Covering Letter

Date : 12-04-11

To, The Chief Organiser e-World Forum 2011 New Delhi Sub : Regarding the paper to be considered for presentation & publication in eWorld Forum 2011 Dear Sir, We are submitting herewith the write-up titled Challenges Before Hospital Management & Its Solutions, to be considered for e-world Forum 2011. Best Wishes & Warm Regards. Sd/-

(Dr. R. Harsvardhan) Dept. of Hospital Administration, AIIMS

Communication : Corresponding Author Dr. Rajesh Harsvardhan C/o, Dr. D. K. Upadhyay, Qr. No. E-9, D. D. U. Hospital Residential Complex, Harinagar, New Delhi 110064.

E-mail drrharsvardhan@yahoo.co.in
Mobile + 91- 9350597571
1

Undertaking

This is to certify that the the write-up titled Challenges Before Hospital Management & Its Solutions is a bonafide write-up of the following authors.

Sd/-

Dr. Rajesh Harsvardhan

Senior Resident Administrator,
Deptt. of Hospital Administration, AIIMS

Sd/-

Dr. D. K. Sharma
Medical Superintendent, AIIMS

Title page

Title : Challenges Before Hospital Management & Its Solutions

Name & Affiliation :

1.

Dr. Rajesh Harsvardhan, Senior Resident Administrator, Dept. of Hospital Administration, AIIMS, New Delhi.

2.

Dr. D. K. Sharma, Medical Superintendent, AIIMS, New Delhi

Address : Corresponding Author

Dr. Rajesh Harsvardhan

C/o, Dr. D. K. Upadhyay, Qr. No. E - 9, D. D. U. Hospital Residential Complex, Harinagar, New Delhi 110064.(INDIA)

E-mail drrharsvardhan@yahoo.co.in
Mobile + 91 - 9350597571

THE WRITE-UP Challenges Before Hospital Management & Its Solutions

Dr. Rajesh Harsvardhan*, Dr. D. K. Sharma**

Background
Challenges are opportunities, in disguise.
Hospitals dominate health care in most parts of the world and for a variety of reasons are likely to continue being a key factor in the overall performance of the health care system. Any efforts to improve this performance must therefore give greater hospital efficiency the highest priority. The criticism leveled, against the hospital is that it exists in splendid isolation in the community, acquiring the euphemism "an ivory tower of disease". Hospitals absorbs a vast proportion (50 to 80 %) of health budget; it is not people-oriented; its procedures and styles are inflexible; it overlooks the cultural aspects of illness (treating the disease without treating the patient); the treatment is expensive; it is intrinsically resistant to change, and so on. The relative isolation of hospitals from the broader health problems of the community, which has its roots in the historical development of health services, has contributed to the dominance of hospital model of health care.

Introduction
It is recognized that in both developed and developing countries, the standard of health services the public expect, are not being provided. A very high proportion of the population in many developing countries including India, and especially in rural areas, do not have any access to health services, which can be used by only the privileged few and urban dwellers. Although there is the recognition that health is a fundamental human right, there is a denial of this right to millions of people who are caught in the vicious circle of poverty and ill-health.

**Medical Superintendent, AIIMS, New Delhi *Senior Resident Administrator, Dept. of Hospital Administration, AIIMS, New Delhi. Communication: C/o, Dr. D. K. Upadhyay, Qr. No. E - 9, D. D. U. Hospital Residential Complex, Harinagar, New Delhi 110064.(INDIA) E-mail drrharsvardhan@yahoo.co.in Mobile 91 + 9350597571
4

In short, there has been a growing dissatisfaction with the existing health services and a clear demand for better health care. The victims of poor medical care are those who have to rely on government hospitals, which are overcrowded, short staffed and have meager funds to provide for medicines and health supplies. Moreover, syringes and surgical equipment are repeatedly used on different patients without adequate sterilization allowing further spread of deadly infections among unsuspecting patients. Worse still, medical waste is not disposed of properly and used medical equipment is scavenged outside hospitals only to be sold again. In fact, this practice has been reported to become an organized profitable business. Sweepers, medical technicians, nurses and even physicians have been reported to be absent for months at a time and have been referred as ghost workers. An Alma Ata declaration has stated that: "the organized application of local state, national and international resources to achieve "Health for All", i.e. attainment by all people of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. Many times the medical miracles in India lie in the idea that some patients actually survive their hospital stay. How can we help to implement this declaration, while at the level of tertiary health care especially government hospitals, poor patients that are the major population of India, are still facing problems for obtaining proper facilities for their treatment ?

