Abhijit Chakravarty

Activity based costing of diagnostic procedures at a nuclear medicine center of a tertiary care hospital.

Context: Escalating health care expenses pose a new challenge to the health care environment of becoming more cost-effective. There is an urgent need for more accurate data on the costs of health care procedures. Demographic changes, changing morbidity profile, and the rising impact of noncommunicable diseases are emphasizing the role of nuclear medicine (NM) in the future health care environment. However, the impact of emerging disease load and stagnant resource availability needs to be balanced by a strategic drive towards optimal utilization of available healthcare resources. Aim: The aim was to ascertain the cost of diagnostic procedures conducted at the NM Department of a tertiary health care facility by employing activity based costing (ABC) method. Materials and Methods: A descriptive cross-sectional study was carried out over a period of 1 year. ABC methodology was utilized for ascertaining unit cost of different diagnostic procedures and such costs were compared with prevalent market rates for estimating cost effectiveness of the department being studied. Results: The cost per unit procedure for various procedures varied from Rs. 869 (USD 14.48) for a thyroid scan to Rs. 11230 (USD 187.16) for a meta-iodo-benzyl-guanidine (MIBG) scan, the most cost-effective investigations being the stress thallium, technetium-99 m myocardial perfusion imaging (MPI) and MIBG scan. The costs obtained from this study were observed to be competitive when compared to prevalent market rates. Conclusion: ABC methodology provides precise costing inputs and should be used for all future costing studies in NM Departments.

TOTAL QUALITY MANAGEMENT - THE NEW PARADIGM IN HEALTH CARE MANAGEMENT

Hospitals are by nature complex organisations and the complexity is compounded in service hospitals with perceived notion of service deficiencies. Quality has emerged as a major issue in health care sector and TQM has been accepted as a major long-term strategic initiative towards continuously improving quality of health care. Key concepts of TQM start with top management leadership with emphasis on process and customer focus. Implementation of TQM in service hospitals will require Quality Management awareness, training and framework development as well as development of customer awareness. TQM has been widely applied in clinical field with successful outcome. TQM is not a short-term solution, it has to be understood and practised as a long-term strategic commitment.

A study of assessment of patient safety climate in tertiary care hospitals

BACKGROUND Medical errors are being detected with increasing frequency in healthcare environment, in many cases leading to patient harm. Measurement and improvement of patient safety climate has been identified as a strategic effort towards addressing this vital issue. METHOD Safety Attitude Questionnaire (SAQ), validated by previous research was administered to 300 respondents in three tertiary care hospitals of India, the respondents representing various categories of healthcare workers and variations in safety scale score was analyzed by various statistical tools. RESULTS No variation was observed in the Patient Safety Index score among the study hospitals. However, significant variations were observed among different categories of healthcare workers across dimensions of Teamwork, Perception of Management and Stress Recognition. Multiple Regression models identified Teamwork and Perception of Management to have significant correlation with Patient Safety Index Score. CONCLUSION Patient Safety Climate can be effectively assessed and such assessment utilized for focused improvement efforts towards safety in healthcare organizations.

Inappropriate Use of Hospital Beds in a Tertiary Care Service Hospital

BACKGROUND The cost of medical care is continuing to rise and cost containment measures need to focus on inappropriate hospitalization. Armed Forces Medical Services ensure universal access to its consumers but continuous increase in patient load is stretching the capability of service hospitals. The present study was undertaken to determine the rate of inappropriate hospitalization in a large tertiary care service hospital. METHODS Appropriateness Evaluation Protocol (AEP) was used to assess the appropriateness of hospital days, the study being carried out in the acute medical and acute surgical wards of the hospital on randomly selected days over a period of three months. RESULTS Inappropriate patient days were found to be 29.48% during the study period, with 34% of acute surgical patient days and 24.4% of acute medical patient days found to be inappropriate. No statistically significant difference was observed in the rate of inappropriate hospital stay between serving personnel and ex-servicemen. 31.25% non local patients as compared to 25.81% of local patients were found to have inappropriate hospital stays, though the difference was not found to be statistically significant. 60.71% of inappropriate stays were found in the initial period of admission (1-5 days), the phenomenon being observed both in the acute surgical and acute medical wards. CONCLUSION The study shows that the rate of inappropriate patient days is quite high among the study population and regular utilization reviews need to be carried out to conserve health care resources available with the service hospitals.

A qualitative study to develop an instrument for initial nurse assessment

Complex health care needs focus on accountability and necessity of inclusion of nurses in documenting and monitoring clinical care plans have brought in the concept of initial nurse assessment and nursing process. However, no standardized form exists in the Armed Forces Medical Services to document initial nursing observations while a patient is being admitted in service hospitals. A focus group design was utilized to explore and conceptualize an initial nurse assessment form that may be utilized by service hospitals.

Medication error: An unfortunate reality

Although a substantial body of literature exists describing medication errors and preventable adverse drug events, medication safety has not been a topic that has generated much attention. The release of Institute of medicine (IOM) report “To Err is Human” brought the scope of medical errors and patient safety in front of the world.1 With estimates of 44,000 to 98,000 deaths annually due to medical errors, out of which 7000 deaths per year can be traced to medication errors have generated substantial interest and debate on the subject in recent years. The first IOM report defined an error as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Medication errors by nature are largely preventable, do not always cause harm and can be caused by errors in planning (prescribing) and execution (dispensing and administering medications). We report a case of medication error reported in a service hospital, with a series of errors precipitating an adverse event requiring hospitalization and in – patient management.

For Whom Do We Toil

Dear Editor, This is with reference to the article titled “For Whom Do We Toil” which appeared in MJAFI 2001; 57: 52-4. Utilisation of a hospital is studied by a complex of hospital bed and population utilisation indices. Average length of stay alone is an unreliable indicator, as the figure will vary as per the role of the hospital and the type of patients being treated. Moreover, low mortality Figure, as mentioned in the study, simply represents an outcome measure of the hospital. To be meaningful, these data should have been case-mix adjusted. Efficiency in health care is an elusive concept due to intangibility of most of the outcomes of a health care organisation. I think the author meant effectiveness and efficiency, while discussing the delivery profile of the hospital. I wish the author could have carried out a more comprehensive study of the utilisation indices and the outcome profile of the hospital and then benchmark these data with that of similar sized service and civil hospitals, before commenting on the efficiency of patient care being delivered. I congratulate the author for bringing out the tremendous wastage of scarce resources due to admissions for medical board, which needs to be addressed by our service HQ.

HOSTILITY PATTERN AMONG TERRITORIAL ARMY PERSONNEL

A comparative study of hostility and direction of hostility was carried out on 26 Territorial Army personnel, 23 regular Army personnel, 23 patients with minor depression and 30 controls. No statistically significant difference in scores on any of the hostility subscales was found between the two groups of Army personnel and controls. The depressive group showed significantly high scores on self-criticism, guilt and total hostility as compared to the Territorial Army personnel. The difference in these intropunitive subscales (self-criticism and guilt) points to less proneness to depression in Indian Territorial Army personnel. Direction of hostility was found to be more extropunitive in regular Army and Territorial Army personnel as compared to normal group, which might be an outcome of military training.