the budget has to be tailored to the need of
each department keeping in view the overall hospital objectives.
Evaluation of the “Methods”
Evaluation of the “method” is
determining whether there is an effective utilization of the available human
and material resources and whether the hospital’s policies and working
procedures are sound and judicious. Understandably, if the hospital’s
functioning and administration is poor , then the quality of its care cannot be
of good standard. This is an evaluation of “process” and” content” of the
hospital care.
The quality assurance committee lays down the
standing instructions for various procedures, patient documentation, and other
records. The evaluation is carried out through many standing subcommittees like
tissue, utilization, therapeutic, nursing and infection control.
Evaluation of the “end-results”
Evaluation of the “end-results”
means judging the effectiveness or ultimate outcome of the benefits derived by
individual patients and the community from the hospital. This is an evaluation
of the “outcome” and “impact”.
Evaluation studies of each of the above five
aspects of a hospital’s operation, i.e. the organization. Process, content,
outcome and impact can be a very complex process. For example, the evaluation
of organization and process requires detail analysis with the help of operations
research techniques and qualitative methods. On the other hand, a lot of
subjectivity is involves in evaluating the range, quality and quantity of
services provided by the hospital.
It is not always possible, or even
necessary, that evaluation of all the above should be carries simultaneously,
although the need for such simultaneous evaluations apparent in the overall
context. But since the objectives, and the derivative objectives of hospitals
are not available in clear terms, sometimes what is only possible is evaluation
of output both in terms of qualitative and quantitative determinants, and
evaluation in terms of cost and utilization.
Evaluation of Structure
Organizational structure:
1. Centralized or decentralized
2. Unity of command
3. Span of control of key
functionaries
4. Authority and
responsibility
5. Delegation
6. Coordination
7. Governing and executive
body
Physical facilities:
A. General
1. Location of hospital
2. Roads and parking space
3. Circulation
B. Departmental
1. Indoor
2. Outdoor
3. Emergency
4. Operation theaters
5. Radiology
6. Laboratory
7. Pharmacy.
8. CSSD.
9. Laundry
!0.Dietary
11. Blood bank
12. Medical record.
Human
Resource:
Medical Staff
1. Organizational hierarchy
2. Number of medical staffs
3. Qualification and training
5. Promotional avenues
6. Behavior and attitude
7. Job satisfaction.
Nursing and Technical/paramedical staffs
1. Number.
2. Qualification and Training
3. Promotional avenues
4. Behavior and attitude
5. Job satisfaction.
6. Grievances Procedure
UTILIZATION
Various indices are commonly used in assessment of hospital
utilization but taken singly none of them can give a proper picture of
utilization.
Any discussion on utilization can not be precise unless the
terms that are used uniformly
understood.
DEFINITIONS
Hospital Beds-Beds
which are staffed and equipped for round the clock care of patients.
It includes- observation beds, beds for sick and premature
infants.
It excludes-
1. Bassinets used for healthy new born
2. Beds in labour room.
3. Recovery room beds
Bed Complement- It
is the number of authorized or sanctioned beds.
Hospital Death- It
does not include death in causality.
Dead Bed Space- This
refers to beds un occupied in a hospital due to a rigid compartmentalization of
nursing units among specialties. This may be up to 15% in large hospital.
Daily Ward Census-
It is conducted either at mid night or mid day. Studies have revealed that the difference
between midnight census and
mid day census of less than 2 Percent.
Bed Days/ Patient
Days- A full day is counted when admission is before mid day and discharge
is after mid day. It is generally accepted that the day of admission is counted
and the day of discharge is ignored in counting.
Utilization Indices
Average Daily Census
or
Average Daily Bed
Occupancy
Average daily census denotes the daily load of patients over
a given period, and is obtained by adding up the daily census for the period in
question, and dividing it by number of days in that period. It can also be
calculated based on discharges, by adding up the number of days in hospital for each discharged patient
during a period and dividing the figure by the number of days in that period. The
differences in the figures obtained by the two methods are insignificant.
Average daily census indicates pressure on hospital beds on a day to day basis.
Bed occupancy rate
Bed occupancy rate indicates d the relationship between
availability and utilization of hospital beds and facilities. It is expressed
as percentage by either of the following two methods.
1. Ratio of actual patient days to the maximum possible
patient days during a given period
2. Ratio of the average daily census to the bed complement.
BOR = Average daily census/Bed complement*100
Optimum bed occupancy rate for most hospitals is considered
to be between 85 and 90 percent, wherein the remaining 15 to 5 percent beds are available foe
undergoing maintenance, change of linen and being generally readied for
incoming patients.
A high occupancy
rate indicates stretching and over utilization of services resulting in
probable dilution of the quality of care, while as a low rate is indicative of
underutilization of facilities. Usually smaller hospitals have lower occupancy
than larger hospitals. In many public hospitals, because of the perpetual
shortage of beds, patients are put on the floor when a regular bed is not
available in which case the occupancy rate goes up to 110 or120 percent.
To find out the
load of work in different areas, occupancy rate should be worked out ward wise,
specialty and unit wise.