Case Study : The Eastern Experience

With large migrations occurring form rural to urban areas, urban health problems have been aggravated and include overcrowding in hospitals, inadequate staff and scarcity of certain essential drugs and medicine. As every person has his own opinion about these problems so a study was performed to analyse the reasons for the problems faced by patients, at Jinnah Postgraduate Medical Center, Karachi; to assess the reasons for the problems faced by patients in the government hospitals to make an emphasis on higher authorities for identification of problems and implementation of effective measures. A questionnaire-based doctor's survey was conducted at Jinnah Postgraduate Medical Centre (JPMC). The survey included 10 doctors each from 5 wards of JPMC. Informed consent was obtained from study participants and ethical considerations were fulfilled. All the doctors were asked questions related to the problems created by hospital management, due to the irresponsibility and concerns of the doctors and also due to the patients themselves. The responses were evaluated separately. A total of 50 doctors participated. Out of which, 19 were males and 31 females. Out of all the reasons listed, 84% doctors favored the reason of inadequate salary to doctors & paramedical staff by 5

government. While other two reasons favored by 80% doctors were lack of facilities and security for doctors and illiteracy and poverty of patients. The reasons for the problems, related to hospital, were six. Out of six reasons, "lack of facilities & security of doctors" was marked true by 80% of doctors. Other reasons were in the range of 30% to 60%. The reasons for the problems related to doctors were four. Out of four reasons, "Inadequate salary to doctors and paramedical staff by government" was marked true by 84% of doctors. Other reasons were in the range of 30% to 50%. The reasons for the problems, related to patients, were three. Of these three reasons, "Illiteracy and poverty of patients are factors that create problems for them in government hospital" was marked true by 80% of doctors. Other reasons in a range of 30% to 60% The study was conducted to deduce certain root causes of major problems. Though a vast variety of problems were considered, three most significant ones emerged drew full attention. The third query of the questionnaire which was regarding facilities and security of doctors was marked "true" by almost 80% responders, which is itself an indicator of still lasting fear regarding security probably due to killings of doctors in the recent past. This should of course, be a main sector of concern for the higher authorities as no one can do their best until they feel adequately secured. As the questionnaire also focussed on the facilities for doctors, 80% responders were dissatisfied with the current privileges. This shows that peace of mind is an important factor for efficient working. This can be acquired by improving the facilities provided. The provision of adequate, accessible, appropriate and affordable health is one of the fundamental rights, recognized by global leadership under banner of World Health Assemblies of 1978 and 1998. Improving health services in poor communities might involve changing the incentive structure for public providers. Introducing incentives in the public sector is often difficult due to non-flexibility of civil service rules. Incentives as paying extra allowances for hardship posts have been implied in many countries. All mechanisms of incentives have their own risks and none of them is problem free. The eighth query of the questionnaire dealt with inadequate salary of doctors and was also responded in affirmative was by 84%. This, indeed, reflects that doctors and paramedical staff are not satisfied or content with their current benefits rendered to them for their hard and diligent work. The query elucidates that performance of doctors and paramedical staff can be enhanced by giving appropriate incentives to them. Lack of supervision from senior physicians, inadequate laboratory, radiology and pathology facilities do not allow thorough medical work up of patients. "Senior doctors including professors, who are paid meager salaries of up to 20,000 rupees a month, are involved in lucrative private practice in

