Hospital Management Module Final Version

260
1 Suitable for: Hospital Administrators and Managers Jan 2010

Transcript of Hospital Management Module Final Version

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Suitable for: Hospital Administrators and Managers

Jan 2010

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Table of Content Table of Content ................................................................................................................. 2

Introduction......................................................................................................................... 8

Session1: Overview .......................................................................................................... 10

What is Hospitals? ............................................................................................................ 10

History of Hospitals .......................................................................................................... 11

Role of Hospitals in Health System.................................................................................. 13

Changing Role of Hospitals .......................................................................................... 16

Reasons for changing role of hospitals ......................................................................... 16

Function of an Acute Care Hospital.................................................................................. 17

Hospital viewed as a System............................................................................................. 19

Peculiarities of a Hospital System ................................................................................ 20

Component or Structure of a Hospital .............................................................................. 22

A. Administration Services........................................................................................ 23

B. Informational Services .......................................................................................... 23

C. Therapeutic Services ............................................................................................. 23

D. Diagnostic Services............................................................................................... 25

E. Support Services ................................................................................................... 25

Organization of Hospitals in Afghanistan......................................................................... 27

The Future of Hospitals in Afghanistan............................................................................ 28

Group work and Facilitator Notes: ............................................................................... 29

Materials ................................................................................................................... 29

Process ...................................................................................................................... 29

Hospital Policies in Afghanistan....................................................................................... 30

Levels of Hospitals in the country ................................................................................ 31

District Hospital ........................................................................................................ 32

Provincial Hospital.................................................................................................... 32

Regional Hospital...................................................................................................... 32

Rationalization of Hospital Services (components)...................................................... 33

Aga Khan University Hospital Components and Activities ............................................. 34

Hospital and Challenges in Afghanistan........................................................................... 36

Hospital and Community .................................................................................................. 37

The provider, support group and community ............................................................... 39

Community and its Participation .................................................................................. 39

Hospital community relationship.................................................................................. 40

Session 2: Effective Management at Hospitals................................................................. 42

Medical profession and management................................................................................ 42

Principles of Management ................................................................................................ 42

Administration or management......................................................................................... 44

The governing board of hospitals ................................................................................. 45

Hospital Administrator.............................................................................................. 46

Choice of Hospital Director (Administrator)............................................................ 46

Role and functions of Hospital Administrator .......................................................... 47

Management Styles........................................................................................................... 48

Laissez-faire Management style : ............................................................................. 48

Democratic Management Style:................................................................................ 48

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Autocratic Management Style: ................................................................................. 48

Group work: .................................................................................................................. 48

Skills of effective managers.............................................................................................. 51

Conceptual Skills .......................................................................................................... 51

Communication Skills................................................................................................... 52

Interpersonal Skills ....................................................................................................... 52

Importance of the managerial skills .................................................................................. 52

Ways to Improve Your Managerial Skills ........................................................................ 54

Coordination ..................................................................................................................... 58

Facilitation of coordination........................................................................................... 59

Characteristics of effective Hospital Manger ................................................................... 59

Efficiency versus Effectiveness ........................................................................................ 60

What is Efficiency?....................................................................................................... 60

What is Effectiveness?.................................................................................................. 60

Comparison of effectiveness and efficiency ................................................................. 61

Session 3: Hospital Planning and Design ......................................................................... 63

Guiding principles in Planning ......................................................................................... 63

Patient care of high quality ........................................................................................... 63

Effective community orientation .................................................................................. 64

Economic Viability ....................................................................................................... 64

Orderly Planning........................................................................................................... 65

A sound architectural plan ................................................................................................ 65

Hospital Utilization and planning ..................................................................................... 66

Bed Planning in Hospitals................................................................................................. 67

Planning for equipment in hospitals ................................................................................. 69

Session 4: Basics of Strategic Planning in Hospitals........................................................ 72

Importance of Strategic Planning...................................................................................... 72

Roles and Responsibilities in planning process ................................................................ 73

Strategic Planning Committee ...................................................................................... 73

The General Director/Chief Executive Officer............................................................. 74

Medical Staff................................................................................................................. 74

Patients and Community............................................................................................... 74

Planner and consultants................................................................................................. 75

The Steps of the Strategic Planning .................................................................................. 75

Get Organized ............................................................................................................... 76

Analysis of the Situations ............................................................................................. 77

Develop a Vision........................................................................................................... 78

Development or Review the Mission Statement........................................................... 78

Value statement............................................................................................................. 79

Develop Strategies ........................................................................................................ 79

Goal approach ........................................................................................................... 80

Critical Issues Approach ........................................................................................... 81

SMART Objectives................................................................................................... 82

Scenario Approach.................................................................................................... 82

Strategic Plan preparation ................................................................................................. 83

Taking Approval of the Plan......................................................................................... 84

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Implementation of the Plan........................................................................................... 84

Monitoring and Updating the Strategic Plan ................................................................ 84

Operational Planning and Activity Scheduling................................................................. 85

What is Operational Plan? ............................................................................................ 88

Importance of Operational Plan .................................................................................... 89

Steps in developing Operational Planning.................................................................... 89

Step 1 – List Main Activities .................................................................................... 89

Session 5: Hospital Costing and Budgeting...................................................................... 93

Budget Principles .............................................................................................................. 93

What is cost? ..................................................................................................................... 94

Classification of Costs ...................................................................................................... 95

Classification by type.................................................................................................... 95

Classification by behavior............................................................................................. 95

Classification by function/activity ................................................................................ 97

Classification by level................................................................................................... 98

Layout of Methodology of Framework............................................................................. 99

Goals summary ............................................................................................................. 99

Resources (Inputs) ........................................................................................................ 99

Converting the costing to a budget ................................................................................. 100

Steps for creating a budget.............................................................................................. 100

Hospital Budgeting ......................................................................................................... 104

Preparing to draw up a Budget.................................................................................... 105

STEP 1: list the inputs............................................................................................. 105

STEP 2: cost of inputs............................................................................................. 105

STEP 3: Combine the costs..................................................................................... 106

Budgeting for Revenue: .............................................................................................. 106

Cost consciousness.......................................................................................................... 107

Cost containment and improving profitability............................................................ 107

A checklist for cost containment................................................................................. 108

Cost Effectiveness........................................................................................................... 109

Program Budgeting In Afghanistan ................................................................................ 111

Implementing Program Budgeting.............................................................................. 112

Group work: ................................................................................................................ 114

Session 6: Hospital Monitoring and Evaluation ............................................................. 116

Justifications for Monitoring Hospitals ...................................................................... 117

Monitoring Framework................................................................................................... 117

Evaluation Framework.................................................................................................... 118

Planning for Monitoring and Evaluation ........................................................................ 118

Hospital as a System for Monitoring .............................................................................. 119

Quality Monitoring Framework.................................................................................. 121

What is Quality Monitoring? ...................................................................................... 124

Criteria .................................................................................................................... 124

Standards................................................................................................................. 124

Hospital Monitoring Indicators....................................................................................... 126

Length of Stay (LS...................................................................................................... 127

Occupancy Rate (OR):................................................................................................ 127

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Proportion of all Births in the Hospital:...................................................................... 128

Cesarean Sections as a Proportion of all Births: ......................................................... 128

Case Fatality Rate (CFR):........................................................................................... 129

Incidence rate (IR) (6 EPI target diseases, diarrhea, ARI): ........................................ 130

Mortality rate under age 5 (U5MR):........................................................................... 130

Post Operative Infection proportion: .......................................................................... 130

External and Internal Monitoring.................................................................................... 131

Hospital Monitoring of Adverse Drug Reactions ........................................................... 131

Monitoring of Absenteeism in Hospitals ........................................................................ 133

Why absenteeism ........................................................................................................ 133

Management issues: .................................................................................................... 133

Staff issues: ................................................................................................................. 133

How to deal with absenteeism .................................................................................... 134

Session 7: SWOT Analysis of Hospital .......................................................................... 136

Strengths: .................................................................................................................... 136

Weaknesses: ................................................................................................................ 136

Opportunities: ............................................................................................................. 136

Threats: ....................................................................................................................... 137

Group work: ................................................................................................................ 137

Session 8: Medical Audit and Quality Assurance........................................................... 139

Definitions....................................................................................................................... 139

History of medical audit.................................................................................................. 140

Types of audit ................................................................................................................. 141

Standards-based audit ................................................................................................. 141

Adverse occurrence screening and critical incident monitoring................................. 141

Peers review................................................................................................................ 141

Patient surveys and focus groups................................................................................ 141

Protocol for medical audit............................................................................................... 141

Process of clinical audit .............................................................................................. 143

Stage 1: Identify the problem or issue ........................................................................ 144

Stage 2: Define criteria & standards ........................................................................... 144

Stage 3: Data collection .............................................................................................. 144

Stage 4: Compare performance with criteria and standards ....................................... 145

Stage 5: Implementing change.................................................................................... 145

Re-audit: Sustaining Improvements............................................................................ 146

Evaluation, Research, Medical and Clinical Audit ......................................................... 147

How to Write an Audit Report.................................................................................... 148

Hospital Standards in Afghanistan.................................................................................. 149

Section 1: Governance ................................................................................................ 149

Section 2: Clinical Care .............................................................................................. 150

Section 3: Nursing Services ........................................................................................ 151

Section 4: Ancillary and Support Services ................................................................. 151

Section 5: Administration and Management............................................................... 152

Standards and Performance at Hospitals..................................................................... 152

Importance of Clinical Audit ...................................................................................... 158

Areas and Time of clinical audit ................................................................................. 160

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Quality Care in Hospitals................................................................................................ 161

Choice of Quality Healthcare...................................................................................... 162

Checklist for choice of Quality Healthcare............................................................. 163

The way forward ............................................................................................................. 164

Session 9: Financial Management in Hospitals .............................................................. 166

Health Providers in Hospital System .............................................................................. 166

Payers in Hospital System .............................................................................................. 168

Hospital Revenues: How Hospitals are earning money?................................................ 169

Hospital Expenses: How Hospitals are spending money?.............................................. 172

Financial Information in the Hospitals ........................................................................... 173

The Income Statement .................................................................................................... 174

What Is Profit? ............................................................................................................ 175

The Balance Sheet........................................................................................................... 176

The Cash Flow Statement ............................................................................................... 179

Evaluation of Hospital Financials conditions ................................................................. 181

Ratio Analysis............................................................................................................. 181

Cash Flow Analysis .................................................................................................... 183

Affiliate Charts................................................................................................................ 183

Financial report and information system ........................................................................ 183

Session 10: Grievance and complaint Management in Hospitals................................... 185

Importance of facing complaints as challenge................................................................ 186

Follow-up actions taken by the hospital ..................................................................... 190

Six rules for pursuing hospital complaints through patient’s perspective .................. 191

Patients’ rights ................................................................................................................ 191

Session 11: Hospital Information System....................................................................... 194

Working principles for revising the HMIS ................................................................. 195

Criteria for Health Indicator selection ........................................................................ 195

Importance of Health Information System ................................................................. 196

Hospital Information System Forms in MoPH ............................................................... 198

Monthly Integrated Activity Report – Facilities OPD (MIAR).................................. 198

Hospital Monthly Inpatient Report (HMIR) ............................................................... 204

Hospital Status Report Form (HSR) ........................................................................... 211

Session 12: Waste Management in Hospitals ................................................................. 218

Types of wastes........................................................................................................... 218

Characteristics of a good waste disposal system ........................................................ 220

Collection and Removal of wastes.............................................................................. 220

Disposal of waste ........................................................................................................ 221

Classification of waste ................................................................................................ 221

1. Type 0 wastes: Trash ...................................................................................... 221

2. Type 1 waste: Rubbish:................................................................................... 222

3. Type 2 Waste: Refuge..................................................................................... 222

4. Type 3 Waste: Garbage................................................................................... 222

5. Type 4 Waste: Pathological ............................................................................ 222

6. Type 5 and 6 Waste: Industrial Operations..................................................... 222

Methods of disposal .................................................................................................... 222

Infection Prevention and Waste Management in Hospitals............................................ 223

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Policy: ......................................................................................................................... 223

Waste Segregation ...................................................................................................... 223

Color coding: Clinical Waste Segregation.................................................................. 229

Session 13: Report writing.............................................................................................. 231

Why report writing?.................................................................................................... 231

Structure of Report Writing ........................................................................................ 232

Annexes: ......................................................................................................................... 237

Annex A: Quiz on Organizational Structure of Hospitals .......................................... 237

Annex B: Sample of strategic plan (partially) ............................................................ 238

Annex C: Patients’ Rights and Responsibilities at Aga Khan University Hospital.... 244

Annex D: HMIS form (Monthly Integrated Activity Report- MIAR)........................ 248

Annex E: HMIS form (Hospital Monthly Inpatient Report- HMIR).......................... 250

Annex F: HMIS form (Hospital Status Report- HSR)................................................ 252

Annexé G: Waste Colour Coding ............................................................................... 256

References:...................................................................................................................... 258

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Introduction Hospitals are an important component of the health care system and are central

to the process of reform, and yet, as institutions, they have received remarkably

little attention from government and stakeholders. They are important within the

health care system for several reasons. Although donors are less interested to

support tertiary healthcare system in Afghanistan, however they account for a

substantial proportion of the health care budget through ministry of public health

(MoPH). Second, their position at the apex of the health care system means that

the policies they adopt, which determine access to specialist services, have a

major impact on overall health care. Third, the specialists who work in hospitals

provide professional leadership. Finally, technological and pharmaceutical

developments, as well as more attention to evidence-based health care, mean

that the services that hospitals provide can potentially contribute significantly to

population health. If hospitals are ineffectively organized, however, their

potentially positive impact on health will be reduced or even be negative.

In Afghanistan the hospitals are at the stage growing and rapidly changing

pressures in public and private sector. These include the impact of changes in

populations, patterns of disease, opportunities for medical intervention with new

knowledge and technology, and public and political expectations. As we are

faced with double burden of diseases and there is a need to focus on primary,

secondary and tertiary care at the same time, therefore new types of hospitals,

new configurations of buildings, qualified people with different skills and new

ways of working are required. There is the need to shift the boundary between

hospital and primary care, where hospitals are thought to provide just advance

medical healthcare. Hospitals increasingly focus on acute care, only admitting

people with conditions requiring relatively intensive medical or nursing care or

sophisticated diagnosis or treatment. Hospitals must adapt internally to these

new circumstances.

There is now considerable information on what does and what does not work,

although this is not always easy to locate and evaluate. Using experiences of

developing countries and WHO recommendation we should proceed. In this

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regard we can use the Essential Package of Hospital Services (EPHS) and

Hospital Policy in Afghanistan which is developed and available. In this training

module it is tried to discuss the reasonable and modern ways of managing

hospitals in country context. This is not, however, a textbook on how to manage

a hospital. The module is focusing on the role of hospitals as part of a wider

health care system, in improving health and responding to the legitimate needs of

people who use hospitals.

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Session1: Overview

What is Hospitals? At the outset, it is necessary to be clear about the subject of this module. What,

precisely, is a hospital? One definition is that it is ‘an institution which provides

beds, meals, and constant nursing care for its patients while they undergo

medical therapy at the hands of professional physicians. In carrying out these

services, the hospital is striving to restore its patients to health. Although this

captures its essence, a hospital can cover very diverse structures.

There are definitions of medical care and hospital which is published by WHO in

1959.

Medical care is a programme of services that should make available to the

individual, and thereby to the community, all facilities of medical and allied

services necessary to promote and maintain health of mind and body. The

programme should take into account the physical, social and family environment,

with a view to prevention of diseases, the restoration of health and the alleviation

of disability. (WHO, 1959)

A Hospital is an integral part of a Social and Medical organization, the function of

which is to provide for the population complete healthcare, both curative and

preventive, and whose outpatients services reach out to the family and its home

environment; the hospital is also a center for the training of health workers and

bio-social research. (WHO definition of Hospital)

Thus, Hospital is a health facility where patients receive treatment. It is a medical

institution where sick or injured people are given medical or surgical care. A

hospital today is an institution for professional health care provided in part by

physicians and nurses.

A hospital might be a ten-bed building without running water in a district or a

large specialist centre equipped with the most advanced technology in a capital

of the country. This diversity is not surprising, given that some countries in

Europe spend less than a 50 euro per head of population per year on hospitals,

whereas others spend almost a14, 000. Second, the type of hospital can be

difficult to classify. For example, how does one classify a facility that links a small

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acute care service to a larger long term care facility? What is the difference

between a small private hospital offering mainly nursing care and an examination

home visited daily by a physician? How about public hospitals that are semi

closed afternoons and how about private hospitals that are semi closed in the

morning? Does the definition of a hospital cover only the activities undertaken

within its walls? Hospitals in the United States have embarked on vertical

mergers that incorporate other service types such as rehabilitation and post-

discharge care. “Hospital without walls’ or ‘hospital at home’ links the hospital to

a wide range of outreach services.

History of Hospitals During the middle Ages the hospital could serve other functions, such as

almshouse for the poor, or hostel for pilgrims. The name comes from Latin

hospes (host), which is also the root for the English words hotel, hostel, and

hospitality. The modern word hotel derives from the French word hostel, which

featured a silent s, which was eventually removed from the word; French for

hospital is hôpital. Some patients just come for diagnosis and/or therapy and

then leave (outpatients); while others are admitted and stay overnight or for

several weeks or months (inpatients). Hospitals are usually distinguished from

other types of medical facilities by their ability to admit and care for inpatients.

In ancient cultures, religion and medicine were linked. The earliest documented

institutions aiming to provide cures were Egyptian temples. Classical Greek

temples dedicated to the healer-god Asclepius might admit the sick, who would

wait for guidance from the deity in a dream. The Romans adopted his worship.

Under his Roman name Æsculapius, he was provided with a temple (291 BC) on

an island in the Tiber in Rome, where similar rites were performed. The

Sinhalese (Sri Lankans) may have been responsible for introducing the concept

of dedicated hospitals to the rest of the world. According to the Mahavamsa, the

ancient chronicle of Sinhalese royalty, written in the sixth century A.D., King

Pandukabhaya (fourth century B.C.) had lying-in-homes and hospitals

(Sivikasotthi-Sala) built in various parts of the country. This is the earliest

documentary evidence we have of institutions specifically dedicated to the care

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of the sick anywhere in the world. Institutions created specifically to care for the ill

also appeared early in India. King Ashoka is said to have founded at least

eighteen hospitals 230 B.C., with physicians and nursing staff, the expense being

borne by the royal treasury. Stanley Finger (2001) in his book, Origins of

Neuroscience: A History of Explorations Into Brain Function, cites an Ashokan

edict translated as: "Everywhere King Piyadasi (Asoka) erected two kinds of

hospitals, hospitals for people and hospitals for animals. Where there were no

healing herbs for people and animals, he ordered that they be bought and

planted. The first teaching hospital where students were authorized to practice

methodically on patients under the supervision of physicians as part of their

education was the Academy of Gundishapur in the Persian Empire. One expert

has argued that "to a very large extent, the credit for the whole hospital system

must be given to Persia. The Romans created valetudinaria for the care of sick

slaves, gladiators, and soldiers around 100 B.C., and many were identified by

later archeology. The adoption of Christianity as the state religion of the Roman

Empire drove an expansion of the provision of care. The First Council of Nicaea

in 325 A.D. urged the church to provide for the poor, sick, widows, and strangers.

It ordered the construction of a hospital in every cathedral town. Among the

earliest were those built by the physician Saint Sampson in Constantinople and

by Basil, bishop of Caesarea. The earliest recorded hospital in the medieval

Islamic world was that of al-Walid ibn 'Abdul Malik (ruled 705-715 CE) which he

built in 86 AH (706-707 CE). It somewhat resembled the Persian bimaristan and

Byzantine nosocomia, but was more general, as it extended its services to

lepers, invalid, and destitute people. All treatment and care was free of charge

and there was more than one physician employed in this hospital. In the

medieval Islamic world, the word "bimaristan" was used to indicate an

establishment where the ill were welcomed and cared for by qualified staff. In this

way Muslim physicians distinguished between a hospital and a hospice, asylum,

lazaret, or leper-house, all of which were more concerned with isolating the sick

and the mad (insane) from society than offering them a cure. Some thus consider

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the medieval Bimaristan hospitals as "the first hospitals" in the modern sense of

the word.