Bed Turnover Rate
(BTR)
Bed turnover rate gives the number of discharged per
hospital be over a given period of time , i.e. how many times a bed was turned
over during the period , say a year .It is directly related to the average
length of stay(ALS) and the bed turnover interval(BTI)
BTR = Total number of patients discharged (including
deaths)/Bed complement
Bed Turnover Interval
It denotes the average time in days elapsing between the
discharge of one patient and the admission of the next on that bed, i.e. the
time a bed remains vacant between admissions. It is obtained by subtracting the
actual no of hospitalization days from the given potential number of
hospitalization days in a given period , and dividing the resultant figure by the
number of discharges in the same period. For example, for a 300-bedded
hospital,, the potential hospitalization days in a year are 300*365=1,09500. If
the actual totaled-up hospitalization days are 98,00 , and the number of
discharges during the year are 5,680, then
BTI = 1.09500-98.200/5,680=1.9, which means
That each bed remained vacant during the year for an average
1.9 days between one discharge and the next admission on that bed.
The turnover interval
will be zero when bed occupancy rate is 100 percent but will become negative
when the occupancy rate goes over 100 percent. Generally, if BTI is more than
2, it is considered very high and indicates low demand or defective admission
procedures. Ideally, BTI should be around 0.5 day. Too long or too short BTI
are both undesirable. In order to be meaningful, BTI should be calculated
separately by wards and specialties
Average length of stay
Average length of day (ALS) is the average period in the
hospital per patient admitted, i.e. the average number of days in service
rendered to each inpatient.
ALS = Number of Inpatient days care during the year/Total
number of discharges and deaths
The formula is quite satisfactory in acute general hospitals
with a quick patient turnover, but is unsatisfactory where there is
considerable difference between the number of patients admitted and those
discharged during the year, e.g. in chronic disease hospitals
In this calculation
of ALS, the day of admission is included, but the day of discharge is excluded.
The ALS in influenced by the following factors.
1. Patient
characteristics. such as sex, age and also educational and socio-economic
status.
2. Disease
characteristics. Chronic disorders and certain other diseases will account
for longer hospital stays.
3. Hospital
characteristics. Teaching and research hospitals tend to have longer ALS
than others. Cumbersome admission and discharge procedures of the hospital also
influence ALS.
In most acute care
general hospitals, the ALS varies from 8 days to 15 days. Reduction of ALS from
15 to 10 days in 500-bedded hospital means that the hospital can service over
6,000 additional patients during the year. Wardwise, unitwise, diseasewise,
doctorwise and specialitywise studies of ALS are more useful than overall ALS
for the hospital.
OUTPATIENTS AND OTHER SERVISES UTILIZATION STATISTICS
Outpatient Services
Outpatient services data is extracted from the registers
maintained at the registration counters in the outpatient department, specialty
clinics and casualty services. The data will be useful to the extent that these
registers contain comprehensive information columns. Commonly used statistics
pertaining to outpatient services are as follows.
- Number of new cases
- Number of repeat cases
- Specialitywise break-up cases
- Unitwise break-up cases
- Age and Sex distribution of cases
- Diagnostic statistics
1. Daily Average outpatient
attendance
Total number of outpatient attendance during the period/Number of OPD
working days during the period
2. Average outpatient attendance
per patient (Average duration of the spell of sickness treated in OPD)
Total number of outpatient attendance/Total number of new cases
Surgical services
1. Total number of operations
2. Break-up of major and minor
operations. There is still no unanimity among the surgeons about the nature of
the operation, i.e. major or minor. Some hospital consider any operation
requiring general anesthesia as major where as others consider the time
duration as main variable in deciding whether an operation is major or minor.
It is suggested that combination of both, i.e. the type of anesthesia the time
duration should decide whether an operation is major or minor.
Laboratory
Services
1. Total number of examinations
2.
Break-down of types, viz. Haematology
·
Biochemistry
·
Routine urine
·
Microbiology
·
Histopathology
Imaging Services
1. Number
of Radiographs done
2. Break-up
of radiographs by sizes of the films
3. Number
of special examinations, e.g. barium studies, urographies
4. Number
of Ultrasonographies
5. Number
of CT scan studies
ECG and EEG
1. Number of ECG and EEG
2. Number of emergency ECG
Minimum cases required for
Installation of imaging services:
Rule of thumb: 1.3 to 1.5 X
rays examn/hosp bed/week will be reqd (0.18 to 0.20 examinations/bed days).
* One X ray for every 2.5 to 3 OPD patients.
* Approx % of examinations by type: Chest - 40%, GI Tract - 20 to 25%, Extremities - 15%, Head & neck - 7.5%,
Spl procedures – 3 to 5%, Others - 15 to 20%.
* One X ray for every 2.5 to 3 OPD patients.
* Approx % of examinations by type: Chest - 40%, GI Tract - 20 to 25%, Extremities - 15%, Head & neck - 7.5%,
Spl procedures – 3 to 5%, Others - 15 to 20%.
•
Estimating number of Diagnostic Rooms
–
Rule of thumb: 1.3 to 1.5 X rays exams/hosp
bed/week
–
0.18 to 0.20 examinations/bed / day
–
One X ray for every 5- 6 OPD patients
–
One X ray for every 2.5- 3 emergency patients
( Laufmann)
•
Estimated mean time for a radiological
examination – 13.3 mins
CT SCAN
1 scanner for 1.5 lac
population, 2500 scans / yr, 300 bedded hospitals (BIS).
* WORKLOAD: Head (65%), Abdomen (18%), Thorax (45),
Pelvis (6%), Limbs (7%).
* WORKLOAD: Head (65%), Abdomen (18%), Thorax (45),
Pelvis (6%), Limbs (7%).
MRI-1000 to 2000 scans / year.
•
LAB: Avg
-8 to 20 lab tests in ALS of 10 days
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