order to lead a decent life and thus have no time or drive to care for patients or mentor medical trainees. Several physicians in the government hospitals solicit business and lure patients into seeing them in their private clinics. Moreover, doctors charge fees for their services without following any particular fee schedule. Job dissatisfaction and stress among doctors affect the quality of health care. Majority of doctors working at these teaching hospitals of Karachi had a poor satisfaction level and higher levels of job stress. This suggests that immediate steps should be taken for rectification. The last and the thirteenth query dealing with illiteracy and poverty of patients gave a positive response by 80% doctors, reflects that patients behavior with the doctors and to disregard doctors' advice. Patients usually don't observe the follow-up probably owing to overload in govt. hospital. Sometimes after initial response and feeling better they ignore doctor's advices. So measures should definitely be taken to improve the understanding, the importance of follow-ups and the doctor's advice. The results of this study warrant a prompt corrective action by the all concerned. The last and the thirteenth query dealing with illiteracy and poverty of patients gave a positive response by 80% doctors, reflects that patients behavior with the doctors and to disregard doctors' advice. Patients usually don't observe the follow-up probably owing to overload in govt. hospital. Sometimes after initial response and feeling better they ignore doctor's advices. So measures should definitely be taken to improve the understanding, the importance of follow-ups and the doctor's advice. The results of this study warrants a prompt corrective action by the all concerned. This hospital based study showed that the causes were related mainly to hospital management, doctors' attitude and responsibility and also to patients' illiteracy and poverty. Changing Paradigm New realities are placing pressures on the healthcare industry, and how patient care is delivered. Rising hospital management costs, an aging population, a shortage of healthcare workers, challenges in accessing services, timely availability of information, issues of safety and quality, and rising consumerism are some of the facts of todays healthcare system. The industry has reached a point of chasm, where they need to decide how services could be delivered more effectively to reduce costs, improve quality, and extend reach. The critical questions facing the industry today include - How can we effectively manage hospitals and provide enhanced services without placing additional burden on a system already pushed to its limits ? How can we provide care in a cost-efficient manner at a time when healthcare spending is rising ? How do we most 7

efficiently use our resources and support front-line staff in order to reduce medical errors and enhance quality of care ? These are just a few questions facing the industry. Future looks bleak, but a recourse to following measures can assure that theres hope. Modern management techniques Computerization of services in the medical field including technological and telemedicine innovation. The management of human resources, materials and equipment. The relationship between hospitals and partners. The management of medicines & the relationship with patients. Waste management within hospitals and medical centers. Financial management in hospitals & Health Insurance.

Case Study : The Western Experience

Top Issues Confronting Hospitals : 2009; was the survey conducted, in which questionnaire was sent to hospital CEOs who were ACHE members, respondents were asked to rank 13 issues affecting their hospitals in order of importance and to identify specific areas of concern within their top three issues. Following are the results of the survey, which was sent to 1,275 hospital CEOs in October and November 2009, of whom 525, or 41 percent, responded.

Financial challenges ranked No. 1 on the list of hospital CEOs top concerns in 2009, making it their No. 1 issue for the last five years, according to the American College of Healthcare Executives (ACHE) annual survey of top issues confronting hospital CEOs. Within each of their three top issues, respondents identified specific concerns facing their hospital. Following are those concerns in order of importance for the top three issues identified in the survey: Financial Challenges (n=393)

Specific Concern
Medicaid reimbursement Bad debt Medicare reimbursement Increasing costs for staff, supplies, etc.

%age
87% 80% 78% 72%
9

Inadequate funding for capital improvements Managed care payments Other commercial insurance reimbursement Revenue cycle management (converting charges to cash) Emergency department Competition from specialty hospitals Other

64% 47% 46% 45% 43% 25% 10%

Healthcare Reform Implications (n=275)

Reduced reimbursement as a result of: Reduction in Medicare reimbursement Public option Bundling payments instead of fee for service Tax on Cadillac-type plans Other Increased demand for services such as: Queues for emergency services 46% 91% 83% 80% 25% 11%

10

Queues for preventive care (e.g., mammography) Access to primary care* Other Reduced quality of care: Less innovation in diagnosis and treatment Standardized (cookbook) medical protocols Other

29% 5% 2%

40% 35% 9%

Care for the Uninsured (n=187)

Medicaid Advocacy for funding Underwriting costs Reaching out to all community members Response to other hospital closings Increasing numbers*

91% 79% 61% 34% 11% 6%

11

Emergency department overuse* Other

5% 3%

*This item was derived from written-in responses. Frequencies for this variable should be taken as an underestimate of perceived importance.

Hospital Management : Faces Many Challenges

Hospital management is becoming increasingly difficult in todays market. The demand is growing and the challenges are increasing. Overburdened emergency rooms and acute care wards are straining the hospitals capacity - and drive up overall costs - because of underinsured patients who delay or forego primary care. Then what is the way out ? Answer lies in many or, any of them - Assess emergency and surgery capacity management practices. Look for opportunities to improve patient flow, treatment pathways, length-of-stay and case management based on leading practices. Workforce shortages, especially in nursing and primary care, grow worse. It calls for analyzing the staffing pattern to learn how to use the workforce more efficiently or, to train the staff in change management and leading practices or, even to reduce the staff turnover by facilitating and respecting their patient care responsibilities.