The first hospital in Egypt was opened in 872 A.D. and thereafter public hospitals

sprang up all over the empire from Spain and the Maghrib to Persia. As the

system developed, physicians and surgeons were appointed who gave lectures

to medical students and issued diplomas to those who were considered qualified

to practice - an early parallel to modern medical schools. Between the eighth and

twelfth centuries CE Muslim hospitals developed a high standard of care.

Hospitals in Baghdad in the ninth and tenth centuries employed up to twenty-five

staff physicians and had separate wards for different conditions.

Role of Hospitals in Health System Basically there are various roles and functions that a hospital might be expected

to perform. A hospital may undertake several functions, depending on the type of

hospital, its role in the health care system and its relationship with other health

care services. Hospitals should and may offer a range of health care services

covering a simple medical check up to specified tertiary care at competitive

process. They should develop services as per the needs of the different

consumers with provision of good quality services that can compete in the

market. Hospitals can be classified into four basic categories - the private,

income generating hospitals; the hospitals run by NGOs; the military hospitals

and finally, the public hospitals, both large and small. Traditionally, hospitals

have been regarded as big institutions, rather than just as a place for cure and a

place for disease. For health professionals they are centers of technical

excellence for both learning and practice. However, hospitals now need to re-

think their traditional roles and look at aspects that they did not consider as part

of health care. The reason for this is the growing trend of globalization.

Globalization is a modern phenomenon, a development of the last few decades

of the 20th Century. Globalization is inevitable and desirable. However, it poses

considerable challenges and uncertainties in the provision of health care. If we

are not prepared for these changes, they could lead to policy mistakes, which

could prove to be costly. For Afghanistan government it is required to move away

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from the monopolies that currently exist in this country and introducing

competitiveness. There is a need to encourage foreign companies to invest

comprehensive tertiary hospital in zones. Time consuming and lengthy

procedures are needed to be removed and facilitated. In addition, it is necessary

that the basic services for the poor and under served are not forgotten and

continued.

In last years, in Afghanistan, another area of trade is foreign direct investment in

the private hospitals. With no control on their standards and quality of services,

for sure there will be poor impact on health system of the country. Some feel that

this would enhance investment opportunities, increase competition for quality

health care and remove the burden on the public sector. Others feel that the

foreign facilities would attract the best medical professionals from the public

sector and thus lead to internal brain drain.

Another component which is newly added to some private and public hospitals in

the country is Telemedicine. Using such advanced technology will facilitate

diagnostic, curative, preventive and building the capacity of health professionals

at the hospital sector. In fact this is a new area of investment the country which

still requires growing and development. This could improve the quality of care

and improve skills and knowledge of the professionals but would also need

substantial investment. By establishment of such mechanism, that is possible to

provide advice for medical professionals at provinces through on-line services on

the internet, thus affecting the quality of healthcare delivery. Production of more

medical doctors as compare to nurses and paramedical has affected the quality

of hospital services in big cities. It seems the country is flooded with service

providers in terms of medical doctors whereas there is dire need for nursing

activities. Certainly hospitals are the only hope for poor people of the country for

receiving health. There are some issues such as qualification of health

professionals, standards of hospitals, observation of policy and their accreditation

procedures need to be discussed, debated and settled by the health authorities

in collaboration with other sectors and professional organizations.

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If we claim and say that health care is a “right” not a “privilege” then we should

work for accessibility of everyone to health. Now the government should, based

on bazaar economy, believe that there should be competition in health care and

that the market should prevail. Nowadays despite advanced technology in private

and public hospitals, most expensive hospital technology is the physician’s pen.

As part supplier induced demand, the physicians order more tests and demand

more technology, hospitals scramble to provide the needed facilities and

equipment. In Afghanistan the hospitals are owned by public and private

organizations with different facilities and charges. Some are public and owned by

government while others are private for profit and are owned by individuals and

may even be publicly traded.

With low capacity public or private hospital in the country, the sick people travel

to neighboring countries in order to receive care. The government is always

criticized by public and member of assemblies due to low attention to tertiary

care hospitals. Though in post conflict situations there is a need to focus on

access of population of basic package of health services, however now it is time

to focus partially the secondary and tertiary services by the government. If you

evaluate the current status of the country more progress has been made in terms

of communications (mobile phones), banks, roads, agriculture, electricity and so

on, therefore Are banks and mobile companies more important than essential

hospitals to our nation’s well being? Thus hospitals should be part of health care

reform.

Hospitals, usually looked up to for leadership in the total health care effort,

cannot do the job alone but ideally can contribute to the comprehensive plan.

Primary Health Care (PHC) is a strategy now internationally accepted as the

most important means of meeting the health needs of people in communities

around the world. Therefore by involvement of PHC in we will have a good

answer to the mounting crisis in health care today. We are suffering from double

burden of health problems. It means beside communicable diseases people have

started to over-eat, over-smoke, over- drink, over-drive, and over-stress.

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Hospitals can and must play an important role in helping to overcome these

challenges.

Changing Role of Hospitals

From its gradual evolution through the 18th and 19th centuries, the hospital both in

the eastern and western- has come of age only recently during the past 50 years

or so, the concept of today’ hospital contrasting fundamentally from the old idea

of a hospital as no more than a place for the treatment of the sick. With the wide

coverage of every aspect of human welfare as part of healthcare versus physical,

mental and social wellbeing, a reach-out to the community, training of health

workers, biosocial research, etc— the healthcare services have undergone a

steady metamorphosis, and the role of hospital has changed, with the emphasis

shifting from:

# From To

1 Acute Chronic illness

2 Curative Preventive medicine

3 Restorative Comprehensive medicine

4 Inpatient care Outpatient and home care

5 Individual orientations Community orientations

6 Isolated functions Area-wise or regional functions

7 Tertiary and secondary Primary Health Care

8 Episodic care Total care

Reasons for changing role of hospitals

The important factors which have led to the changing role and functions of the

hospitals are as follows.

• Expansion of the clientele from the dying, the destitute, the poor and

needy to all classes of people

• Improved economic and social status of the community

• Control of communicable diseases and increase in chronic degenerative

diseases

• Progress in the means of communications and transportation

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• Political obligation of the governments to provide comprehensive care

• Increasing health awareness

• Rising standards of living especially in urban areas and sociopolitical

awareness especially in semi urban and rural areas with the result that

expect better services and facilities in healthcare institutions

• Control and promotion of quality of care by government and professional

associations

• Rapid advances in medical sciences and technology

• Increase in population requiring more number of hospital beds

• Sophisticated instrumentations, equipment and better diagnostic and

therapeutic tools

• Advances in administrative procedures and management technique

• Reorientation of health care delivery system with emphasis on delivery of

primary health care.

• Awareness of the community

If the role of hospital is to restore health and not merely to cure a disease entity,

the role and responsibility of hospitals assumes great significance. It goes for

beyond the diseased organ or individual. The modern hospital is a modern a

social universe with a multiplicity of goals, profusion of personnel and extremely

fine division of labor.

Function of an Acute Care Hospital The questions commonly asked by policy-makers include: What size population

should the hospital serve? How many patients, beds and specialties should it

contain? Where should the boundary lie between the hospital and other health

services? The answers will depend on the values and objectives of the individual

or organization asking the questions. In many cases, competing objectives must

be balanced. For example, surgeons may want large hospitals that can support

large clinical teams and complex equipment, whereas the public may want ‘their’

hospital close to where they live.

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The core function of a hospital is to treat patients who are ill, but an analysis

confined to this function would be misleading. The hospital may also be an

important setting for teaching and research and may actively support its

surrounding health care system. Furthermore, the hospital may be an important

source of local employment and may play several societal roles. The

expectations that accompany each of these roles have important implications for

the organization of the hospital and its relationship with its wider environment.

Following is the main functions and sub functions which is needed to be

performed in ideal hospitals.

• Patient care

o Inpatient, outpatient and day patient

o Emergency and elective

o Rehabilitation

• Teaching

o Vocational

o Undergraduate

o Postgraduate

o Continuing education

• Research

o Basic research

o Clinical research

o Health services research

o Educational research

• Health system support

o Source for referrals

o Professional leadership

o Base for outreach activities

o Management of primary care

• Employment

o Inside hospital:

� Health professionals

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� Other health care workers

o Outside hospital:

� Suppliers

� Transport services

• Societal

o State legitimacy

o Political symbol

o Provider of social care

o Base for medical power

o Civic pride

In the course of last six years (2004-2010) the Basic Package of Health Services

(BPHS) is being expanded (85%) throughout Afghanistan. The BPHS is an

important element in the redevelopment of the health system because it deals

with the priority health problems of the country. Hospitals have an important role

in this PHC-focused strategy because district, provincial, and regional hospitals

are required to form an integrated referral system providing a range of needed

services: from health promotion to disease prevention to basic treatment to

disability care to specialized inpatient care. This policy establishes the guidelines

for the redevelopment of hospitals as a key element of the Afghan health system.

Hospital viewed as a System A hospital can be variously described as a factory, and office building, a hotel,

and eating establishment, a medical care agency, a social service institution and

a business institution. In fact it is all of these in one, and more. Sometimes it is

run by business means but not necessarily for business ends. This complex

character of hospital has fascinated social scientists as well as lay people.

Management sciences define a system as “a collection of components

subsystem which, operating together, perform a set of operations in

accomplishment of defined objectives.” A system is views as anything formed of

parts placed together or adjusted into a cohesive whole. Every system is

therefore a part of a large system and has its own subsystems. A system is

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construed as having inputs which undergo certain processing and get

transformed into output, the output itself in turn sending feedback to the input and

the process, which can be altered to achieve still better output. A system is

therefore a continuous and dynamic phenomenon.

Figure: conceptual representation of a system

Peculiarities of a Hospital System

In spite of simple definition of a system, a hospital system is more than the sum

of its parts. The peculiarities hospital systems are as follows.

• A hospital is an open system which interacts with its environemtn

• Although a system generally has boundary, the boundaries separating the

hospital system from other social systems are not clear but rather fuzzy

• A system must produce enough outputs through use of inputs. But the

output of a hospital system is not clearly measureable

• A hospital has to be in a dynamic equilibrium with the wider social system

• A hospital system is not an end it itself. it must function, as a part of larger

health care system.

• A hospital like other open social systems tends towards elaboration and

differentiation i.e. as it grows, the hospital system tends to become more

specialized in its elements and elaborate in structure, manifesting in the

creation of more and more specialized departments, acquisition of new

technology, expansion of the “product lines” and scope of services.

INPUT PROCESS

(TRANSFORMATION)

OUTPT

FEEDBACK

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In considering the hospital as a system for the delivery of personal services,

which is the more important of its functions Anand (1984) views the system from

four different perspectives which are as follows.

1. Client oriented perspective: which is that of access to service, use

of services, and quality of care, maintenance of client autonomy

and dignity, responsiveness to client needs, wishes and freedom of

choice.

2. Provider oriented perspective: that of the physicians, nurses and

other professionals working for the hospital, and include freedom of

professional judgment and activities, maintenance of proficiency

and quality of care, adequate compensations, control over

traditions and terms of practice and maintenance of professional

norms.

3. Organization oriented perspective: which covers cost control,

control of quality, efficiency, ability to attract clients, ability to attract

employees and staff, and mobilization of community support.

4. Collective orientation perspective: that includes proper allocation of

resources among competing needs, political representation,

representation of interests affected by the organization, and

collaboration with other agencies.

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Component or Structure of a Hospital The hospital is more the sum of its parts. The major components of a hospital

system are depicted in the flowing figure.

Figure: components of a hospital system

It is easily understandable to see the organ gram of the hospital and know what

its components are because every hospital, large or small, has an organizational

structure that allows for the efficient management of departments. Basically

grouping of Hospital Departments within the Organizational Structure is done.

Although each hospital department performs specific functions, departments are

generally grouped according to similarity of duties and promotion of efficiency of

the healthcare facility. Anyway common organizational categories might include:

Administration Services, Informational Services, Therapeutic Services,

Diagnostic Services and Support Services (sometimes referred to as

Hospital System

Care

Subsystem Cure

Subsystem

Diagnostic

Subsystem

Therapeutic

Subsystem

Supportive

Subsystem

Nursing

Subsystem

Technical

Minor

Subsystem

Administrative

Circulation

Environmental

Social, etc

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“Environmental Services”). For more information following each service is

outlined in more detail.

A. Administration Services—business people who “run” the hospital

o Hospital Administrators

o manage and oversee the operation of departments

� oversee budgeting and finance

� establish hospital policies and procedures

� perform public relation duties

o generally include: Hospital President, Vice Presidents, Executive

Assistants, Department Heads

B. Informational Services—documents and process information

o Admissions-often the public’s first contact with hospital personnel

o checks patients into hospital

� responsibilities include: obtaining vital information (patient’s

full name, address, phone number, admitting doctor,

admitting diagnosis, social security number, date of birth, all

insurance information)

� frequently, admissions will assign in-house patients their

hospital room

o Billing and Collection Departments - responsible for billing patients for

services rendered

o Medical Records - responsible for maintaining copies of all patient records

o Information Systems - responsible for computers and hospital network

o Health Education - responsible for staff and patient health-related

education

o Human Resources - responsible for recruiting/ hiring employees and

employee benefits

C. Therapeutic Services – provides treatment to patients

o includes the following departments:

a. Medical Therapy (including adults, children and infants)

b. Surgical Therapy (including adults, children and infants)

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c. Physical Therapy (PT)

i. provide treatment to improve large-muscle mobility and

prevent or limit permanent disability

ii. treatments may include: exercise, massage, hydrotherapy,

ultrasound, electrical stimulation, heat application

d. Occupational Therapy (OT)

i. goal of treatment is to help patient regain fine motor skills so

that they can function independently at home and work

ii. treatments might include: arts and crafts that help with hand-

eye coordination, games and recreation to help patients

develop balance and coordination, social activities to assist

patient’s with emotional health

e. Speech/Language Pathology

i. identify, evaluate, and treat patients with speech and

language disorders

ii. also help patients cope with problems created by speech

impairments

f. Respiratory Therapy (RT)

i. treat patient’s with heart and lung diseases

ii. treatment might include: oxygen, medications, breathing

exercises

g. Medical Psychology

i. concerned with mental well-being of patients

ii. treatments might include: talk therapy, behavior modification,

muscle relaxation, medications, group therapy, recreational

therapies (art, music, dance)

h. Social Services

i. aid patients by referring them to community resources for

living assistance (housing, medical, mental, financial)

ii. social worker specialties include: child welfare, geriatrics,

family, correctional

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i. Pharmacy

i. Dispense medications per written orders of physician,

dentists, etc.

ii. provide information on drugs and correct ways to use them

iii. ensure drug compatibility

j. Dietary - responsible for helping patients maintain nutritionally

sound diets

k. Sports Medicine

i. provide rehabilitative services to athletes

ii. teaches proper nutrition

iii. prescribe exercises to increase strength and flexibility or

correct weaknesses

iv. apply tape or padding to protect body parts

v. administer first aid for sports injuries

l. Nursing (RN, LVN, LPN)

i. provide care for patients as directed by physicians

ii. many nursing specialties include: nurse practitioner, labor

and delivery nurse, neonatal nurse, emergency room nurse,

nurse midwife, surgical nurse, nurse anesthetist

iii. In some facilities, Nursing is a service in and of itself.

D. Diagnostic Services – determines cause(s) of illness or injury

o includes the following departments:

a. Medical Laboratory (MT) - studies body tissues to determine

abnormalities

b. Imaging

i. image body parts to determine lesions and abnormalities

ii. includes the following: Diagnostic Radiology, MRI, CT, Ultra

Sound

c. Emergency Medicine - provides emergency diagnoses and

treatment

E. Support Services—provides support to entire hospital

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o includes the following departments:

a. Central Supply

i. in charge of ordering, receiving, stocking and distributing all

equipment and supplies used by healthcare facility

ii. sterilize instruments or supplies

iii. clean and maintain hospital linen and patient gowns

b. Biomedical Technology

i. design and build biomedical equipment (engineers)

ii. diagnose and repair defective equipment (biomedical

technicians)

iii. provide preventative maintenance to all hospital equipment

(biomedical technicians)

iv. pilot use of medical equipment to other hospital employees

(biomedical technicians)

c. Housekeeping and Maintenance

i. maintain safe clean environment

ii. cleaners, electricians, carpenters, gardeners

The above structure could be depicted easily in a chart that is the organ gram of

the hospitals.

Board of the Hospitals

Administration

Information Services

Therapeutic Services

Diagnostic Services

Supportive Services

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Organization of Hospitals in Afghanistan The way in which the general administration of hospitals in Afghanistan should

be organized is illustrated in following Figure. The figure shows the staff

positions, the relationship among the various hospital departments, and the

necessary reporting relationships. As noted in the following section, hospital

boards will be introduced to make sure that hospitals are overseen by community

members who can identify the true needs of the community and ensure the

accountability of the hospital administration.

While the Hospital Director is responsible for the hospital’s operation and the

day-today management of the facility and its services, the Director is also

expected to develop a management team of key staff. Team members should

meet on a weekly basis to discuss and resolve the hospital’s major plans,

problems, and budgets. By promoting participatory management and teamwork,

the Hospital Director will be able to improve the quality of care, performance,

operation, and management of the hospital.

Figure: organization of hospitals in Afghanistan

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The Future of Hospitals in Afghanistan According to EPHS, the top three priorities of the hospital sector in the coming

years are to increase access to hospital services, improve the quality of patient

care, and to increase the efficiency of hospital operation. Bringing about these

improvements will require several initiatives.

The following three initiatives can be expected to be operational within the next

five to 10 years.

First, standards must be established. Hospitals require standards for both clinical

and administrative operations in order to improve clinical and managerial

performance and to attain an acceptable level of patient care and hospital

operation. Standards establish what is expected of hospitals and their staff at all

levels of operation; standards permit the monitoring of operations and the

measurement of performance. The national hospital policy outlines the six areas

for which basic standards need to be developed. Specific elements of each

standard must be developed and specified in greater detail by the Ministry of

Public Health.

Second, to strengthen community involvement and support, hospital boards must

be established. Community support for hospitals is often poor; communities using

a hospital tend to regard it as the “government’s hospital” or the “NGO’s hospital”

rather than “their” hospital. A hospital board will provide general direction and

guidance for the management and operation of the hospital, as well as serving as

a link between the community and hospital. Hospital community boards will be

made up of volunteers with diverse skills and experiences who will be

responsible for the long-term viability of the hospital and ensure that it meets the

real and felt needs of the community. Their responsibilities will include:

ensuring that high quality services are provided;

maintaining community and government relations and generating

community support for the hospital;

serving as the policy and strategy-setting body of the hospital;

supporting the leadership of the hospital;

providing financial oversight;

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Helping develop the hospital’s strategic plan.

Third, as the number of hospitals operated by government, NGOs and private

entities increases, hospital certification or accreditation will be needed to ensure

that all hospitals provide a basic standard of care. Accreditation is the process of

assessing health institutions against a commonly accepted set of standards in

order to ensure and improve the quality of health services. The goal of

accreditation is to ensure that providers, both the hospital as an institution and its

physicians and nurses, provide high quality care to patients. Table 5 lists the

elements of quality of care that would be considered in an accreditation process.

Group work and Facilitator Notes:

Purpose: The main goal of the exercise is to draw the organizational chart of a

hospital. By this group work despite of promoting teamwork you will encourage

participants to execute logic and problem solving skills and make use of creativity

and innovative thoughts.

Materials: colored markers or colored pencils, white butcher paper (3 x 2’) or

poster board

Process:

1. Divide participants into groups of 4 to 5.

2. Using the Organizational Structure, show the students how a hospital’s

organizational structure can be demonstrated in a non-traditional way.

3. Discuss the hierarchy of the structure and its relationship

4. Each group gets a piece of butcher paper and colored markers.

5. Instruct the students to think of a symbolic way in which to represent the

organizational structure of the hospital. Here is a simplistic example to get

them thinking: (tree in a field)

i. ground represents support services

ii. trunk of tree represents administration services

iii. sun in sky represents information services

iv. main branches represent diagnostic services

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v. leaves represent various therapeutic services

6. Each department and service should be labeled.

7. Tell participants that they must be able to explain why they think their

drawing symbolically represents each service.

