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.

1. 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.
2. 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.
3. 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.

1. The organization
2. The process
3. The content
4. 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.

1. Number of new cases
2. Number of repeat cases
3. Specialitywise break-up cases
4. Unitwise break-up cases
5. Age and Sex distribution of cases
6. 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%.

•      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%).

MRI-1000 to 2000 scans / year.

•         LAB: Avg -8 to 20 lab tests in ALS of 10 days