The Road Ahead

The aim is to reduce the overall cost of medical careand improve patient satisfactionby offering wellness programs, palliative care, and disease management. It warrants evaluation of such programs carefully, since their effectiveness in improving long-term costs or outcomes is difficult to measure. The constant pressure to be more transparent and to drive costs out of your operations can be neutralized : Analyzing the clinical and business processes and publicizing the results. Using them to identify opportunities to streamline workflows, eliminate unneeded procedures and improve management of supply chain and revenue cycle. 12

Collaborating better with employers and payers.

Hospital management is becoming increasingly difficult in todays market. The demand is growing and the challenges are increasing, as has already been said. From inadequate reimbursement and productivity management to rising insurance costs and patient satisfaction concerns, recruiting hospital management is becoming a greater and greater challenge. Indeed, its not just nurses and doctors, but the hospital management thats hard to come by these days. An aging population and chronic illnesses are straining hospital management as much as nurses and doctors. The problem has been highly publicized, yet hospital management shortages are still a reality. Whats more, the shortage of nurses and doctors is putting additional strain on hospital management that is charged with filling those positions. Hospital management is required to manage the right staff levels across the facility. Recent studies demonstrate that about one third of facilities dont have enough staff available, putting a dam in the flow of operations of hospital management. Even if hospital management attracts the right talent to fill the shifts, turnover is a major issue in the healthcare industry, especially nursing staff. Hospital management is also tasked with keeping overtime costs in check. With too few medical staff, the available personnel tends to work long hours and has to be paid for it. Hospital management also entails quality compliance and patient safety, managing premium labor costs, revenue enhancement and governmental regulations and mandates. Concepts like universal healthcare could complicate matters for hospital management, according to recent surveys. Eleven percent of doctors said they would change occupations and nine percent said they would retire if universal healthcare practices are implemented, according to physician recruiting firm LocumTenens.com. That would add to the already forecasted problems for hospital management. Hospital management is in look out for strategies to stem the tide before its too late. Risk resilient healthcare organizations assume risks profitably while effectively managing the complexities of a rapidly evolving regulatory and compliance environment. By integrating risk management, internal control and compliance systems, management decisions can be made with increased confidence and clarity. Effectively designed enterprise wide risk management also enables the ability to provide transparency to key stakeholders, such as community boards, public bond authorities, government regulators and valued employees and patients. Risk-resilient organizations understand how to effectively align business processes to minimize compliance risks. Healthcare providers understand the increased scrutiny occurring in a new wave of regulatory activity. Increasingly enterprise-wide assessments are indicating the need for integrated compliance programs that drive down risk while increasing value. So for example, billing compliance remediation leads to more patient revenue, and preparation for recovery audit contractor reviews leads to operational and quality improvements. 13

My View Point
Successful organizations will understand the need for enterprise-wide risk management and the need for integrated responses to risks that impact their people, processes and technology. Making a commitment to becoming a risk resilient organization includes a rigorous assessment of an organizations current activities and their alignment with business processes and strategy. As organizations continue to grapple with healthcare reform, investments in digital technologies like electronic medical records, Quality initiatives and reporting and operational improvements, new risks will emerge and existing risks will require effective management. Risk resilient organizations will have to ensure that traditional internal barriers are eliminated to ensure effective risk mitigation. As they develop their response strategy and how to integrate it, they will need new methodologies, approached and expertise than previously required. Competition is relentless and pressing. So are the demands from all quarters that you deliver better care for less money. Consumer choices, reimbursement restrictions and investments in information and medical technologies squeeze your already-slim operating margins. One can no longer stay competitive by delivering traditional models of patient care. One needs to adapt ones services and business processes to keep both ones patients and ones bottom line healthy. The challenges being faced are many and varied. Growth strategy must address them better, faster than the competitors. Quality differentiates the organization in a competitive marketplace. But quality care is more than a business strategy. It is should be the organizations mission and reason for being. ==== x ====

14