8. To strengthen their understanding the facilitator may use the quiz

regarding structure of the hospital which is attached in as annex A. at the

end of module

Hospital Policies in Afghanistan According to Hospital Policy in Afghanistan Health System the hospitals of

country will provide a comprehensive referral network of secondary and tertiary

health facilities. The policies guiding the hospital sector are:

1. Hospitals, as part of a unified national health system, will provide

necessary curative and emergency services, which complement the Basic

Package of Health Services that includes disability care, offered at basic

and comprehensive health centers.

2. Hospitals must be rationally distributed so their services are accessible on

an equitable basis for the entire population.

3. The MoPH will carefully plan the number of hospitals, their location,

hospital beds, and types of hospital beds to ensure that the resources

committed to hospitals result in the maximum impact on the population’s

health status. Because Afghanistan does not have unlimited resources to

finance hospitals, so health planning, resource allocation and financial

management of hospitals will be undertaken by MOH for the entire

hospital sector as a means for maximizing the impact and effectiveness of

hospitals on the country’s health status.

4. Provision of hospital care must be based on need for hospital care and not

on ability to pay.

5. Hospitals must be managed in an efficient manner that adheres to basic

clinical and managerial standards that ensure the provision of quality care

to all patients, including patients with disabilities.

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6. The proportion of the government’s annual operational budget for

hospitals will not exceed 40% of the total health budget.

7. To ensure budgetary accountability and transparency, the MOH will

develop the appropriate financial systems and develop proper

mechanisms, such as empowering financial management of hospitals to

their board of directors.

8. Equitable cost-sharing strategies which are appropriate for Afghanistan

will be developed to he lp make the operation of hospitals more financially

sustainable.

9. Hospitals also have a role within the health system to provide supervision

of lower level health facilities, a place for professional training of

physicians, nurses, midwives and other health providers as well as

supporting necessary national medical and health systems research.

10. Private hospitals are permitted and are part of the health system and must

comply with all standards for providing good quality care, be accredited

and adhere to all MOH policies.

Levels of Hospitals in the country

There are three levels of hospitals: district (as a part of the BPHS), provincial,

and regional, including specialized hospitals. Differentiation of hospital levels is

based on the patient services offered. Five core clinical functions will exist in

each level of hospital: medicine, surgery, pediatrics, obstetrics and gynecology,

and mental health. An escalating level of sophistication will exist from district to

urban hospitals. The health post, basic health center and comprehensive health

center will offer basic curative and preventative services.

Hospitals in conjunction with the Provincial Coordination Committees (PCC) will

ensure the enforcement of a well-functioning referral system. A two-way referral

mechanism will be established maintaining a functional link between hospitals

and primary health care facilities. First line referrals will stem from health centers

to district hospital outpatient departments from where consultation will define

whether patients need to be further referred to higher levels or treated at that

level. Similarly patients are referred back to primary health care facilities for

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follow-up. The following general specification of services for various hospital

levels will be supplemented by the Basic Package of Hospital Services, to be

developed by MoPH, will identify, in detail, the clinical services provided at each

level, the equipment and supplies required and the minimum staffing required.

District Hospital

Each district hospital will have from 30 to 75 beds and serve a population of

100,000 to 300,000, covering from one to four districts. The basic services

offered at a district hospital are:

• Surgery,

• Medicine,

• Pediatrics;

• Obstetrics and gynecology;

• Mental health;

• Dental services;

The district hospital will also have nutrition, physical therapy, laboratory,

radiology, blood bank, and pharmacy services.

Provincial Hospital

A provincial hospital serves a province and will have from 100 to 200 beds. In

addition to the services offered at a district hospital, the provincial hospital has:

• Physical therapy and rehabilitation services

• Nutrition services

• Infectious disease medicine;

Regional Hospital

A regional hospital serves several provinces and will have from 200 to 400 beds.

In addition to the services offered at a provincial hospital, the regional hospital

has:

• Surgery with ENT, urology, neurosurgery, orthopedics, plastic surgery and

physiotherapy

• Medicine with cardiovascular, pulmonary, endocrinology, and dermatology

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• Oncology

• Forensic medicine

Diagnostic services include:

• Laboratory: hematology, parasitology, bacteriology, virology, allergy and

immunology, biochemistry, toxicology, cytology, and pathology.

• Blood Bank/Transfusion Services: Provides for the taking, preserving, and

distributing blood to patients and the diagnosis of blood related diseases

(hemophilia, thalassemia, and leukemia, and viral diseases— hepatitis,

HIV/AIDS).

• Imaging: routine and specialized radiography, ultra-sonography.

Rationalization of Hospital Services (components)

There will be rationalization of services, such as polyclinics, where specialized

diagnostic and curative services are provided on an outpatient basis. These

facilities will be linked to regional and specialized hospitals for referral of

complicated cases requiring inpatient care in order to reduce the burden on these

hospitals and to give quality services at an outpatient level. They will not have

beds as this duplicates what exists in hospitals and is expensive for the health

system.

While there may be a need for some additional specialized diagnostic services

for the country, these services are too expensive and for too few patients to be

available at every regional hospitals. Further rationalization of services will occur

at the urban level where clinical and diagnostic services specialized and

equipment will be centralized. These include: pathology and forensic medicine,

histology, bio-technical support, centralized statistic s center, and research.

Equipment and services such as CT-scan and radiotherapy will be located at

only one hospital in the country to provide the services for the entire the country

rather than being provided at each regional hospital. Specialized hospitals will be

combined into regional hospitals with multiple specialties, as much as possible.

As current specialized hospitals are rehabilitated and new facilities planned, the

MOH will seek to combine them with other major hospitals in order to rationalize

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the number and type of hospitals. The current specialized hospitals include eye,

mental health, disabilities, tuberculosis, chest, oncology, orthopedic and

prosthesis, maternity, pediatrics, and emergency hospitals.

Aga Khan University Hospital Components and Activities Aga Khan University Hospital, Karachi, (AKUH, K) started operations is an

integrated, health care delivery component of Aga Khan University (AKU). It is a

multidisciplinary approach to diagnosis and care ensures a continuum of safe

and high-quality care for patients – all services under one roof. This University

Hospital has 563 beds in operation and provides services to over 50,000

hospitalized patients and to over 600,000 outpatients annually with the help of

professional staff and facilities that are among the best in the region. Care is

available to all patients in need. Those who are unable to pay for treatment,

receive assistance through a variety of subsidies and through Hospital’s Patient

Welfare Program. AKUH is the first hospital in Pakistan and among the first few

teaching hospitals in the world to be awarded the prestigious Joint Commission

International Accreditation (JCIA) for practicing the highest internationally

recognized quality standards in health care. Similarly, the Hospital also holds ISO

9001:2008 certification for practicing consistent international standards of quality

services.

The Hospital is equipped to diagnose and treat Medical (including Cardiology,

Endocrinology, Gastroenterology, Hematology, Nephrology, Neurology and

Pulmonology), Surgical (Dental, General, Neurosurgery, Ophthalmology,

Orthopedics, Otolaryngology, Urology and Plastic), Obstetrics and Gynecology,

Pediatrics and Psychiatry patients. The Hospital also provides comprehensive

Oncology Services including: Medical and Surgical Management, Radiation

Therapy, Chemotherapy, Brach therapy and Bone Marrow Transplant.

Enough critical care beds are available in the Intensive Care Unit (ICU),

Coronary Care Unit (CCU), Coronary Intensive Care Unit (CICU) and Neonatal

Intensive Care Unit (NICU). The Hospital has 11 main operating theaters. There

are an additional 3 operating theaters in Surgical Day Care, 2 in the Community

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Health Centre, 1 in Obstetrics and Gynecology and 2 mini-theatres in Section of

Emergency. State-of-the-art Pharmacy, Radiology (including nuclear medicine),

Laboratory, Cardiopulmonary, Neurophysiology, and Rehabilitation services are

available at AKUH. A fully equipped Emergency Room is open 24 hours a day

with a Triage desk and Fast Track System to ensure prompt medical attention for

all patients. AKUH Laboratory operates over 180 phlebotomy or specimen

collection centers in Karachi and all major cities of Pakistan and Afghanistan.

The Hospital also operates nine off-site medical centers (Integrated Medical

Service Units) in various parts of Karachi. Home Physiotherapy and Home

Nursing and Health Care Services are also available in almost all areas of the

city. These off-site services are a part of AKUH's outreach program to facilitate

public accessibility to quality health care. The Hospital draws a large number of

referrals from outside Karachi and Pakistan and operates Patient Information and

Referral Desks in Hyderabad and Quetta and a Representative Office in Dubai,

U.A.E. These offices provide assistance by coordinating all necessary

arrangements, including review of medical history by consultants prior to the

patient's arrival at the Hospital. Aga Khan University Hospital, Karachi provides a

broad range of latest and technically advanced diagnostics and therapeutic

services.

• Inpatient services

• Consulting services

• Emergency

• Radiology

• Cardiopulmonary services

• Neurophysiology

• Executive clinic

• Pharmacy services

• Physiotherapy and Rehabilitation services

• Home Health Services

• Clifton Medical Services

• Other Off-sit Medical Services

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• Corporate Services

• Support Services

• Special Services

Hospital and Challenges in Afghanistan In Essential Package of Hospital Services (EPHS) it is enshrined that hospitals

play a critical role in the Afghan health sector: they are part of the referral

system, which aims to reduce high maternal and early childhood mortality rates.

In addition, hospitals utilize many of the most skilled health workers and much of

the financial resources available in the health system. Hospital management

must dramatically improve to ensure that these scarce resources are used in an

effective and efficient manner and to enable hospitals to function more effectively

as part of the health system. Serious need for improvement exists at all hospital

levels—district, provincial and regional hospitals—as well as at Kabul’s tertiary

and specialty hospitals.

The Hospital Management Task Force determined that the key issues facing

hospitals could be summarized by six problems and the resulting consequences.

The mentioned problems and consequences are arranged in the following table.

Table: problems and consequences with respect to Hospitals

# Problem Consequences

1 Poor distribution of hospitals

and hospital beds throughout

the Country

Lack of equitable access to hospital care

throughout the country: people in urban

areas have access, but semi-urban and

rural populations have only limited access.

Kabul has 1.28 beds per 1000 people,

while provinces have only 20% of that

amount (0.22 beds per 1000 population).

2 Lack of standards for clinical

patient care

Poor quality of care

3 Lack of management skills for Inefficiently run hospitals, poorly managed

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operation of hospitals

staff, lack of supplies, and unusable

equipment due to lack of maintenance

4 A fragmented and

uncoordinated hospital system

that is not integrated into the

health system

A referral system that does not work—

people from rural areas and basic health

centers are not referred to hospitals for

problems such as problem pregnancies.

Support for a BPHS-based system for

secondary and tertiary services is lacking;

the roles of hospitals in a BPHS-based

health system have not been spelled out.

5 Limited financial resources for

hospitals, and sustainability

Virtually all hospitals in Afghanistan lack

adequate financial resources. A user fee

system must be developed to help finance

hospitals while at the same time ensuring

that exemption mechanisms allow the poor

continued access to care.

6 Lack of qualified personnel,

especially female, in remote

areas

Difficulty in guaranteeing 24-hour

coverage, problems with quality of care

provided to female patients.

Hospital and Community Sociologists have considered hospital as a social system based on bureaucracy,

hierarchy and super ordination- subordination. A hospital manifests

characteristics of a bureaucratic organization with dual lines of authority which

are administrative and professional. In teaching hospitals and in some others,

many professionals at the lower and middle level are transitory, while as in

others, all medical professionals are permanent with tenured positions and

nontransferable jobs. In order to continue in a orderly fashion, every socials

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system has to fulfill the functional needs of that system versus the need for

pattern maintenance, the need for adaptation, for goal attainment and integration.

In a hospital system, the patients’ need determine the interactions within the

system. When a patient is cured and discharged, in his or her place a new patent

is admitted. This new patient also demands all the attentation and skills of

doctors, nurses and others, forcing the essential and separative components into

immediate action, repeatedly as each patient is admitted. Free upward and

lateral communication is an important characteristic of any system.

Anyway the ultimate purpose of health services is to meet the total health needs

of the community. There are a lot of factors which determine the health needs of

the community and solutions to them. Some of the important factors are listed

here in the following table.

Table: factors determine the health needs of community

# Main factors Contributing factors

1 Demographic factors • Age

• Sex

• Marital status

• Family compositions

• educations

2 Enabling factors • family financial resources

• family relationship in the households

• availability and accessibility of

services

• Health insurance

• Attitude to health and disease

3 Internal or Health system

factors

• Manpower availability

• Physical facilities

• Organization and structure

• Interface with users

4 External factors • Political

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• Social

• Administrative

A good hospital would build its services on the knowledge and understanding of

the community it is to serve, its success will depend upon the involvement of

many groups, both professionals, within and outside the hospitals.

The provider, support group and community

The hospitals being a distinct, albeit integral, part of the health services, is

influenced by all the above mentioned factors and the health services in turn

influence those factors. It has to deal with three different groups which form the

larger community.

1. Providers: the first group is the providers of medical care, viz. the doctors,

nurses, technicians and paramedical personnel.

2. Management: the second group is management, administrative and

support group comprising of personnel dealing with non clinical functions

of the hospital, such as diet, supplies, maintenance, accounts,

housekeeping, water and ward, etc.

3. Community: the third group is the most important one for whose benefit

the first two groups exists in the first place, is that of the patients who seek

hospital services and their attendants, relatives, and associates who,

along with patient come in close contact of the hospital. This group is

broadly termed as community.

Community and its Participation

Community is a unit of society and each community is a microcosm of a nation.

It may be consist of educational and professional groups, members of fraternal

organizations, women's and garden clubs. It is business and industry, civic

leaders, youth, media, labor and church leaders and the elderly. So Community

is people, and they need to participate in hospital activities. Community

participation is a social process where by specific groups with shared needs

living in defined geographic area actively participates in identifying their needs,

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take decisions and establish mechanisms to meet these needs. The hospital is

responsive to the community’s (health) needs and its services are accessible to

the community. It should be ensured that patient are treated with dignity and

have a right to be treated in a respectful manner. They want quick and efficient

service and good quality care. They expect satisfaction with care, food and

cleanliness of the hospital.

There are some benefits as a result of community participation such as

decentralization of the process of decision making, participation of the people in

setting the goals and their prioritization, generation of resources from within the

community to take remedial steps, sharing of benefits by the masses,

development of mechanism of control for assessing the outcome, involvement in

the efforts to evaluate the program, involvement /self help for sustaining the

program without -external help and involvement in implementation.

Hospital community relationship

In a complex juxtaposition between the providers of care and immediate support

group on the one hand and the patient and community on the other, it will not be

unusual to expect conflicts between the two groups. The nature of the

relationship between the two group influences community relationship, and on its

relationship depends the image of the hospital. To better this image, hospitals

have to re-orientate themselves to the expectations of the community. Following

figure shows the relationship.

Figure: Hospital Community Relationship

INTERACTION

H C

O U

S L

P T

I U

T R

A E

L

PROFESSIN

AL G

ROPS

H

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Relevant communication and information must reach the user community in

order to promote their participation and involvement. A community that is well

informed and aware of its social responsibilities can become an effective

instrument of cooperation and support. People go to hospitals with high

expectations believing that every disease is fully and quickly curable. The

average health consumer regards contemporary hospitals as the panacea to his

health problems. They can not appreciate the limitations of the hospital. There is

an increasing demand for better care and quick cure. Despite of giving care to

every patient public expects sympathetic understanding of the behavior of the

patient and his or her attendants and relatives. This shift has necessitated a new

approach to doctor-patient and hospital community relationship. Respect of the

dignity of the patient is one of the most basic rights and needs of the patient.

Concern for care of the human being as a whole requires contribution from

everyone working in the hospital. Therefore there has to be a growing interest in

the importance of human well-being, in the integration of health services

provided.

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Session 2: Effective Management at Hospitals

Management has been defined in many ways by many authorities, but the

original definition by Henri Foyal, considered the father of modern management,

over seventy years ago still holds good. “ tom manage is to forecast and plan, to

organize, to command, to co-ordinate and to control”. The task of the

management of each enterprise incorporates:

• Determining the goals and objectives

• Acquisition and utilization of resources

• Instituting communication system

• Determining control procedures, and

• Evaluating the performance of the enterprise

Medical profession and management In the not very distant past, hospitals were run by Medical Superintendents,

directors, secretaries, but rarely by “hospital administrators”. The initiative for

development of hospitals has come from the medical and nursing professions

themselves. Primarily being dedicated professionals; to them the administrator

function naturally became secondary, necessary to practice of healing but

definitely subordinate to it. Many learnt It along the way during their careers. But

generally doctors were traditionally uninterested in ways and means, often

seeing medical administration and management as an escape for those who

have no taste for, or were not particularly successful in, the practice of medicine.

Therefore , most doctors have very little idea of what administration and

management really is.

Principles of Management Fourteen Principles of Management were developed by Henri Fayol (1841-1925)

and have been considered as one of the classical organization theory that is

universally applicable to every type of organization. Classical organization theory

was the traditional theory and remains to be the foundation upon which other

schools of organization theory have built. Therefore many subsequent analyses

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presume an understanding of it. Influenced by the industrial revolution in the

1700s and related to the professions of mechanical and industrial engineering,

the principles were developed under fundamental assumptions as follows:

Organization and individuals behave in conformity with rational economic

principles.

Fayol proposed that management was a common activity to all human beings

who involve in organization. His principles consist of the elements as follows:

1. Division of work. Output can be increased by specialization, making

employees more efficient.

2. Authority. The right or power to give orders to subordinates is authority.

Wherever authority exists, responsibility arises.

3. Discipline. Employees must obey the organizational rules. Good

discipline must result from an agreement between firm and employees

with fairness and clear understanding of both sides. Penalties can be

applied to violations of rule.

4. Unity of Command. Each subordinate should receive orders from one

superior.

5. Unity of Direction. Organizational activities that have the same objective

should be guided by one manager, using one plan.

6. Subordination of individual Interests to the General Interest. The

interests of one employee (or group of employees) should not precede

over the interests of the organization as a whole.

7. Remuneration. Employees must be paid a fair wage. Rewards should be

used as a tool of encouragement.

8. Centralization. The degree to which subordinates are involved in

decision-making. Whether the decision is centralized or decentralized is a

question of proportion.

9. Scalar Chain. The line of authority from top to the lowest ranks of

management. Communication should go along this chain. To avoid

delays, cross communications can be allowed if agreed by all involved

parties.

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10. Order. Materials and people should be in right place at right time.

11. Equity. Managers should be kind and fair to their subordinates

12. Stability of Tenure of Personnel. High employee turnover causes

inefficiency. Managers should ensure replacements at hand when

vacancies arise.

13. Initiative. The power of thinking out, proposing and executing.

Management should encourage employees to originate and carry out

plans. This urging tends to boost levels of effort.

14. Esprit de Corps. Fostering team spirit is the way to construct harmony

and unity among employees.

Administration or management The terms of management and administration have interchangeably been used.

Some people have tried to define management and administration as two distinct

entities. To them administrations seems to connote some higher and broader

function than management. They continue to distinguish them without agreeing

clearly on what the distinction is about. But management is not an academic

discipline alone. It is get ting job done through people and by people. It is a

practical art and a science, calling for development of knowledge, skills and

attitudes. Managing and administration make use of organized knowledge i.e. the

best use of the enterprise. The science and art of management is not are not

mutually exclusive, but complementary.

Managerial activities of a hospital

The following activities are common to the management of all hospitals.

• Determination of goals and objectives

• Facility and programme planning

• Financial management

• Personnel management

• Coordinating departmental operations

• Programme review and evaluations

• Public and community activities

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• Health industry activities

• Government related activities

• Educational development

The governing board of hospitals

There are a number of important people in the hospital to whom a person asking

to see the chief in a hospital maybe led to. He could be led to the chief physician,

or the office superintendent, or the medical superintendent, or the secretary of

governing board, to mention a few. Most organizations have a chief, who is in

charge on every thing goes on there. But who controls the hospitals’ activities

services?

There appear to be several people and several groups who all have something to

do with controlling the above activities, but no single person or group appears to

be in charge of the whole set up. The administrator on the other hand, if asked as

to what goes on his office, might go so far as to say that it is the placed form

where the hospital is run.

Except in single proprietorship hospital, there has to be a body of person

statutorily responsible for running the hospital. This body is variously called the

board of directors, governing board, and board of trustees, governing body, or

management board. A governing board, as a body of persons, can make and

guide policy but cannot, by its vary compositions, run a hospital. The task is

carried out by the hospital administrator. As the board chief executive officer he

has overall charge of the affairs of the hospital. However, the extent of his control

depends upon the following factors.

1. how he perceives his job

2. how the board perceives the job

3. how much freedom he is allowed in doing the job

a typical hospital management board is scarcely different from many other

dissimilar organizations. Some boards may interpret their role as of running the

hospitals day-to-day affairs. On the other hand, the administrator could be

inhibited from showing his initiative.

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Hospital Administrator

Thus at the hospital level the function of administration rests with the hospital

administrator, variously called the chief executive officer (CEO), medical

superintendent, director (administrator), hospital manager, hospital director etc.

Nevertheless managing a hospital always involves partnership with medical and

nursing staff. Therefore, the hospital administrator can never have quite the

same degree of autonomy as his industrial counterpart. In many situations, it may

be the medical staff that will be making of many of vital decision on operational

policy, but they will have to exercise this authority in conjunction with the hospital

administrator, giving him or her in the difficult job of providing efficient services.

One of the principles of organization is that responsibility must be given and

matched with authority. Therefore, it is natural to suppose that the administrator,

charged with this responsibility would have the full authority to act on its behalf.

The job of the administrator is to plan, to organize, to direct and to control—

functions which are inherent to the job of each administrator. As a general

manger he represents the hospital to higher authorities and outside organization.

He is responsible for policy and procedures, the overall administrative structure,

financial management, personnel management, reporting to the board, relations

with the medical staff, overseeing medical care, maintaining physical facilities,

legal matters and maintaining good public relations.

Having a deal with multiple groups with conflicting interests, the demands on a

top hospital administrator are almost unending. He must be a generalist and

specialists combined in one, capable of understanding and interpreting medical,

financial, economic, functional and logistic matters, and he must excel at

personnel management.

Choice of Hospital Director (Administrator)

Opinion is divided whether a hospital administrator should be a person with

medical background or a non-medical person. For too long, all types of hospitals

were headed and administered by highly qualified medical professionals who had

hardly any time, let alone the background, to devote to administrative functions.

Even though in some western countries non medical persons trained in medical

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administration are heading hospitals, there is now an increasing realization that

medical professionals with training in hospital administration would be more

qualified to head all types of hospitals without being burdened with clinical

functions.

Hospital chief executive should spend almost 100% of their time on non medical

functions and activities, far removed from direct patient care. This precludes

appointing senior practicing doctors as chief executives. Medical doctors trained

in medical and hospital administration, who are alive to the medical needs of the

patients also understand the needs of the hospital and professionals working in

them, and are thus more suitable to head hospitals. Following table shows time

distribution.

Table: time distribution on administrative functions

# Activity Percentage of time

1 Planning 25

2 Directing and controlling the hospitals 48

3 Personal meeting people 11

4 Controlling 12

5 Organizing 4

Role and functions of Hospital Administrator

The following is the main roles and functions the hospital administrator.

• Working with people

• The enabling role

• Staff motivation

• Facilitating decision making

• Management of resources

• Negotiating

• Containing costs

• Dealing with new technology

• Establishing managerial climate

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• Management development

• Evaluation

• Social commitment

Management Styles

Laissez-faire Management style :

The laissez-faire management style gives people almost complete freedom to

organize and carry out their work: It is only limited if a task has to be completed

by a certain date or - if flexible working hours are agreed on - to make sure that

during certain hours of the day all employees are present. There is no formal

structure of decision making.

Democratic Management Style:

This style makes use of the fact that people are more motivated if their non-

monetary needs are met: job satisfaction and a feeling of belonging. Employees

are involved in taking decisions: They are either consulted directly or through

their representatives. This is particularly important if an organisation plans to

change the product design or working conditions, methods and practices.

Autocratic Management Style:

The manager of the organisation takes complete responsibility for decisions that

are made in his firm. He sets the objectives for the firm and allocates the tasks

the employees. He expects his subordinates to carry out exactly what he has told

them to do in the way that he has decided on. Employees are told exactly how

and when work has to be started and to be finished. Non-monetary needs of the

employees are not taken into account. The employees are not consulted and do

not take part in decision making.

Group work:

Read the sentences below the box. Decide which management style is advisable

(or not advisable respectively) under the conditions that are described in the

sentences.

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Mark the respective box with an “A” if the management style is advisable; mark it

with an “N” if the management style is not advisable.

Laissez

faire

démocratique autocratic

A

B

C

D

E

F

G

H

I

J

K

L

M

N

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Q

A. There are very serious risks to health and safety when total control is

lacking.

B. Employees are more satisfied with their jobs and more motivated because

they feel that their opinions are valued and they take part in decision

making. Their team spirit also improves.

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C. In the markets that are served by the firm changes are so rapid and

unpredictable that it takes too much time to ask employees.

D. The kind of business requires the development of individual talents,

initiatives and creative thinking.

E. An employee may build up his own area of work, which may prevent the

organization as a whole from reaching its objectives.

F. An organization can take fuller advantage of its human resources by

tapping their skills, knowledge and experience.

G. It is more difficult to identify an employee who misuses the greater

freedom and puts too little effort into his job.

H. Consultation needs time and slows down decision making. During the time

that is lost problems may become more serious and chances may be lost.

I. Employees work away from their offices in their own homes.

J. The workforce consists of unskilled people with little motivation beyond

their pay.

K. People who represent the other employees in meetings with management

put their interests before those of the members of the staff that they

represent.

L. If a manager is not able to explain the role of employees who take part in

decision making the employees may think the manager only pretends or

he might look condescending.

M. Employees feel that they are in charge of their working lives. That is how

stress can be reduced.

N. Employees want to have a greater chance to choose the people they work

with. They will only choose those people with whom they feel they will

form a harmonious and efficient working team.

O. Employees do not like that every aspect of their work is controlled by a

leader and might seek every chance to relax in their efforts when they are

not supervised.

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P. More personal contact between management and other employees is

needed– they get to know each other as individuals and understand more

fully the stress under which each of them works.

Q. In small organizations the leader is in a position to get involved in even

day-to-day decisions.

Skills of effective managers After a lot of research, it has now been established that successful management

rests on three basic skills— technical, human and conceptual, these three skills

are not absolute and mutually exclusive, but interrelated. Technical skills include

knowledge of and proficiency in a certain specialized field, such as engineering,

computers, financial and managerial accounting, or manufacturing. These are

more important at lower levels of management since these managers are dealing

directly with employees doing the organization's work. Human skills involve the

ability to work well with other people both individually and in a group. Because

managers deal directly with people, this is crucial! Managers with good human

skills are able to get the best out of their people. They know how to

communicate, motivate, lead, and inspire enthusiasm and trust. These are

equally important at all levels of management. Finally conceptual skills are those

managers must have to think and conceptualize about abstract and complex

situations. Using these skills managers must be able to see the organization as a

whole, understand the relationship among various subunits, and visualize how

the organization fits into its broader environment. These are most important at

top level management.

A professional association of practicing managers, the American Management

Association, has identified important skills for managers that encompass

conceptual, communication, effectiveness, and interpersonal aspects. These are

briefly described below:

Conceptual Skills: Ability to use information to solve business problems,

identification of opportunities for innovation, recognizing problem areas and

implementing solutions, selecting critical information from masses of data,

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understanding the business uses of technology, understanding the organization's

business model.

Communication Skills: Ability to transform ideas into words and actions,

credibility among colleagues, peers, and subordinates, listening and asking

questions, presentation skills and spoken format, presentation skills; written and

graphic formats

Effectiveness Skills: Contributing to corporate mission/departmental objectives,

customer focus, multitasking; working at multiple tasks at parallel, negotiating

skills, project management, reviewing operations and implementing

improvements, setting and maintaining performance standards internally and

externally, setting priorities for attention and activity, time management.

Interpersonal Skills: Coaching and mentoring, diversity ; working with

diverse people and culture, networking within the organization, networking

outside the organization, working in teams; cooperation and commitment.

Importance of the managerial skills The mix of these skills varies as an individual advances in management form

supervisory to top management positions. At the lower levels of each

organization, technical skills are very important. As manger movers from lower to

higher levels less technical skills tends to be needed. Although it is important at

all levels, human skills assumes paramount important at the middle management

level. At the higher levels conceptual skills assumes more important in policy

decisions, strategy formulations and planning actions. Following figure shows the

importance of each skill and levels of management.

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Figure: importance of managerial skills and level of management

Technical skill Human skill Conceptual skills

In today's demanding and dynamic workplace, employees who are invaluable to

an organization must be willing to constantly upgrade their skills and take on

extra work outside their own specific job areas. There is no doubt that skills will

continue to be an important way of describing what a manager does.

The managerial skills are the quality of the manager which is found in the

managers. The work need of the different organization and business requires the

different skills in the managers in order to handle the business environment and

to make it successful in the market. So there are different types of skills which

the managers need in order to exercise the skills in the person in the different

people. So managers have to deal with the lot of problem which requires special

skills of the mangers in order to solve them. So when the manager counters a

problem then they require some special skills in order to deal with the specific

problems.

So there are many different organizations which require different skills in the

people in order to get the proper job done. So the demand jobs skills of today

managers are intuitiveness, work under pressure, manage the people, conflict

management, crises management and motivate the people under their

supervision so these are the skills which are needed in order to carry the different

operations of the business. So this is the reason the manager use their skills in

order to counter the problems. So this is all about the manager skills.

TOP LEVEL

LOW LEVEL

MID LEVEL

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Ways to Improve Your Managerial Skills Robert W. Bly has listed some ways to improve the managerial skills. Here are

his eight tips that will help you to manage and to guide your people more

effectively.

The Human Touch

The most valuable qualities you can develop within yourself are patience,

kindness, and consideration for other people. Although machines and chemicals

don't care whether you scream and curse at them, people do. Your subordinates

are not just engineers, scientists, administrators, clerks, and programmers they're

people, first and foremost. Respect them as people and you'll get their respect

and loyalty in return. But treat them coldly and impersonally and they will lose

motivation to perform for you.

Corny as it sounds, the Golden Rule "Do unto others as you would have others

do unto you'' -is a sound, proven management principle. The next time you're

about to discipline a worker or voice your displeasure, ask yourself, "Would I like

to be spoken to the way I'm thinking of speaking to him or her?'' Give your people

the same kindness and consideration that you would want to receive if you were

in their place.

Don’t Be Overly Critical

As a manager, it's part of your job to keep your people on the right track. And that

involves pointing out errors and telling them where they've gone wrong.

But some managers are overly critical. They're not happy unless they are

criticizing. They rarely accomplish much or take on anything new themselves, but

they are only too happy to tell others where they went wrong, why they're doing it

incorrectly, and why they could do the job better. Don't be this type of person.

Chances are, you have more knowledge and experience in your field than a good

many of the people you supervise. But that's why the company made you the

boss! Your job is to guide and teach these people not to yell or nit-pick or show

them how dumb they are compared to you.

Mary Kay Ash, founder and director of Mary Kay Cosmetics, says that successful

managers encourage their people instead of criticizing them. “Forget their

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mistakes," she advises, "and zero in on one small thing they do right. Praise

them and they'll do more things right and discover talents and abilities they never

realized they had."

Let Them Fail

Of course, to follow through on Mary Kay's advice, you've got to let your people

make some mistakes. Does this shock you? I'm not surprised. Most workers

expect to be punished for every mistake. Most managers think it's a "black eye"

on their record when an employee goofs.

But successful managers know that the best way for their people to learn and

grow is through experience and that means taking chances and making errors.

Give your people the chance to try new skills or tasks without a supervisor

looking over their shoulders but only on smaller, less crucial projects. That way,

mistakes won't hurt the company and can quickly and easily be corrected. On

major projects, where performance is critical, you'll want to give as much

supervision as is needed to ensure successful completion of the task.

Be Available

Have you ever been enthusiastic about a project, only to find yourself stuck,

unable to continue, while you waited for someone higher up to check your work

before giving the go ahead for the next phase? Few things dampen employee

motivation more than management inattention. As a manager, you have a million

things to worry about besides the report sitting in your mailbox, waiting for your

approval. But to the person who wrote that report, each day's delay causes

frustration, anger, worry, and insecurity.

So, although you've got a lot to do, give your first attention to approving,

reviewing, and okaying projects in progress. If employees stop by to ask a

question or discuss a project, invite them to sit down for a few minutes. If you're

pressed for time, set up an appointment for later that day, and keep it. This will

let your people know you are genuinely interested in them. And that's something

they'll really appreciate.

Improve the Workplace

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People are most productive when they have the right tools and work in pleasant,

comfortable surroundings. According to a study by the Buffalo Organization, a

comfortable office environment creates an extra $1600 of productivity annually

for professionals and managers.

Be aware that you may not be the best judge of what your employees need to do

their jobs effectively. Even if you've done the job yourself, someone else may

work best with a different set of tools, or in a different setup because each person

is different.

If your people complain about work conditions, listen. These complaints are

usually not made for self gain, but stem from each worker's desire to do the best

job possible. And by providing the right equipment or work space, you can

achieve enormous increases in output . . . open with a minimal investment.

A Personal Interest in People

When is the last time you asked your secretary how her son was doing in Little

League or how she enjoyed her vacation?

Good salespeople know that relating to the customer on a person-to-person level

is the fastest way to win friends and sales. Yet many technical managers remain

aloof and avoid conversation that does not relate directly to business. Why?

Perhaps it's because engineers are more comfortable with equations and

inanimate objects than with people, and feel uncomfortable in social situations.

But just as a salesperson wants to get to know his customer, you can benefit by

showing a little personal interest in your people their problems, family life, health,

and hobbies. This doesn't have to be insincere or overdone just the type of

routine conversation that should naturally pass between people who work

closely.

If you've been ignoring your employees, get into the habit of taking a few minutes

every week (or every day) to say "hello" and chat for a minute or two If an

employee has a personal problem affecting his mood or performance, try to find

out what it is and how you might help. Send a card or small gift on important

occasions and holidays, such as a 10th anniversary with the firm or a birthday.

Often, it is the little things we do for people (such as letting workers with long

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commutes leave early on a snowy day, or springing for dinner when overtime is

required) that determine their loyally to you.

Be Open to Ideas

You may think the sign of a good manager is to have a department where

everybody is busy at work on their assigned tasks. But if your people are merely

"doing their jobs," they're only working at about half their potential. A truly

productive department is one in which every employee is actively thinking of

better, more efficient methods of working ways in which to produce a higher

quality product. In less time, at lower cost

To get this kind of innovation from your people, you have to be receptive to new

ideas; what's more, you have to encourage your people to produce new ideas.

Incentives are one way you can offer a cash bonus, time off, a gift. But a more

potent form of motivation is simply the employee's knowing that management

does listen and does put employee suggestions and ideas to work. Quality

Circles, used by Westinghouse and other major firms, are one way of putting this

into action. The old standby, the suggestion box - Is another time tested method.

And when you listen to new ideas, be open minded. Don't shoot down a

suggestion before you've heard it in full. Many of us are too quick, too eager, to

show off our own experience and knowledge and say that something won't work

because “we've tried it before” or “we don't do it that way.” Well, maybe you did

try it before, but that doesn't mean it won't work now. And having done things a

certain way in the past doesn't mean you've necessarily been doing them the

best way. A good manager is open-minded and receptive to new ideas.

Give Your People a Place to Go

If a worker doesn't have a place to go a position to aspire to, a promotion to work

toward then his job is a dead end. And dead-end workers are usually bored,

unhappy, and unproductive. Organize your department so that everyone has

opportunity for advancement, so that there is a logical progression up the ladder

in terms of title, responsibility, status, and pay. If this isn't possible because your

department is too small, perhaps that progression must inevitably lead to jobs

outside the department. If so, don't hold people back; instead, encourage them to

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aim for these goals so that they will put forth their best efforts during all the years

they are with you?

Coordination Every individual and group in the organization contributes to the realization of the

organizations’ goals, but none is able to realize them alone without working with

others. Because of division of the labors and specialization of functions, the

hospital can achieve its objectives only if its part is coordinated into a cohesive

whole. Thus coordination is basic to practice of management at all levels and

pervades all functions in hospital administration. The role of the hospital

administrator in this regard becomes that of coordinator. The work of the

hospitals is characterized by the following.

• Heterogeneous group workers

• Specialization

• Complex interrelationship

• Group work

• Crisis orientation

• Round the clock functioning

• Objectives not clear, results not quantifiable

• Exhibits both authoritative and participative pattern of leadership

• Patients cannot their needs

The above conditions are prevailed and optimum performance in the hospitals

can not be achieved by each unit carrying out its activities in isolation. Good

aggregate results and outcomes are a product of a number of independent

decisions.

Coordination is facilitating different groups in an organization and orchestrates

their efforts to achieve the common goal of good patient care and efficient

hospital operations. The three basic considerations in coordination are as

following.

1. it must start early

2. all interrelated factors in a situation ultimately decide outcome

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3. interpersonal relationship play a major role in coordination

Coordination depends on cooperation improvisations by staff at all levels, and on

the understanding which different individuals have of each others’ roles.

Facilitation of coordination

Administrators at all levels achieve coordination through many actions and

methods. In fact, there may be as many method and styles of coordination as

there are administrators. However certain common actions are evident. These

are as follows.

• Horizontal contact

• Vertical contact

• Motivations

• Participations

• Communication

• Cooperation

Characteristics of effective Hospital Manger Many factors are attributed towards success or failure in administration.

Situation, circumstances, social environment and social connections have all

been put forward as factors affecting success, failure and effectiveness. There

are very large number of variables with determines the effectiveness of

administrators. However, after studying the characteristics of a great many

successful careers, certain common qualities, traits and characteristics of

successful and effective administrator emerge.

• Clear and Realistic Goals

• Professional Par-Excellence

• Perceptual and Cognitive Flexibility

• Professional Growth

• Commitment to chosen field

• Attitudes and Confidence

• Communication

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• Diversity

• Creative Orientation

• Motivation

• Satisfaction

• Self-Esteem

Efficiency versus Effectiveness

What is Efficiency?

“Judgements of efficiency are based on some idea of ‘wastage’. A relatively

efficient process either requires fewer inputs or produces more outputs compared

to a similar process, to achieve the objectives of the process. The authors refer

to this as technical efficiency, which in equation form is:

Technical efficiency = Output quality / Input quantity

Different business units performing the same process can be compared by

calculating the efficiency of each unit (giving a set of measures of absolute

efficiency) and comparing the results [the relative efficiency].

An important variant of efficiency is Allocative efficiency. This involves weighting

the inputs and outputs by their monetary values. Thus:

Allocative efficiency = Value of outputs/Cost of inputs

What is Effectiveness?

Effectiveness is very similar to efficiency, but the measure is related to some

enterprise objective rather than the technical quality of output. For example, one

common indicator of effectiveness is related to customer satisfaction rather than

output. Therefore the effectiveness measure of a business process can be

indicated by the resource inputs needed to produce a level of an enterprise

objective. Being effective means producing powerful effects. Being efficient

means producing results with little wasted effort. It is the ability to carry out

actions quickly. However, by so doing, you may not be achieving effectiveness.

Effectiveness involves achieving your worthwhile goals that support your vision

and mission.

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For instance, you may be very efficient at working through and completing your

to-do list. However, when you shift your focus to being effective, you may choose

to delegate part of your list, stop doing some of it, and focus on one or two things

that enable you to achieve your goals. Perhaps you're efficient at sending follow

up letters to potential clients, but being effective may mean only following up

more comprehensively on certain key ones

Comparison of effectiveness and efficiency

The words efficiency and effectiveness are often considered synonyms, along

with terms like competency, productivity, and proficiency. However, in more

formal management discussions, the words efficiency and effectiveness take on

very different meanings. Another way to look at it is this: efficiency is doing things

right, and effectiveness is doing the right things. Let's consider a surgery

example. A surgeon is very skilled, perhaps the best in the country. The

impending job is to operate on the patient's left knee. However, the surgeon

doesn't perform all the steps of the process leading up to the surgery. Someone

else marks the right knee for surgery. However skilled this surgeon is, however

fast he performs the surgery (i.e., however efficient he is), this process will not be

effective. When the patient awakens from the surgery, he will not be a happy

camper.

Some process efficiency measures are:

• cycle time per unit, transaction, or labor cost;

• queue time per unit, transaction, or process step;

• resources (dollars, labor) expended per unit of output;

• cost of poor quality per unit of output;

• percent of time items were out of stock when needed;

• percent on-time delivery; and

• Inventory turns.

Some effectiveness measures are:

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• how well the output of the process meets the requirements of the end user

or customer;

• how well the output of the sub process meets the requirements of the next

phase in the process (internal customers); and

• how well the inputs from the external suppliers meet the requirements of

the process.

By contrast, measures of ineffectiveness include:

• defective products;

• customer complaints;

• high warranty costs;

• decreased market share; and

• percent of activities that customers perceive to be non-value-added.

Efficiency and effectiveness are often considered synonyms, but they mean

different things when applied to process management. Efficiency is doing things

right, while effectiveness is doing the right things.

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Session 3: Hospital Planning and Design

The picture regarding medical care services in developing countries including

Afghanistan is can be described as chaotic. Standard hospitals are lacking,

hospital beds are inadequate, the hospitals are located far away from where

community lives, most crowded in towns and cities, and heavily biased in favor of

urban population. There are many reasons for the current state of affairs.

Absences of a realistic national health policy, haphazard medical care planning,

more than two decades of conflict, more attention towards primary health care,

lack of willingness of donors to invest in hospitals, and inadequate availability of

funds for the health sector are amongst the main reasons. Experience from many

countries having advanced medical care system has shown that hospitals are

very expensive to build. The initial capital costs are high, and the construction

and equipment consumes tremendous capital investment. But what is more

important is they are also very expensive to operate, with their running cost

amounting to approximately one third of the initial construction costs for each

year of operation. Haphazard planning at initial stages by inexperienced and

uncommitted technical personnel results in changes at constructional stage

resulting in avoidable drainage of funds.

Guiding principles in Planning A hospital is responsible to render an essential service. In fulfilling this

responsibility, hospital planning should be guided by certain universally

acknowledged principles. The principles are useful irrespective of level of

planning, i.e. Weather at the national level, provincial level or individual hospital

level. These principles were developed in the context of American system of

hospitals but have relevance and usefulness to hospital planning in the country.

Patient care of high quality

Patient care of high quality should be achieved by the hospital through adopting

following measures.

• Provision of appropriate technical equipment and facilities necessary to

support the hospital objectives

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• And organizational structure that assigns responsibility appropriately and

requires accountability for the various functions within the institutions

• A continuous review of the adequacy of care provided by physicians,

nursing and paramedical personnel and the adequacy with which it is

supported by other hospital activities.

Effective community orientation

Effective community orientation should be achieved by the hospital through

adopting following measures.

• A governing board made up of persons who have demonstrated concern

for the community and leadership ability.

• Policies that assure availability of services to all the people in the hospitals

service area.

• Participation of hospital in community programmes to provide preventive

care

• A public information program that keeps the community identified with the

hospitals goals, objectives and plans.

Economic Viability

Economic viability should be achieved by the hospital through taking these

measures.

• A corporate organization that accepts responsibility for sound financial

management in keeping with desirable quality of care

• Patient care objective that are consistent with projected service demands,

availability of operating finances and adequate personnel and equipment.

• A planned program of expansion based solely on demonstrated

community need.

• A specific program of funding that will assure replacement, improvement

and expansion of facilities and equipment without imposing too much cost

burden on patient charges.

• An annul budget plan that will permit the hospital to keep pace with times.

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Orderly Planning

Orderly planning should be achieved by the hospital through the following.

• Acceptance by the hospital administrators of the primary responsibility for

short and long range planning, with support and assistance from

competent financial organizational, functional and architectural advisors.

• Establishment of short and long range planning objectives with a list of

priorities and target dates on which such objectives maybe achieved.

• Preparation of a functional program that describes the short range

objectives and the facilities equipment and staffing necessary to achieve

them.

A sound architectural plan A sound architectural plan should be achieved by the hospital through the

following.

• Engaging an architectural experienced in hospital design and construction

• Selection of site large enough to provide for future expansion and

accessibility of population.

• Recognition of the need of uncluttered traffic patterns within and without

the hospital for movement of physicians, hospital staff, patients, and

visitors and for efficient transportation of supplies.

• An architectural design that permit efficient use of personnel,

interchangeably of rooms and provide for flexibility.

• Adequate attention to important concepts such as infection control and

disaster planning.

Medical technology and planning

Development in medical technology is taking place so rapidly that now the use of

sophisticated technology determines professional status. The diffusion of medical

technology vis-à-vis shortage of resources constantly plays on the minds of

planners. Even in western countries rational planning for medical technology is

an evasive subject.

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Hospital Utilization and planning Social, economic, educational and cultural characteristics of the people and the

attitude of medical professionals influence both the manner in which the existing

hospital facilities are utilized and the extent of utilization. However where hospital

facilities fall woefully short of the bare minimum requirements, utilization statistics

doesn’t depict the correct picture. The following factors affect the manner and

extent of hospital bed utilization, a knowledge of which will be of help during the

planning process.

• Hospital bed availability: as opposed to developed countries where

utilization is high because of large availability of hospital beds, in

developing countries because of low bed population ratio. A high available

bed complement may lead to low bed occupancy rate.

• Population coverage and bed distribution: since full coverage of

population depends upon equitable regional distribution rather than on

total number of beds, an even distribution increases hospital utilization by

wider coverage of population. People from scarcely populated areas

generally find it necessary to travel to provincial and regional hospitals or

metropolitan towns for more sophisticate type of medical care.

• Age profile of population: a population with high life expectancy tends to

raise the volume of hospitalization.

• Availability of medical services: availability of well- organized

dispensaries, outpatient clinics, mobile clinics, and competent general

practitioners reduce the load on hospital beds in an area.

• Customs on attitude of medical profession: doctors order admissions

primarily for medical reasons. On the other hand, people themselves

influence the decisions for admission if strong hospital habit is developed

in them, or against admission because of fear of the hospital and

unwillingness for separation from family.

• Methods for payment for hospital services: hospital services can be

free, on payment by patient directly to the hospital, or indirect payment

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through other channels. Hospital utilization is greatly influenced in the last

case.

• Availability of qualified medical manpower: in areas with very small

number of qualified doctors, much illness remains undetected, and

therefore admission rates are low. However the costumes and attitudes of

medical profession and pattern of services available influence hospital

utilization more than number of doctors.

• Housing: break up of the joint family system and a trend for nuclear

families living in independent houses result in increasing hospital

admission because of inconveniences encountered in caring for the sick

person at home.

• Mobility pattern: acute communicable diseases result in a demand for

short stay hospitals, while as chronic infective and degenerative diseases

creates demands for long stay institutions

• Hospital bottlenecks: the efficiency with which supportive services

support and reinforce the total hospital organization has direct effect on

hospital utilization.

• Internal organization: a high degree of specialization where specialists

departments functions as watertight compartments result in segmentation

within a hospital resulting in lesser degree of utilization due to tight

compartmentalization of beds.

• Public attitudes: these are certain factors which are of considerable

importance in determining where people will go to receive medical care,

these are public attitudes. The category includes social and religious

attitudes, local customs and traditions, beliefs and mores, and group

preferences.

Bed Planning in Hospitals It is unlikely that elaborate calculation to determine number of beds will be

required in starting a new hospital anywhere because no where has the bed:

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population ratio reached adequate levels. Even in cities where it has achieved

such figures, more beds are required because of increasing urbanization.

Here it should be realized that the hospital facilities in an area are not only

utilized primarily population in the vicinity of the hospital— the direct population,

but also by people who will constitute the indirect population in the larger

catchment area. When these population factors are worked out, the calculation

for total bed requirements can proceed as per guidelines of WHO.

Indices of direct and indirect admissions give the coverage hoped to be attained,

the assumed average length of stay and the occupancy rate indicate efficiency in

the use of services. About 85% bed occupancy is considered optimum.

Example:

Data

Direct population (DP) 600000

Indirect population (IP) 800000

Admission per year per 1000 (DP) 165

Admission per year per 1000 (IP) 55

Average length of stay in days (ALS) 10

Occupancy rate desired (BOR) 85%

Procedures

Admission per year (DP) 600000X165/1000= 99000

Admission per year (I1P) 800000X55/1000=44000

Total admission per year 143000

Total bed days per year 143000X10=1430000

(Total admissions X ALS)

Total beds required with 100% BOR 1430000/365= 3918

(Total beds required per day/365)

Total beds required with 85% BOR 3918X100/85= 4610

Deduction the number of already available beds in the region from the figures

arrived at will give shortfall of beds and therefore beds to be planned for that

region.

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Planning for equipment in hospitals The mechanical and electrical installations and the plant and equipment

component in a modern general hospital has been estimated to cost about 40%

of the entire hospital project out of which about half (20%) is required for medical

equipments. Hospital equipment covers a broad range of items necessary for

functioning of all the services. Various ways of classifying the equipment in the

hospital can be used. However for universal applications the equipment in

hospital can be classified as:

1. hospital plant

2. hospital furniture and appliances

3. general purpose furniture and appliances, and

4. therapeutic and diagnostic equipment

For more detailed information a broad range of the plant and equipment that is

required in t he general hospital is given in the following table.

Table: plants and equipment required in a general hospital.

1 Physical plant • lifts

• refrigeration and air

conditioning

• fixed sterilizers

• incinerators

• boilers

• pumps

• kitchen equipment

• mechanical laundry

• central oxygen

• suction

• generator

2 Hospital furniture and appliances • beds

• stretchers

• trolleys

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• wheelchairs

• bedside lockers

• dressing drums

• kitchen utensils

• bedside lamps

• moveable screens

• hand wash stands

• operation tables

• instrument trolleys

• bedpans

• waste bins

• hospital Lenin

3 General purpose furniture and appliances

1. office machines

• intercom sets

• typewriters

• calculators

• cash registers

• filling system

• electronic exchange

• computers

4 2. office furniture

5 3. crockery and cutlery

6 Diagnostic and therapeutic equipment

1. equipment for general use

• surgical instruments

• BP instrument

• Suction machines

• Rehabilitation

department equipment

• Physiotherapy

department equipment

• Sterilizers

• Equipment for clinical

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laboratory

• Glassware washers

• Voltage stabilizers

• Refrigerators

• Chemical analyzers

• microscopes

7 2. equipment interfacing with patients during

Diagnostic and therapeutic procedures

• short way diathermy

machines

• electric cautery

machines

• defibrillators

• X— Ray machines

• Monitoring equipment

• Respirators

• Incubators

• ECG machines

• USG machines

During the last decades, there has been an explosive growth of sophisticated

electronic biomedical equipment in the hospital field. However a rapid

introduction of electronic equipment without thorough assessment may pose

problems of economy, safety and unsuitable system. Apart from selection of the

equipment, it is equally important that procurement, installation and maintenance

of each item of major equipment is planned accordingly.

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Session 4: Basics of Strategic Planning in Hospitals Prior to development and implementation of operational plan there is necessary

to have strategic framework as strategic planning. Positioning the hospital for the

future is the purpose of strategic planning. The strategic planning process

provides a hospital/health system with the ability to determine its future and

achieve it. A strategic planning process must be established to position the

hospital in a rapidly changing environment.

Strategic planning is the process of determining what an organization wants to be

in the future and how it will get there. Hospitals that develop and implement

strategic plans tend to be more successful than those that don’t. Strategic

planning is different from short-term or operational planning. Operational

planning usually focuses on an annual cycle and requires the development of

yearly objectives and plans. This becomes part of the annual budgeting process.

Operational plans lay out how the hospital will move toward its future during that

year. The future is described in the hospital’s strategic plan. Strategic planning

requires that choices be made about your hospital’s future. These choices

concern your vision and mission, the goals to be pursued, what services will be

offered and to whom, the resources that will be needed (people, facilities,

technology, money and knowledge) and how they will be acquired.

Importance of Strategic Planning Strategic planning is widely practiced by successful hospitals and health

systems. Strategic planning can have a positive effect on a hospital, but it is not

the answer in all situations or to all problems. A hospital should plan for its future

to:

• Improve the hospital’s performance

• Determine the hospital’s future direction

• Provide high quality health care services

• Optimize resource allocation

• Meet accreditation and regulatory requirements

• Meet the hospital’s vision and mission statement

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• Maximize its chances for success

Although it is said failing to plan is planning to fail and either you are not planning

that is plan to not plan. Nevertheless prior to engaging in strategic planning, the

Hospital Board needs to:

• Understand what strategic planning is and how to do it

• Determine if the hospital is stable

• Identify whether a need for change exists

• Be committed to the planning process and include the participation of the

hospital administration, community, physicians and staff

• Decide if the hospital has the capability, resources and commitment

needed for the planning process

Planning takes time and money. Both must be allotted to the process. It is

important to make sure that the necessary resources, including Board and staff

time, are available to plan for the future and keep operating in the present.

Roles and Responsibilities in planning process The Executive/ Governing Board have the principal responsibility for strategic

planning. The Board guides the development of the plan consistent with the

hospital’s mission, philosophy and values. The role of the Governing Board in

strategic planning process includes:

• Approval of the hospital’s vision, mission statement and goals

• Suggestion and considerations of strategies

• Approval of the strategic plan and its implementation

• Monitoring and updating the plan and its implementation

Strategic Planning Committee

The chair of the Governing Board appoints the Strategic Planning Committee and

the Committee is responsible for:

• Organizing the planning process

• Scheduling and conducting meetings

• Focusing the planning process

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• Ensuring that Board and community values are reflected in the plan

• Developing the strategic plan

• Periodically reviewing the hospital’s mission and vision statement

• Monitoring trends, demographics, technology and community needs

• Reviewing and approving annual strategic planning goals and objectives

• Monitoring progress toward objectives

The General Director/Chief Executive Officer

Although the position of hospital’s chief executive officer (CEO) is usual in private

as compare to public sector in the country, however, there is a resemble position

for it in public hospitals as well. He or she is involved in the planning process as

a strategist, organizer, tactician and facilitator. The CEO is responsible for

carrying out the strategic plan after it is approved by the Board.

Medical Staff

Involvement of the medical staff in strategic planning is fundamental to ensuring

the development and implementation of the strategic plan. This involvement can

take several forms. Representatives of the medical staff should serve on the

Strategic Planning Committee. The medical staff may have its own planning

responsibilities and, upon completion of those responsibilities, report the results

to the Strategic Planning Committee. Hospital department heads make an

extremely valuable contribution to the strategic planning process. Their internal,

functional planning serves a major role in developing objectives, weighing

alternatives and implementing the Board-approved plan.

Patients and Community

The role of patients and the community in the strategic planning process merits

special consideration, for these groups provide information which nourishes two

vital steps in the hospital’s planning: analysis of the internal and external

environments, and development of the hospital’s mission. While actual

participation by these groups in the process may be limited, community and

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patient use of and attitudes about the hospital are reflected in all steps of the

planning process.

Planner and consultants

The hospital planner and / or manager are involved in staffing all aspects of the

planning process. The planner performs feasibility and planning studies,

develops the environmental assessment for the Strategic Planning Committee’s

consideration and provides assistance in developing the plan’s format, timetables

and evaluation procedures. In hospitals without a planner, these functions are

the responsibility of the chief executive officer and/or administrative staff.

Consultants are helpful in the strategic planning process to prepare the

Governing Board for the planning process through education or retreats and give

an objective assessment of the hospital’s strengths and weaknesses. In addition

they can steer the Board and Strategic Planning Committee through the process

and keep the planning process on track. A consultant cannot substitute for the

Board’s unique knowledge of the hospital and its mission. The consultant is not

the planner and, for sure, he is just a facilitator and technical advisor.

The Steps of the Strategic Planning The Governing Board should design a process that is realistic and that works for

its hospital. In order to develop technical and functional strategic plans for

hospitals there is a need to follow a predetermined process. The steps of the

strategic planning process usually include:

• Get organized

• Perform an environmental assessment

• Develop a vision

• Develop the mission statement

• Develop Value Statement

• Develop strategies

• Prepare the strategic plan

• Approve the plan

• Implement the plan

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• Monitor and update the plan

Mostly the steps are not linear and they can be combined and completed at the

same time. They may be completed in a different order depending on the

planning process. Planning should focus on the critical issues that will determine

the hospital’s future success or failure. As you design your strategic planning

process, answer questions such as what is the Governing Board’s experience

with planning? What is the Board’s commitment to strategic planning? How much

time and resources are needed from the Board, administration and staff? Does

the Board or hospital have a knowledgeable person to guide the planning

process? What technical or political issues may arise? After making adjustment

for these issues the avenue will be opened to commence the process.

Strategic plans have been completed in a one-day retreat. However, it is more

likely to take minimally 40 to 120 hours of actual Strategic Planning Committee

meeting time. The length of time depends on the availability of needed

information, the expertise of the Strategic Planning Committee and the staff and

resources allocated to the process.

With the recent rapid changes in the health care environment, hospitals may

want to develop a two- to three-year (maximum five year) strategic plan with an

annual update and review. Let’s have a look of above mentioned processes a bit

in detail.

Get Organized

Everyone needs to be committed to the planning process. Don’t begin without

the commitment of members and the medical staff. Learn about strategic

planning and how your hospital can use it. Discuss what strategic planning can

accomplish, any concerns Board members have and what problems may occur.

Decide if outside help is needed. Outline the planning steps your hospital will

take. It is important not to design a planning process that takes more time than

can realistically be expected from staff or the Board. Form a planning team of

five to ten people. The larger the team, the more structure will be needed at

strategic planning team meetings. The team could include: Board

representatives, the CEO, medical and technical staff representatives, staff

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members who have patient care responsibilities, community representatives,

consultants or other resource people. The planning team members need to be

able to work together, have different viewpoints, be creative and understand

health care trends and the hospital.

Analysis of the Situations

One step in strategic planning is a thorough, objective environmental

assessment. This includes a realistic assessment of the hospital’s history and

present situation, its strengths, weaknesses, opportunities and threats (SWOT).

The result of this analysis is a list of critical issues for the future. The hospital

functions in two environments – external and internal.

For assessment of internal environment review your hospital’s history including

its beginning, original mission and services, any significant events, major

changes, successes or failures and values or traditions. In addition review the

hospital’s present environment including services, products, programs, staffing,

financial position and current plans. Historical and projected utilization statistics,

patient origin data and financial reports, as well as medical staff profiles and

patient opinion polls, are instructive and should be gathered. This information,

prepared by consultants or administrative staff, provides a sense of how the

hospital has evolved. This assessment of strengths and weaknesses may be

difficult or even unpleasant. A truthful and candid evaluation performed at this

stage is necessary to position the hospital for a strong future.

In order to perform external assessment we should know that every hospital

functions within a larger setting, and is affected by surrounding forces. The

external assessment focuses on demographic data, political trends, social

change, the economic climate, community perceptions and competitive

providers. Painting scenarios of how the hospital might be affected is helpful in

exploring threats, opportunities and potential strategies. Certainly this portion will

incorporate the assessment of opportunities and threats which is in place and

affect the activities of the hospital positive or negatively.

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Develop a Vision

Strategic planning is about creating your hospital’s future and being ready for the

future. The vision statement describes the way you want the hospital to be in the

future. For development or review of the visions of the hospital we should focus

on some factors such as: clarification of the organization’s values; agreement on

the basic beliefs that guide the hospital; exploring what ideas and trends could

change the way the hospital is doing business; identifying what needs are

emerging as a result of demographic, technological, economical, political and

regulatory trends and identifying who is needed to make the vision possible. The

hospital should make efforts to make the visions shared one. According to Dr

Islam Saeed the head of training department at MoPH the vision should be like of

SIMCARD with everyone which are stands for:

• S-Stimulating

• I-Inspiring

• M-Motivating

• C-Cooperating

• A-Aspiring

• R-Reorienting

• D-Devoting

So that the vision is dreams with action and dreams without action is just

imaginations. A vision is a description of how you want the practice to operate in

the future and how your patients will benefit. Answer the question: What do you

want your practice to look like?

Sample Vision Statement: To be known as the most caring practice and the most

effective in diagnosing and treating every patient through better communication

and understanding. We will lower the critical effects of specific diseases, such as

cardio vascular diseases, diabetes and liver diseases.

Development or Review the Mission Statement

The mission should answer the question why you exist and what is your

business. The mission statement provides the purpose or reasons for the

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hospital’s existence. It expresses philosophy, community service, research or

educational commitments, affiliations and major functions or services offered by

the hospital. The mission statement should be a specific, succinct articulation of

what the Board wishes the hospital to be. Although the mission statement

defines what a hospital is, it also sets forth any limits or restrictions on a

hospital’s activities. The hospital’s policy, charter, enabling legislation, Board

minutes and annual reports are valuable sources for the review and development

of the mission statement. The mission statement establishes the guiding

principles from which the strategic planning process flows. Your mission

statement is unique to your hospital. Mission statements include a brief

description of your practice’s purpose. It should be posted in a prominent location

in your office. The mission should answer the question: what are you involved in?

Whom do you focus? And, how do you wish to render value to your patients?

Sample Mission Statement: To deliver the highest possible quality of care to

each patient, with respect and special attention to each person’s racial, ethnic

and socio-cultural background and needs.

Value statement

Whatever you believe you should practice and promote in your hospital. List how

you want the practice to operate, including moral values such as integrity,

honesty and respect, as well as operational values such as increased efficiency,

timeliness and communication.

Sample Values Statement: All patients are to be treated equally, regardless of

race, ethnicity or socio-economic background and give the best possible

available care and consideration. These values are the responsibility of each

individual within our organization.

Develop Strategies

Strategies tell “how to get there.” Many methods are for developing strategies.

Once the Board has approved vision and mission statements, development and

prioritization of goals becomes the next challenge. Here are three methods which

are used for developing strategies for the future.

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Goal approach: In Goal Approach a goal identifies an end to which the

organization aspires, what is hoped to be achieved. For purposes of clarification,

this is distinguished from an objective, which is an activity necessary to reach the

goal. Understanding the differences between a goal and an objective can be

confusing. Goals are broad, brief statements of intent that provide focus or vision

for planning. Goals are warm and fuzzy. They are non-specific, non-measurable,

and usually cannot be attained. For instance afghan children will be healthy.

Objectives are meant to be realistic targets for the program or project. Objectives

are written in an active tense and use strong verbs like plan, write, conduct,

produce, etc. rather than learn, understand, feel. Objectives can help you focus

your program on what matters. They will always answer the following question:

WHO is going to do WHAT, WHEN, WHY, and TO WHAT STANDARD?

Each proposed goal should be examined against community need and

acceptability, relation to the mission, feasibility and effectiveness in addressing a

problem or concern. Obtaining a consensus on goal priorities may be difficult, for

it calls into play a complex set of value judgments, biases and differences in

degree of relative urgency or importance. Recognizing that resources are limited

is a key consideration. Here, creativity is a welcome skill for discovering

innovative strategies or solutions. The Strategic Planning Committee generates

several possible approaches to accomplish goals. Each alternative is then

subjected to an evaluation of costs, equipment and personnel resources, benefits

and constraints. Consultants and the experiences of other hospitals may prove

helpful in assembling the information needed to assess each option. Upon

completion of this research, the Committee focuses on selecting the most

appropriate specific course(s) of action. If numerous steps or objectives are

necessary to achieve each goal, develop a breakdown of those goals which

would require two to five years, as well as short-term actions. In this way, goals

are less overwhelming, and organizational achievement of each goal is another

step toward the desired end. To develop a goal outline the specific issues you

want your practice to address over the next year and the results you desire.

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Goals should be quantifiable, consistent, realistic and achievable. You may want

to limit your goals to two or three.

Sample Goals: Reduce the incidence of post surgical infection rate among our

operated patients by 75 % till end of coming two years. Or improve

communication with rural patients to provide better diagnosis, treatment and

positive outcomes. Or Increase proper usage of inhalers by asthmatic patients.

Objectives include how you will achieve your goals. For example: to increase

tetanus immunization rates for selective surgery patients or send staff members

to medical capacity building or develop or access treatment protocols in multiple

local languages. Determine the actions, methods and/or steps needed to achieve

each goal and objective. Consider any budget that might need to be developed

for training or special services. For example if we consider the last objective of

improving inhaler usage the action plan will include the following activities:

• Take into account language barriers and/or cultural considerations

• Let the patient show how he/she thinks the inhaler should be used

• Demonstrate how to properly use the inhaler

• Provide materials explaining the use of an inhaler in the patient’s language

• For patients who need additional help, arrange for a nurse to visit their

home and practice with them

• Have staff follow up with patients to determine their ongoing level of

understanding/ compliance

• Ensure the patients is using the inhaler properly

Critical Issues Approach: After assessment of the environmental there would

be a list of critical issues. Take this list and focus on the four to eight issues most

critical to your hospital’s future. Each issue should be stated in question form.

Put the critical issues in a logical order. Each issue should be discussed,

possible solutions/options identified and the best solutions selected. The

hospital’s strategy for the future becomes clear after all of the critical issues

questions are answered. That strategy needs to be reviewed for clarity and

coherence. The strategic plan is then developed and presented for approval.

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Even when we are choosing some critical issues and strategies are developed to

overcome them, still there is a need to put it in the framework of strategic

directions. Some of the most common errors in writing objectives include: writing

an objective like an activity, writing an objective like a vision; or writing too many

objectives.

SMART Objectives” refers to an acronym built around the five leading

measures of a strong program. This acronym can be very helpful in writing

objects that can be employed to evaluate the quality of Hospital Services

proposed and carried out.

Specific – What exactly are we going to do, with or for whom? The Hospital

states a specific outcome, or a precise objective to be accomplished. The

outcome is stated in numbers, percentages, frequency, reach, scientific outcome,

etc. The objective is clearly defined.

Measurable – Is it measurable & can WE measure it? This means that the

objective can be measured and the measurement source is identified.

If the objective cannot be measured, the question of funding non-measurable

activities is discussed and considered relative to the size of the investment. All

activities should be measurable at some level.

Achievable – Can we get it done in the proposed timeframe/in this political

climate/ for this amount of money? The objective or expectation of what will be

accomplished must be realistic given the market conditions, time period,

resources allocated, etc.

Relevant – Will this objective lead to the desired results? This means that the

outcome or results of the program directly supports the outcomes of the agency

or funder’s long range plan or goal, e.g., the selected MOD priority area.

Time-framed – When will be accomplishing this objective? This means stating

clearly when the objective will be achieved.

Scenario Approach: The scenario approach requires the development of

several pictures (scenarios) of what your hospital might be in one, two, five or

more years. Scenarios should be evaluated in terms of your hospital’s vision and

mission, community needs and financial feasibility. Identify the advantages and

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disadvantages of each scenario and select one. The chosen scenario may be a

combination of more than one original scenario. Determine if the scenario is

feasible, and then translate it into a strategic plan. The scenario approach is

particularly useful when dealing with major changes in health care delivery, its

emphasis or direction. It produces “big picture” thinking, is fairly quick and

people find it interesting. The scenario and critical issues approaches can be

used with the goal approach. After the strategy for your hospital’s future has

been identified using the scenario or critical issues approach, specific goals can

be determined using the goal approach.

Strategic Plan preparation Whatever is discussed and decided during meetings is documented and makes

the basis for preparation of the strategic plan. Focusing on goals, strategies and

objectives, the Strategic Planning Committee assigns responsibility for achieving

these objectives, specifies the timetable by which each is to be accomplished

and determines what resources are required to accomplish each objective. The

plan should serve as a guide for all activity and direct the hospital toward a

preferred future. A simple, brief plan with short- and long-term objectives

encourages the hospital to move ahead and specifically identifies the path for

doing so. Decide on the format for your written strategic plan and outline what it

will look like, based on the needs of your hospital. The plan might include:

• Executive Summary of the strategic planning process

• History of the hospital

• Vision and Mission statement

• Target population

• Catchment area or Community served by the hospital

• Future issues facing the hospital

• Analysis of strengths and weaknesses, opportunities and threats

• Programs and services, medical staff, operations and finances

• Assumptions upon which the plan is based

• Goals and objectives

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• Implementation strategies

• Organizational structure planned for the future

• Plans for buildings, technology or renovation

• Marketing plans

• Key relationships and how they will be maintained, improved or developed

• Organizational polices for the future

• Contingency plans

Draft your strategic plan. It is easier if one to two members of the Strategic

Planning Committee put together the draft of the plan.

Taking Approval of the Plan

Despite of review of draft by Strategic Planning it should also be reviewed by

others, such as staff members, interested community leaders and people who

have a stake in the hospital’s future. Then make needed revisions. It is

important to develop a plan that can be understood and carried out. The

Committee submits the plan for Board approval.

Implementation of the Plan

Now it is time to put it in practice. The Board authorizes the CEO to initiate the

implementation process through policy modifications, hiring staff or purchasing

equipment, appointing special task forces or allocating and budgeting funds. The

Board, the community and the medical and hospital staff should be aware of and

understand the plan. The plan should be communicated to all.

Monitoring and Updating the Strategic Plan

Strategic plans should be monitored continually and updated annually. Given the

rapidly changing health care environment, quarterly reviews of processes may be

needed. Updating of the strategic plan should occur before budget development.

Updating requires reviewing the hospital’s performance, the plan’s objectives,

changes in opportunities, threats, strengths and weaknesses and critical issues.

Revisions to the plan are then made and included in the budget. The strategic

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plan needs to be adjusted when conditions change, when new information

becomes available or when the health care delivery system changes.

Operational Planning and Activity Scheduling Nowadays the business of running a hospital is increasingly complicated.

Hospitals are in need of best practices and sources of competitive advantage.

Hospitals should brings the experience and expertise in the development of new

and redesigned operational processes to allow the institution to maximize their

full potential and achieve their goals of program, superior customer service,

impeccable quality, improved efficiency and effective asset utilization. Hospitals

integrate skills in clinical program planning, technology and facility planning to

deliver innovative solutions that are practical, implementable and infused with the

organizational understanding and support for needed change.

The vision sets the direction for operations by highlighting the key drivers of

change and provides line of sight for reaching a higher level of performance. It is

required to translate the strategic framework into small activities and task to be

manageable and applicable. Before going into detail of operational planning your

attention is requested to pay to concise operation plan of a hospital in the

following table in which the strategic planning and operational planning its related

to each other.

Table: strategic framework and operational planning in a hospital

Mission: “To Heal, Comfort and Serve our Community with Compassion.”

Vision: To Provide each Patient Superior Service & Safety, Exceptional by Any

Standard.”

Values: Reverence ~ Integrity ~ Compassion ~ Excellence

Pillars Strategy Measurements

PEOPLE

Always hire, retain, and

inspire the best.

• Create a culture that

inspires.

• Provide a safe work

environment

• Engage employees to

• <15% Turnover

• 75% Employee

Satisfaction

• 16 Hours Training per

Employee

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achieve new levels of

effectiveness

• 0 Needle Sticks

• <51 L & I Claims

• Reduce Patient

Handling Injuries 50%

SERVICE

Always provide service

that exceeds customer

expectation.

• Provide an exceptional

service experience

• Create loyalty and

sense of ownership

• Create the easiest

access to services

• 75% Patient

Satisfaction

• 80% HCAHPS

• Baseline Physician

Satisfaction

• Baseline Internal

Customer Satisfaction

• Baseline Wait Times

(E.D. & Imaging)

QUALITY

Always achieve

organizational

excellence & patient

Safety.

• Ensure safety of all

patients

• Leverage technologies

to attain “best in class”

outcomes

• Embrace award winning

health care criteria for

performance excellence

• Quality standards are

known & practiced by all

• Quality/Safety/PI

Indicators

⇒ 100% CMS

Compliance

⇒ All Green “Board

quality”

Dashboard

• State Quality Program

Submission 10/08

FINANCE

Always sustain

Robust financial

health.

• Control Expenses

• Manage capital

expenses responsibly

• Staff to Budget

• Negotiate Payer

Contracts

• Maximize public/private

contributions & grants

•100 Days Cash

• 4.0% Operating Profit

Margin

• 60% Medicare

/Medicaid/Healthy

Options

• 4.06 Employees Per

Occupied Bed

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• $150K in Grants &

Donations

GROWTH

Always optimize

Responsible growth to

achieve our mission &

vision.

• Develop and grow new

& existing services

• Recruit well-trained

physicians who exemplify

our Values & Standards

• Invest strategically in

existing facilities.

• 1.5% Market Share

Growth

• 1.5% Increase in

Operating Revenue

• 5,999 Admissions

• New services meet

projected results

When you are developing operational planning it is very necessary to follow the

strategic frameworks. The main areas for which there is a place in strategic

planning in a hospital are the following:

• Clinical services

• Training & education

• Research

• Human resources management

• Financial management

• Administrative support services

• Facilities management

• Quality and safety

• Information systems and communication technology

• General management & corporate governance

To implement all above goals and strategies we need the develop operation

planning in which the following issues will be included.

• Costing Approach: it is possible to include the costs within operational

planning or develop a financial planning as a separated document.

• Assumptions: it will shows the conditions in which the plan will be applied

smoothly and they should be met for implementation.

• Medical equipments: to provide services there is a need to develop a plan

for all equipments which is needed now and in future

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• Non-Medical equipment

• Facilities: facilities may include power, gas, communication,

transportations and so on

• Information and Communication Technology

• Staffing : it may include all staff including technical, administrative and

supportive

• Professional training: if you are providing training to your professional

staff, therefore, training requires a separate operational plan including its

cost is needed.

What is Operational Plan?

The Operational Plan defines how you will operate in practice to implement your

action and monitoring plans – what your capacity needs are, how you will engage

resources, how you will deal with risks, and how you will ensure sustainability of

the Hospital’s achievements.

An Operational Plan does not normally exist as one single standalone plan;

rather the key components are integrated with the other parts of the overall

Strategic Plan. The key components of a complete Operational Plan include

analyses or discussions of:

• Human and Other Capacity Requirements – The human capacity and

skills required to implement your plan, and your current and potential

sources of these resources. Also, other capacity needs required to

implement your plan

• Financial Requirements – The funding required implementing your plan,

your current and potential sources of these funds, and your most critical

resource and funding gaps.

• Risk Assessment and Mitigation Strategy – What risks exist and how

they can be addressed.

• Estimate of Plan Lifespan, Sustainability, and Exit Strategy – How

long your plan will last, when and how you will exit your plan (if feasible to

do so), and how you will ensure sustainability of your plan achievements.

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As the plan moves into Implementation, several of these components are then

defined in more detail and tested in reality. Thus the Operational Plan provides a

critical bridge between strategic plan and Implementation of those plans.

The level of detail and formality of your Operational Plan will vary depending on

the size and complexity of your plan. Small plans may only briefly touch on each

of these topics before moving on to implementation.

Importance of Operational Plan

An Operational Plan ensures you can successfully implement your Action and by

getting your team to prepare your project to raise funds, being clear about how

you will get the resources and arming you with a convincing plan to review with

existing and potential donors. In addition it will help you to use resources

efficiently, to help allocate scarce resources to the most critical gaps and needs.

It helps to clearly define your capacity gaps and most critical resource

requirements and reduce risks where possible, and prepare contingency plans

where necessary. By operational plan we think about the long term future of the

project, including how you will ensure sustainability of your project’s targets and

impacts.

Steps in developing Operational Planning

Operational planning is short-range planning that focuses on particular course of

actions or operational planning provides a detailed statement of the activities and

related budgets that will be undertaken to implement the strategic plan.

Step 1 – List Main Activities

The main activities in the log frame are a summary of what the project must do in

order to achieve project objectives. These can now be used as the basis for

preparation of the activity schedule that will specify activities in operational detail.

Step 2 – Break Activities down into Manageable Tasks

The purpose of breaking activities down into sub-activities or tasks is to make

them sufficiently simple to be organized and managed easily. The technique is to

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break an activity down into its component sub-activities, and then to take each

sub-activity and break it down into its component tasks. Each task can then be

assigned to an individual, and becomes their short-term goal.

The main skill is in getting the level of detail right. The most common mistake is

to break the activities down into too much detail. The breakdown should stop as

soon as the planner has sufficient detail to estimate the time and resources

required, and the person responsible for actually doing the work has sufficient

instructions on what has to be done.

Step 3 – Clarify Sequence and Dependencies

Once the activities have been broken down into sufficient detail, they must be

related to each other to determine their: sequence - in what order should

related activities be undertaken? Dependencies - is the activity dependent on

the start-up or completion of any other activity?

This can best be described with an example. Building a house consists of a

number of separate, but inter-related activities: digging and laying the

foundations; building the walls; installing the doors and windows; plastering the

walls; constructing the roof; installing the plumbing. The sequence dictates that

digging the foundations comes before building the walls; while dependencies

include the fact that you cannot start installing doors and windows until the walls

have reached a certain height; or you cannot finish plastering until the plumbing

has been fully installed. Dependencies may also occur between otherwise

unrelated activities that will be undertaken by the same person.

Step 4 – Estimate Start-up, Duration and Completion of Activities

Specify timing means making a realistic estimate of the duration of each task,

and then building it into the activity schedule to establish likely start-up and

completion dates. Sometimes it is difficult to estimate the probable completion

time. To ensure that the estimates are at least realistic, those who have the

necessary technical knowledge or experience should be consulted. Inaccuracy is

a common mistake, usually resulting in an underestimate of the time required,

and can arise for a number of reasons: omission of essential activities and

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tasks failure to allow sufficiently for interdependence of activities failure to

allow for resource competition (i.e. scheduling the same person or piece of

equipment to do two or more things at once) a desire to impress with the

promise of rapid results

Step 5 – Summarize Scheduling of Main Activities

Having specified the timing of the individual tasks that make up the main

activities, it is useful to provide an overall summary of the startup, duration and

completion of the main activity itself.

Step 6 – Define Milestones

Milestones provide the basis by which project implementation is monitored and

managed. They are key events that provide a measure of progress and a target

for the project team to aim at. The simplest milestones are the dates estimated

for completion of each activity - e.g. Training needs assessment completed by

January 1998.

Step 7 – Define Expertise

When the tasks are known, it is possible to specify the type of expertise required.

Often the available expertise is known in advance. Nonetheless, this provides a

good opportunity to check whether the action plan is feasible given the human

resources available.

Step 8 – Allocate Tasks among Team

This involves more than just saying who does what. With task allocation comes

responsibility for achievement of milestones. In other words, it is a means of

defining each team member’s accountability - to the project manager and to other

team members. Task allocation must therefore take into account the capability,

skills and experience of each member of the team. When delegating tasks to

team members, it is important to ensure that they understand what is required of

them. If not, the level of detail with which the relevant tasks are specified may

have to be increased.

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The easy and important format for operational planning is Gantt chart in which all

steps mentioned above can be accommodated with specification of time and

resources along with activities and tasks.

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Session 5: Hospital Costing and Budgeting

The budget is a financial plan that summarizes the forecasted revenues and

expenditures for an organization/project for a given period of time. Revenue is

the total amount of money received by an organization/company for output,

goods sold or services provided during a certain period of time. Expense is the

money spent by an organization/company to continue its ongoing operations

Budget Principles During budget preparation, some rules and procedures are strictly followed and

these are known as budget principles. Before preparation of budget the

legislative body formulates these principles and distributes it to all line ministries.

An organization can also have its own principles but some main principles to

assess soundness of budget are the following.

• Compliance: all expenditures must comply with all relevant policies and

regulations

• Comprehensiveness : the budget should encompass all operations (off-

budget expenditure and revenue are prohibited)

• Legitimacy: Policy makers, that can change policies during the

implementation , must take part in and agree on

• Predictability: there must be stability in strategic policy and in the funding

of this policy

• Transparency of budgetary process and information: decision makers

should have all relevant issues and information before them when they

take decisions and these decisions and their basis should be widely

communicated

• Accountability: decision-makers are responsible for the actions they take

• Equity: resources are directed according to real needs to all people and

areas of the provinces.

• Flexibility: budget should be enough flexible to fund overseen

circumstances and take advantage of opportunities.

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• Honesty: budget should be delivered from unbiased projections of

revenue and expenditure

• Be realistic, attainable and reasonable: Realistic: should be formulated

to avoid underestimated or overestimated program/project cost.

Attainable: can be performed successfully, possible to do and reasonable:

showing reason and sound judgment

What is cost? Hospitals as a business are conducted by exchanging liquid assets for fixed

assets and vice-versa. A first type of payment occurs when we exchange cash or

another liquid asset for such things as property, machinery and vehicles. These

are material assets that enable us to make things. A second type of payment

occurs when we purchase such things as raw materials, and employ people to

operate the machines, answer telephones and the like. Rent is an example of

this second type of payment. We may decide to hire rather than buy a

photocopier. The rent on the photocopier must be paid for, and we pay rent for

the use of the photocopier. The first type of payment is called an investment, and

the second type of payment is called a cost.

Investments increase the material that is, fixed assets, of the person buying

them. The owner has an item that can be used as a means of production.

Investment in such items is called capital expenditure

We should understand the distinction between fixed and liquid assets. The most

liquid asset is cash. A liquid asset can be used to pay a bill. The more liquid an

asset the more readily it can be exchanged for cash. Fixed assets are those that

take time to be sold. They cannot be exchanged immediately for goods and

services. Factories and vans are examples of fixed assets.

Money is in itself unproductive. It does not make anything. So cash (the

ultimately liquid asset) must be used to by other assets that can be productive,

such as machinery. These fixed assets are used in conjunction with other inputs

– labor and raw materials – so make goods and services that can be sold for

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cash. Hence liquid assets are exchanged for fixed assets, which produce goods

and/or services that result in sales, bringing in further liquid assets.

A capital item is used to make things – in the sense of providing the facilities for

production – a factory, a machine – these are examples of capital items. But the

making of goods requires other factor inputs as well – raw materials and labor.

Every time a good is produced these are consumed. These inputs are called

costs in accounting terms.

Classification of Costs Costs are payments incurred in day-to-day production. It is possible to analyze

costs in two separate ways.

Classification by type

Costs are classified as either arising directly or indirectly. Direct costs are ones

that can be specifically related to the production of a particular good. Indirect

costs are those that are not so specifically related. For example, suppose a

company manufactures chairs. The cost of the labor and raw materials that goes

into the manufacture of the chairs is direct costs. The production overheads

include the factory rent and heat, light and power, and depreciation on plant and

machinery. Indirect costs are also frequently called overheads.

Classification by behavior

This is concerned with the way an impact of a change in output causes a change

in costs. Costs are classified in this way as either fixed or variable. Fixed costs

do not change as the quantity of output changes. Increasing output does not

increase these costs. Variable costs do change. Variable costs increase as

output increases. It is a mistake to confuse indirect costs with fixed costs. Both

direct and indirect costs can and do vary with output, and both can, and do,

contain elements of fixed costs. For example, the amount of energy used by a

company (an overhead) does increase with the number of goods produced.

The usual example of a direct cost that is also fixed is depreciation on machinery.

Depreciation is the loss of value of an asset owing to ageing. Machinery just

wears out, and so loses value. Depreciation on dedicated machinery means

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depreciation on machinery that is used for only one purpose in the production

cycle, and so can be regarded as a direct cost.

Economists classify costs as either fixed or variable. At present we are

concerned with how costs vary with output in the short run. The short run is

defined as a period of time in which at least one factor of production is fixed –

usually capital. That is, a firm as a fixed size of plant. In the long run the firm can

move to larger or smaller premises.

In the short run, because the capital (and hence size of production unit) is fixed,

the fixed costs remain constant. That is, fixed costs are those costs that remain

constant regardless of the quantity produced in the short run.

An example of a fixed cost would be rent on a building. The rent remains

constant regardless of how much business is done in it. Variable costs are those

cost that change as output increases.

Total costs are the sum of fixed costs and variable costs.

Total costs = Fixed costs + Variable costs

TC = FC + VC

To estimate a hospital costs, it is necessary to classify its components. Cost

elements can be broken down in several ways, as illustrated below. A good

classification scheme depends on the needs of the particular situation or

problem, but there are three essential elements:

• It must be relevant to the particular situation.

• The classes (categories) must not overlap.

• The classes chosen must cover all possibilities.

Economists define cost as the value of resources used to produce something,

including a specific health service or a set of services. Resources used for

hospitals can be described in many different ways. For example, a infection

control in hospitals might be described as using the following resources:

personnel, administration and management, anti infections, anti septic,

equipment, trainings and so on. These categories are well defined and their

meaning is clear. However, they do not constitute a very useful way of thinking

about the resources used in the hospital. The main problem is that the categories

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overlap; money from staff can be used to pay administration, and personnel are

likely to be involved disinfection operations. If we add up the value of these three

categories, they may well come to more than the total cost of the programme.

Obviously, several different classification schemes are involved here. These and

others need to be looked at separately, starting with the most basic resource

inputs. Examples of resource inputs include personnel, supplies and equipment.

Describing the resources used in terms of physical inputs, as we have done

above, is one way of dividing them up. However, it is not the only way.

Resources have other characteristics that are important. There are four other

characteristics that you might find helpful in describing and assessing the costs

of your programme. They are usually less important than the inputs scheme, and

are explained briefly below.

Classification by function/activity

The first of the secondary classifications involves the kind of activity or function

for which the resources are used. A maternal health department in the hospital

encompasses a wide range of activities, such as tetanus toxoid vaccinations for

pregnant women, prenatal care, supervision of deliveries, and immunization and

weighing of children. For each of these activities, groups of physical inputs are

required. For example, infant weighing requires personnel to do the weighing and

record the results, scales, tables, charts, building space and possibly vehicles.

The activities mentioned above for MCH are a limited set. They include only the

service provision activities. We should include in our list the essential activities

that support and complement them. Examples that you are likely to find in most

health programmes include: training, supervision, management, monitoring and

evaluation, logistics and transport.

There is one other thing to be careful about when estimating the costs of

multiple-activity programmes. You will have to allocate resources that are shared

among the activities so that each is charged only for its proper share. This is

especially important for personnel in some cases.

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Classification by level

Another way of dividing up resources is according to the level at which they are

used. For most hospitals there is an obvious hierarchy of operations. For

example medical level, administration and supportive level are some levels in the

hospitals.

Planning, costing and budgeting is interlinked to each other at any project

including health service delivery such as hospitals. There is dire need for

effective planning, costing and budgeting tools and methodologies when one is

running the hospitals. Significant amounts of funding have been made available

to help countries combat major health crises and yet the funding is often not

accessed because of weaknesses in the plans and budgets submitted.

Specific weaknesses often encountered include:

• The absence of quantified, time-bound measurable goals and objectives.

• The incorrect quantification of activities and resources

• The inaccurate calculation of resource costs.

An overall and critical weakness in many cases is the lack of clear linkages

between activities, strategies, objectives and goals. In such cases it is not clear

how much the completion of a set of activities will contribute to the achievement

of an objective, or how much the achievement of an objective will contribute to

the achievement of a goal.

The framework we are discussing here, it shows the principles of planning,

costing and budgeting in a practical and easy-to-follow way.

The framework provides a method for:

• Setting out quantified, time-bound measurable goals and objectives.

• Describing and quantifying the activities needed to achieve the goals and

objectives.

• Showing the resources required to carry out the activities.

• Calculating the costs of the resources,

• Showing the sources of funding and estimating financing gaps, and

• Producing a budget.

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The budget should accurately reflect the resources required to achieve the goals

and objectives. The process is best followed by planners, program managers and

financial analysts as a team, since this should help to improve their planning and

budgeting skills and their understanding of the relationship between the

programmatic and financial elements. The resulting plan should be more logical

and realistic and more likely to be funded and successfully implemented.

Layout of Methodology of Framework The Planning, Costing and Budgeting Framework are laid out in a logical, step-

by-step format, which:

• Encourages the user to move from each goal down through the planning

levels to the activities and inputs level, which accentuates the need to

quantify each level and to link each level to the preceding level.

• Encourages the identification and quantification of the critical inputs

needed for each activity and putting a cost to each of these inputs, thereby

arriving at an informed cost of each activity, strategy and objective.

• Shows the funding commitments for the plan and provides estimates of

the funding gap.

The Planning and budgeting document that you develop should contains all the

elements of the plan – the descriptions, targets, inputs, unit costs, total costs and

financing. We should take into account the following framework.

Goals summary

In order to cost and budget easily the Plan should have a Goals Summary which

is used to show an overview of the goals contained in the plan, together with the

target for each goal. Each goal is entered on a separate paragraph. Vertically the

form should explain each goal, each objective under a goal, each strategy under

an objective.

Resources (Inputs)

All goals, strategies and activities are in need of resources to perform the

activities and achieve the results. For examples the inputs maybe staff,

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equipment, supplies and so on. We should develop a table to show the total

numbers of outputs and inputs in quantities, to be easily converted in monetary

values. The total costs for each activity, strategy and objective are what we can

obtain if we follow the steps accordingly. The total for each strategy is the sum of

the figures for all the activities under the strategy.

Converting the costing to a budget If the amount of funding available is less than the total cost, then either the costs

or the activities have to be reduced for the costing to become a budget. The first

step is to review the activities, inputs and costs to see if there are cheaper ways

to carry them out without reducing the quality of the results. If that possibility has

been eliminated then the goals, objectives, strategies and activities may need to

be reduced and some of them may need to be eliminated completely. Removal of

activities, strategies or objectives should be carried out with care since they

generally form parts of packages required to achieve the goals and removing one

or more may result in the goals not being achieved. Reducing the number of

units per output is not recommended since it is likely to reduce quality, for

example, less training for a nurse. Reductions should, therefore, generally be

made by changing the target population, providing the target and numbers of

activities have been linked to the target population. After the plan is adjusted to

match the available funding it effectively becomes a budget.

Goals Description Unit of Cost Quantity Total Cost

Objective

Strategy

Activities

Inputs

Steps for creating a budget Step 1:

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You should have already been determined hospital revenue. Revenue can come

from patient payments, tax dollars, donations, and other sources. Be sure to

deduct a percentage of the patient bills that will remain uncollected, the charity

work expected by the hospital and the pro bono work it does. Probably the

hospital would have identified how much is going as average on welfare services.

Step 2:

How is your figure out expenses in the hospital? Start with the physical facility.

How much does it cost to keep up the building? What is the maintenance cost of

each department, engineering, air-conditioning, heat, water, other utilities? Know

what equipment costs, how much must be replaced per patient day, and if any

can be recycled. Include the non-medical cost of each bed in the hospital. You

should include advertising and marketing cost as well.

Step 3:

Certainly the manager should understand and know the cost of personnel, all

employees and ancillary staff, including consultants, outsourced contracts,

perhaps laundry or nurse staffing services. For all employees of the hospital,

from janitorial to hospitalists, figure the fringe benefits the hospital must pay for

each.

Step 4:

Add all medical equipment costs, ongoing and expected expansion or

replacement of new diagnostic equipment. In addition there are some

accessories for equipment as well and should be indentified and forecasted.

Step 5:

Based on the number of beds you may know the medical costs of each bed. How

many staff hours are spent on each bed, occupied or not. Use this figure as an

average to get a cost per patient year. Add to that the non medical costs per bed.

Include every possible cost that keeps that bed in the hospital. Don't forget

replacement costs per annum for any and all patient needs.

Step 6:

Nowadays the hospitals are not meeting the requirement of society. What about

expansion? Are you planning a new wing, or the renovation of an old one? Are

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you expanding into a new specialty that could bring in extra revenue? Estimate

that revenue when planning your budget.

Step 7:

You may need in your hospital waiting room for attendants and gift shop and

some canteen. Don't forget parking garages, lots, landscaping, rehabilitation

center, grounds keeping or window washing.

Step 8:

If you have the facility of insurance in the country then you should include all

insurance for the facility and personnel. It may be deducted from their monthly

salary after putting in the budget or some other mechanism could be used.

Step 9:

Contingency financial plan is helping in unforeseen situation. Write in an

emergency expense fund. Disasters occur and the hospital must be prepared for

them when they arrive. That is very necessary for disaster particularly flood and

earthquake prone areas.

Step 10:

Finally when all data is available and all activities and their inputs are listed, then

you can do the budget, use a spreadsheet. Enter all categories and the cost of

each. Add all taxable items and the percentage of each. You probably get

reduced rates on utilities, or least a break on the taxes on them. Enter all

formulas for those. It is possible your hospital system has one already available.

If the spreadsheet exists, use it or modify it for your own needs. If it does not,

make one, so making next year's budget is simply a matter of entering numbers

and letting the computer do the work.

When we are costing and making budget for hospitals it is very necessary to to

categorize the components into separate heads and then put all other sub

categories under them. For example in a hospital the following major heads

would be needed to run the departments.

• Capital

o Vehicles

o Equipments

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o Buildings

o Training which is not recurrent

• Recurrent

o Personnel

o Supplies

o Vehicle operation and maintenance

o Building Operation and Maintenance

o Training recurrent

o Other operating inputs

• Overhead

o Space

o Electricity

o Gas

o Other utilities

o Institution charging

Input Budget (currency...)

Expenditure (currency...)

Capital

Vehicles

Equipment

Buildings, space

Training, non-recurrent

Social mobilization, non-recurrent

Subtotal, capital

Recurrent

Personnel

Supplies

Vehicles, operation & maintenance

Buildings, operation & maintenance

Training, recurrent

Social mobilization, recurrent

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Other operating inputs

Subtotal, recurrent

Total

Hospital Budgeting A budget reflects the service priorities. It is the framework for spending money

and for assessing financial performance. A budget does the following:

• Shows how much it costs.

• Reflects policy choices.

• Sets in motion implementation.

• Reflects what monies will be collected (revenue) and what monies will be

spent (expenditure).

• Provides the framework.

The budget is made up of line items covering all the input needs to render a

service. These are called line items. For each of the cost centers the budget is

structured according to line items such as:

• Personnel - costs for all the staff requirements, such as salaries,

overtime, bonuses and employer contributions for medical schemes.

• Administration - administration costs such as telephones, postage, travel

and subsistence, study expenses and transport costs.

• Stores and Livestock - costs related to the purchase of consumable

items such as stationery, drugs, protective clothing and fuel.

• Equipment - costs to purchase or hire equipment and items such as

furniture and hospital equipment.

• Land and Buildings - costs to hire office space.

• Professional and Specialized Services - payments for professional type

of services such as medical services, laboratory services and consultancy

services.

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• Transfer Payments - payments transferred to people outside government

who render goods and services per special agreement as well as

subsidies.

These line items are further unpacked as minor items. Each minor item also has

an identity code that is used for purposes of budgeting and recording

transactions. A minor item in personnel, for example, is medical aid or housing

schemes. Minor items for operational costs such as stores will include cleaning

materials or drugs.

Preparing to draw up a Budget

Budgeting for inputs:

Budgeting for inputs follows some important steps. The inputs required flow from

unpacking the Service.

STEP 1: list the inputs

List the amount and type of inputs required and prepare the list according to all

the applicable line and minor items. Differentiate between current inputs that

require continuation and new inputs that are required.

STEP 2: cost of inputs

The costing process could follow different approaches, as demonstrated below.

Personnel

• Make sure that all the staff working in the cost centre appears on the

personnel list.

• Make sure that staff numbers and staff mix is appropriate for the service

activity.

• Identify key posts that need to be filled if there are any vacant.

• Make sure at the end that the added cost will fit your expenditure

framework.

• Determine all costs related to personnel

Administration

Determine the administration costs for the cost centre. These include costs for

telephone calls, hiring of telephones and post boxes and transport costs. A

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critical evaluation of previous expenditure history will assist. If a manager knows

that s/he has to attend monthly meetings requiring subsistence and travelling,

these can be calculated.

Equipments

Prepare a list of new equipment required. Number the list. This will ensure that

purchases during the financial year are made according to an approved list.

Estimate the cost of each piece of equipment.

Other items

Follow similar processes for each of the other items and minor items of your

financial system. It is important to remember that any capital spending such as

building a new clinic has financial implications for running the facility in the future.

STEP 3: Combine the costs.

Once every cost centre has compiled a budget, the budget team needs to

examine and verify the budget before incorporating all the cost centers’ budgets

into a single district budget.

The final hospital budget needs to reflect priorities and ensure that more

resources are distributed to entities in more need. Not all funds should be locked

in fixed costs such as staff, but there should be sufficient funds for operation.

Budgeting for Revenue:

Hospitals need to budget for the revenue they will collect. The revenue could

come from subsidies, from other sources such as donor and patient fees or from

own revenue, such as from the hospital revenue system.

The following measures would indicate a good budgeting process:

• Having a picture and understanding of financial performance for the

previous year and using this information for financial planning in the

forthcoming year.

• Clearly identifying input items, prioritizing them and listing them.

• Having available equipment inventories to support decisions on

maintenance and replacement.

• Having estimates for each applicable minor and line item.

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• Setting revenue targets.

• Completing an estimated expenditure and revenue report which is

accompanied by supporting documentation.

Cost consciousness It is a behavior of healthcare provider at service delivery points including

hospitals which is affected by their attitude and beliefs. Because most health care

expenditures are the results of doctors' decisions, whether doctors are cost-

conscious is an important matter. Many decisions regarding medical tests and

treatments are influenced by factors other than the expected benefit to the

patient, including the doctor's demographic characteristics, training, work context,

financial incentives and information about costs. Medical decisions are also

influenced by subjective considerations, including risk aversion, tolerance for

uncertainty, and concerns about cost and income. Cost-consciousness is

associated with lower self-reported estimates of resource use. However, whether

cost-consciousness leads to less costly medical care is not known. Therefore the

Predictors of cost-consciousness or the determinants of cost-consciousness

include socio-demographic characteristics (age, sex), time since graduation from

medical school, type of practice (public versus private), medical specialty,

workload characteristics (number of patients per week, time spent with a new

patient), stress from uncertainty, and work-related satisfaction.

Cost containment and improving profitability

As in other field, there has been a steady increase in the cost of medical care,

but the raise in costs has been very rapid during the last one decade. Every type

of hospital and healthcare institution is concerned over the rising cost of patient

care. There are three elements in a cost containment process.

• Cost awareness: Inculcate the awareness amongst all the hospital

personnel, and the process of available to contain them.

• Cost monitoring: provide a mechanism for identify report, and analyze

actual expenditure against budget and standards.

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• Cost management: establish a responsibility and accountability system for

attainment of plans

On analysis generally three causes for differences between budgeted and actual

costs emerge. They are as follows.

• Prices paid for inputs were different than budgeted prices

• Outputs level were lower than budgeted

• Actual quantities of inputs used were different from budgeted levels.

It is generally accepted that hospital costs could be contained with approaches

such as reduction the cost of input resources, improving efficiency and reduction

of volumes.

A checklist for cost containment

Any cost containment programme should be viewed as a continuing program and

one which should maintain the critical balance between quality and cost of

services.

Certain costs of hospitals are seen as being controlled more by the physicians

than administration. Case-mix, admissions, scope of service, intensity and length

of stay fall in this class. The bases for cost containment is by self-discipline

(humanism, efficiency and morale) and financial discipline ( capital control,

utilization control, and budget control ), by intensifying the organizational

awareness by everyone— from the class four employees to the chief of various

services— of the processes available to contain them. The following is a

checklist for cost containment to achieve improved efficiency with limited

resources.

• Reduction in staff by eliminating redundant positions

• Budget control. Instituting a department wise quarterly budget variance

report to review actual to budget comparisons and pinpoint problem areas.

• Computerization of patient accounting and administrative records

• Computerization of inventory management

• Streamlining paperwork

• Reducing dependence on outside services by creating them in-house

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• Participation in shared services with other neighborhood hospitals

• Developing in-house servicing and maintenance facility

• Control on stationery, forms, duplicating and printing

• Shutting down electricity when not in use

• Shutting down AC plant at night where possible

• Market surveys for less expensive product

• Plan ahead purchasing

• Eliminating wastage and pilferage

• Good security and vigilance

• Standardization

• Economy in supplies and expenditure

• Motivational trainings for staff

The list is not exhaustive and you can add some other strategies which is

working in your own setting.

Cost Effectiveness Cost-effectiveness analysis is the primary tool for comparing the cost of a health

intervention with the expected health gains. An intervention can be understood to

be any activity, using human, financial, and other inputs, that aims to improve

health. The health gain might be reducing the risk of a health problem, reducing

the severity or duration of an illness or disability, or preventing death. If the health

outcome is the same, say preventing death from measles either by immunizing a

child or by treating the disease, then analysts need only compare the costs of

different interventions that can achieve that outcome. The result is a cost-

effectiveness ratio, expressed as cost per outcome, which can be compared

across various types of services or various service locations that perform the

same function. The ratio is always discussed in relative terms, as there is no

“best” or absolute level of cost-effectiveness.

Basically cost effective analysis is the technique for choosing, form alternative

courses of actions, a preferred choice when objectives are not very clear in such

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areas as sales, costs or profits. In cost effective analysis, decision criteria may

include:

• Achieving a given objectives at least cost,

• Attaining it with reasonable resources, or

• Providing a trade-off cost for effectiveness

Therefore cost effective analysis is not an analysis for cost reduction— it is an

approach to specific set of goals.

The cost-effectiveness of an intervention can vary greatly depending on a

program’s size and scope. Typically, as program coverage expands and more

people are served, the cost per outcome drops. For example, if more children

can be immunized with the same fixed costs like nurses and clinics, then each

additional immunization will be cheaper until the service approaches full capacity.

Using child immunizations as an example, the incremental cost of adding mobile

vaccination teams might be lower than expanding fixed clinic services,

particularly if the unvaccinated children are dispersed and hard to reach. As

shown in the following figure, several alternatives might be available for

expanding the coverage of a current intervention (the status quo shown at point

“X”). If an alternative is more effective and less costly, decision makers should

usually opt in favor of adopting it, while they should abandon options that are

more costly and less effective. The trade-offs are less clear in the unmarked

quadrants, requiring decision makers to weigh whether the benefits that might be

gained merit a change in strategy.

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Program Budgeting In Afghanistan Program Budget Documents are meant for Line ministries to present their

budgets in a program format i.e. in terms of resources allocated to each program

and the expected results to be achieved from those resources. It enables

Ministers, Government, Parliament and the Public to measure the performance of

the program in terms of benefits it produces for the country and costs of those

benefits and whether a program is providing “value for money”. The Program

Budget Document consists of two major parts:

Narrative Justification of the Ministry’s programs and services it delivers are

represented in components (1) (2) and (3) in the illustration below, and;

Financial Justification of the Ministry’s programs and services are represented

in component (4) in the below illustration.

More

Effective

Less

Effective

Cost More

Alternative

is worse in

both

respects

Cost More

Alternative

is better in

both

respects

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There are four categories of information in the program budget structure:

Program structure: Ministry Programs Sub-Programs Activities

Objectives: Strategic Objectives Program Objectives Operational

Objectives

Performance Indicators: Outcomes Outputs

Expenditures: Summary Costs Expense Summary and Line Item Expenses

In the Program Budget Documents, these elements are structured in the

following way. Each succeeding classification presents a greater level of detail.

This means that each Ministry comprises the sum of its programs, where each of

these programs comprises the sum of its sub-programs, and each sub-program

comprises the sum of its activities. In the same way, strategic objectives are

broken down into more specific program objectives that collectively contribute to

achieving strategic objectives; further, each program objective contains several

operational objectives specifically designed to cumulatively help achieve the

program objective.

Implementing Program Budgeting

Many countries have implemented program or results-based budgeting in one

form or another. Most countries have found that it takes a number of years to

fully implement program budgeting processes and to get the full benefits of

decision making based on expected results.

Program budgeting requires a “mind-set” shift and not just among budget

planners and program managers. Line Ministries and Line ministries and work of

their managers will be more and more assessed and judged on the performance

of Government programs and services in meeting the needs of its citizens.

Particularly in the early stages of program budgeting, the quality of information

provided may be less than is desirable or necessary to assist Governments make

informed budget decisions. This generally reflects either a lack of understanding

or an inability to shift the mindset from the “old ways” of doing things – e.g.

budgeting for salaries and operational expenses, to budgeting for results.

Patience is therefore required as program budgeting will take a number of years

to bed down.

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Some of the more common problems that have been observed with the quality of

program documentation within other countries that have adopted program or

results based approaches include:

Strategic or operational objectives that are not clearly defined;

Programs that are defined based on inputs (eg purchases, transfers or specific

activities) rather than the strategic or operational objectives and expected results

(outputs and outcomes);

Operating and development budget failed to be integrated, and future recurrent

cost not taken into account when planning investment projects;

Resource allocation requests continue to be based on unrealistic and unfunded

legal mandates rather than resources available with the inevitable result of

unrealistic budget expectations never likely to be fulfilled;

Performance measures that are not specified, inappropriate, or submitted without

comparative or time-based benchmarks making assessment by the Government,

Parliament and the public difficult;

Policy priorities are not properly established - ie Line ministries and the Ministry

of Finance do not know which (sub-)programs within Line ministries are the most

important and how do they fit within the Government’s overall economic and

social development strategy, and policy objectives stated in the ANDS;

The link between policy priorities and to budget allocation decisions is unclear –

why do low priority, poor performing programs continue to be funded;

There is often a lack of accountability among Government and Line ministries’

officials for results of Government programs and services (who is or should be

responsible for poor performance or good performance);

There is a lack of fiscal transparency i.e. little public or parliamentary debate

about budget development – the priorities, strategies, and performance of

Government programs. For example, why is the program not achieving its

objectives; is this the most efficient way of delivering this program etc.

Afghanistan is not unique in experiencing “teething” problems. Many countries

implementing program or results-based budgeting have encountered similar

problems. Implementing program budgeting is a long-term commitment and it

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generally takes a number of years for the full benefits of program budgeting to be

realized.

While some of the problems may be the result of a lack of understanding and

even lack of commitment to embracing the new processes, encouraging greater

fiscal transparency through providing program information to parliament and the

public (through publication) can be the catalyst for expediting reform. Greater

scrutiny on the results of Government activity is one of the best means of holding

Government and program managers accountable for the resources they

consume.

Group work:

• Divide the participants into group of four to five individuals

• Request them to discuss the costs concepts at hospitals and classification

of cost among them

• Then distribute the following table to them to work on it and fill the blanks

with appropriate types of cost

• They will present their finding in plenary

• All class will have discussion over important points

• The facilitator will close the exercise with his own feedback

Major and minor heads Types behavior

Staff

Managers Fixed Overhead

Nurses

Doctors

Allied Health

Professionals

Technicians

Supplies

Drugs Variable Direct

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X-ray film

Transport

Utilities

Depreciations

Training and Educations

Property TAX

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Session 6: Hospital Monitoring and Evaluation

Usually the term “monitoring and evaluation” tends to get run together as if it is

only one thing, monitoring and evaluation are, in fact, two distinct sets of

organizational activities, related but not identical.

Monitoring is the systematic collection and analysis of information as a project

progresses. It is aimed at improving the efficiency and effectiveness of a project

or organization. It is based on targets set and activities planned during the

planning phases of work. It helps to keep the work on track, and can let

management know when things are going wrong. If done properly, it is an

invaluable tool for good management, and it provides a useful base for

evaluation. It enables you to determine whether the resources you have available

are sufficient and are being well used, whether the capacity you have is sufficient

and appropriate, and whether you are doing what you planned to do.

Evaluation is the comparison of actual project impacts against the agreed

strategic plans. It looks at what you set out to do, at what you have

accomplished, and how you accomplished it.

What monitoring and evaluation have in common is that they are geared towards

learning from what you are doing and how you are doing it, by focusing on

efficiency, effectiveness and impact. Efficiency tells you that the input into the

work is appropriate in terms of the output. This could be input in terms of money,

time, staff, equipment and so on. When you run a project and are concerned

about its replicability or about going to scale then it is very important to get the

efficiency element right. Effectiveness is a measure of the extent to which a

development program or project achieves the specific objectives it set. If, for

example, we set out to improve the qualifications of all the high school teachers

in a particular area, did we succeed? Impact tells you whether or not what you

did made a difference to the problem situation you were trying to address. In

other words, was your strategy useful?

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Justifications for Monitoring Hospitals

Monitoring and assessment enable you to check the “bottom line” of

development work: Not “are we making a profit?” but “are we making a

difference?” Through monitoring and evaluation, you can review progress,

identify problems in planning and/or implementation and make adjustments so

that you are more likely to “make a difference”. It is important to recognize that

assessment, monitoring and evaluation are not magic wands that can be waved

to make problems disappear, or to cure them or to miraculously make changes

without a lot of hard work being put in by the project or organization. In

themselves, they are not a solution, but they are valuable tools. Monitoring and

evaluation can:

• Help you identify problems and their causes;

• Suggest possible solutions to problems;

• Raise questions about assumptions and strategy;

• Push you to reflect on where you are going and how you are getting there;

• Provide you with information and insight;

• Encourage you to act on the information and insight;

• Increase the likelihood that you will make a positive development

difference

Monitoring Framework In order to perform monitoring effectively and efficiently we should follow the

following steps.

• Establishing indicators) of efficiency, effectiveness and

• impact;

• Setting up systems to collect information relating to these indicators;

• Collecting and recording the information;

• Analyzing the information;

• Using the information to inform day-to-day management.

• Monitoring is an internal function in any project or organization.

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Evaluation Framework In order to perform monitoring effectively and efficiently we should follow the

following steps.

• Looking at what the project or organization intended to achieve – what

difference did it want to make? What impact did it want to make?

• Assessing its progress towards what it wanted to achieve, its impact

targets.

• Looking at the strategy of the project or organization. Did it have a

strategy? Was it effective in following its strategy? Did the strategy work?

If not, why not?

• Looking at how it worked. Was there an efficient use of resources? What

were the opportunity costs (see Glossary of Terms) of the way it chose to

work? How sustainable is the way in which the project or organization

works? What are the implications for the various stakeholders in the way

the organization works?

Planning for Monitoring and Evaluation Monitoring and evaluation should be part of your planning process. It is very

difficult to go back and set up monitoring and evaluation systems once things

have begun to happen. You need to begin gathering information about

performance and in relation to targets from the word go.

When you do your planning process, you will set indicators. These indicators

provide the framework for your monitoring and evaluation system. They tell you

what you want to know and the kinds of information it will be useful to collect. In

this section we look at:

• What do we want to know? This includes looking at indicators for both

internal issues and external issues

• Different kinds of information.

• How will we get information?

• Who should be involved?

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We can measure the status and progress of all our activities through

development of indicators and collection of information about them.

Hospital as a System for Monitoring A system may be defined as an alignment of interdependent parts and processes

that, in turn, deliver an outcome. Too frequently, however, the focus is on only a

specific aspect of healthcare or service being provided, overlooking the

interrelationship between the services and departments that make up a hospital

system. Nothing functions in isolation, and a systems view provides a way to look

at a system as a whole, thus allowing professionals to see how the care or

service provided in one area relates to another. A systems view includes

consideration of the resources—called “inputs”— needed to provide healthcare.

Equally important are the activities, or processes, involved in providing care and

services. These inputs and processes result in an outcome. Table 1 presents a

systems view of some hospital services.

Hospitals are complex systems. Many services, such as rendering emergency

care and providing meals, not only must be kept in operation over two or more

shifts, but also must be implemented across departments. A systems view, for

example, can reveal the process involved in transporting a patient treated in the

emergency department to another part of the hospital for surgery. What is the

process for letting the operating staff know the kind of care that was provided in

the emergency department and the expected outcome of that care? When one

part of the system fails, how does the failure affect the other parts? For example,

if a gurney is not available, it will be difficult to quickly deliver the patient to the

operating room. If there is not a process to inform other caregivers about the

patient’s medical history, the surgical staff may not receive the information they

need to select the most appropriate kind of anesthesia and do so as quickly as

possible. Please review the following table for more understanding of hospital as

a system.

Table: System views of Hospital Services

Aspects of care Inputs Process Outcomes

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management Lab tests

Management of

Diarrhea

Hospital staff

Medications

Rehydration

Lab tests

protocols

Use of protocols

Medication

administrations

Rehydration

administration

Testing

procedures

Health education

Diarrhea is

resolved

Dehydration is

resolved

Patient and family

can describe

preventive

measures

Medication

availability

Medications

Pharmacist

Nurse

Medication

storage cart

Stock

management

Medication

distribution

Medications are

available in the

pharmacy

Medications are

delivered to the

unit/ department in

a timely manner

Normal delivery/

discharge

planning

New mothers

Physicians

Nurses

Family

Midwives

Teaching

materials

Communication

between providers

Education of

patients and

family

Midwife had

information

regarding the

mothers condition

and follow-up care

They

patient/family has

home instructions

Infection control

(post operative

cesarean

section)

All healthcare

workers

Cleaning staff

Soap

Sterile equipment

Sterilizers

Hand washing

Sterilization of

equipment

Wound care

Cleaning

procedures

Patients don’t

acquire infections

while hospitalized

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Materials for

sterile dressing

changes

We should understand that Inputs are the resources needed to provide a

service, while processes are the activities that use these inputs to produce out

puts and outcomes. Similarly the outcomes are the results of the processes. If

we are thinking of immediate results in that case we are using outputs. Or if we

are using change in social condition and health status then we are using the

impact as a proxy to show the results.

Quality Monitoring Framework

As it was discussed above the hospital is like a system in which the input is used

by performing some activities and outcome is produces as a result of these

expenses and activities. Therefore hospital processes is easily understood for

reviewing the following chart.

Hospital Process

Diagnostic

exams, tests,

procedures

Medical

treatment

Follow-up /

discharge plans

Counseling

and patient

education

Complementar

y services Patient

outcomes

Admissions Patients

enter

hospital

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The framework presented above is based on the systems model. As the diagram

shows, a patient who enters the hospital becomes involved in a variety of

processes that will lead to an outcome. Most patients will experience all or most

of these processes during an inpatient stay. Some of the processes can be

defined as “supportive” inasmuch as they are not direct care. For example, the

admission process and medical record systems are needed to support patient

care and treatment. During the admission process, the patient or family provides

biographical information, and the staff creates a medical record (the information

system). The physician, laboratory, and radiology staff carry out various

diagnostic exams, tests, and procedures. Nursing care is an integral process to

the hospital system as are other complementary services such as nutrition, social

services, and physical therapy. Counseling and patient education take place all

along the continuum of care as physicians, nurses, and others explain what can

be expected during the tests, procedures, and treatment processes as well as

the diagnosis and follow-up/ discharge plan. Following chart demonstrates the

systems view and shows how the various hospital processes interrelate.

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Chart: Hospital System Model

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What is Quality Monitoring?

Most hospitals have a health information system to collect data. The data often

include the number and types of diseases treated, surgeries performed, and

patients seen per day. Typically, the data are tabulated in the Medical Records

Department, which submits a report to the hospital director. However, the

information may not be sufficient or may be presented in a way that would not

help healthcare providers draw conclusions on the quality of care and make

sound decisions to improve it. A monitoring system should enable healthcare

providers to set priorities, establish quality indicators, and assess the hospital’s

systems performance to ensure that desired outcomes are achieved.

The foundation of a monitoring system is standards. Standards are the guidepost

for achieving quality in care. The data collected through monitoring provide a way

to compare performance with standards, both at a specific point in time and over

a period of time, and also with the performance of other hospitals. The results

provide a way to determine causes for variance and identify areas for

improvement.

Criteria

An effective monitoring system meets the following criteria:

• Data are collected regularly and over a significant period of time so that

the hospital can monitor the trends in the indicators

• Data collection is a routine activity integrated into daily tasks

• Data are used to identify the presence and causes of system problems

that can result in poor performance

• Data are used to guide management decisions

Standards

A standard is an expectation of quality that is explicit (written) or implicit

(understood). “Implicit” healthcare standards derive from the expertise of

professionals who work in a specific environment. For example, professionals

who work on the pediatric ward may know the treatment that a dehydrated child

needs, but differ on ideas about the most appropriate way to provide the

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treatment (e.g., dosage, duration, and frequency). Converting implicit standards

to explicit standards provides uniformity in the way to provide quality care and

allows a baseline measure for monitoring quality. “Explicit” healthcare standards

appear in a variety of forms, such as specifications, procedures, or protocols.

These standards may be developed by a Ministry of Public Health, professional

organizations, international organizations (e.g., the World Health Organization:

standards for the treatment of malaria), accrediting organizations (e.g., Joint

Commission Resources), or by a hospital itself. Applied standards should be

based on the most up-to-date research and should be:

• Realistic: The standard can be followed or achieved with existing

resources

• Reliable: Following the standards for a specific intervention results in the

same outcome (all factors being equal)

• Valid: The standard is based on scientific evidence or other acceptable

experience

• Clear: The standard is understood in the same way by everyone

concerned and is not subject to distortion or misinterpretation

• Measurable: The standard is amenable to assessment and quantification

Indicators are measurable or tangible signs that something has been done or that

something has been achieved. In some studies, for example, an increased

number of year’s people live in a community have been used as an indicator that

the standard of living in that community has improved. Higher bed occupancy

rate shows more consultations and clients in the hospital. Common indicators for

something like overall health in a community are the infant/child/maternal

mortality rate, the birth rate, and nutritional status and birth weights.

Indicators are an essential part of a monitoring and evaluation system because

they are what you measure and/or monitor. Through the indicators you can ask

and answer questions such as: Who? How many? How often? How much?

But you need to decide early on what your indicators are going to be so that you

can begin collecting the information immediately.

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To measure indicators there is need for data and/or Information. Information

used in monitoring and evaluation can be classified as: quantitative; or

qualitative. Quantitative measurement tells you “how much or how many”. How

many people consulted the hospital, how many people took lab examinations,

how much a publication cost, how many people were infected with HIV? and so

on. Quantitative measurement can be expressed in absolute numbers,

percentage, rates and ratios. Qualitative measurement tells you how people feel

about a situation or about how things are done or how people behave. So, for

example, although you might discover that 50% of the medical doctors at hospital

are unhappy about the assessment criteria used, this is still qualitative

information, not quantitative information. You get qualitative information by

asking, observing, interpreting.

The monitoring and evaluation process requires a combination of quantitative

and qualitative information in order to be comprehensive. For example, we need

to know what the hospital enrolment figures for females are, as well as why

women do or do not come to hospitals. For data collection there are many

methods and tools. Some are mentioned here.

• Case studies

• Recorded observation

• Observations

• Checklists

• Forms

• Structured questionnaires

• One-on-one interviews

• Focus groups

• Sample surveys

• Systematic review of relevant official statistics.

Hospital Monitoring Indicators An indicator of quality is a measure that is used to determine the degree of

adherence to a standard. Indicators translate a qualitative statement (as

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expressed by a standard) into a quantitative one. For example, “the proportion of

healthcare providers who greet their patients by name” measures the extent to

which the standard for a quality reception is being met. Indicators can be

expressed as a number (a count), an average, or a ratio (a proportion or rate). An

indicator presented as a ratio consists of a numerator (the number of times an

event occurs) and a denominator (the total number of times the event should

have occurred). An example of a ratio is the proportion of post-surgical patients

whose temperature was taken by the healthcare worker according to protocol.

It is useful to select indicators that measure inputs, processes, and outcomes.

The basis for selecting an indicator is its importance or potential impact on the

quality of care. Be aware that outcome indicators measure the level of

achievement of the intervention and, therefore, can serve as indirect measures of

the quality of care and services. However, a good outcome does not necessarily

mean that the process was managed correctly; neither does a poor outcome

mean that the process was managed incorrectly. Therefore, the measurement of

input, process, and outcome indicators is warranted.

Some quality experts believe that organizations should strive for zero defects.

They suggest that setting a level of expected quality limits the highest level of

quality that might otherwise be achieved. The belief is that once the quality

level—e.g., targeted infection control rates—is attained; the staff will be satisfied

with this level rather than continuing to strive to decrease infection control rates

to zero infections. Keeping this view in mind, establishing indicators remains an

established means of setting the bar at a reasonable level of achievement and

the bar can (and should be) raised/lowered as the targets are achieved. As an

example we see some examples below:

Length of Stay (LS): It is the mean number of days that patients remain at

the hospital whereas HD (Hospital Days) is the sum of inpatient days in a specific

period of time. D (Discharge) is the number of discharged patients in the same

period of time.

Occupancy Rate (OR): It is a relative number that expresses the percentage

of beds occupied in relation to the total number of available beds during a

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specific period of time whereas BD (Bed days) is the sum of daily available beds

multiply by the number of days in the same period of time.

Proportion of all Births in the Hospital: The proportion of births that is

delivered in Hospital is calculated as: Number of births delivered in Hospital

facilities in a specified time period divided by estimated number of live births in a

specified time period in the geographical area served by the Hospital. Sources

for numerator is hospital or facility records while the source of data for

denominator is demographic surveys for crude birth rates; census for total

populations.

The proportion of all births that take place in a Hospital serves as a crude

indicator of the utilization of hospital. This indicator is useful because the data are

readily available. Furthermore, it is useful in conjunction with other indicators

such as ‘met need’ to gauge internal consistency. For example, if this indicator

does not change, but ‘met need’ increased substantially, a deeper look at the

facility and the community it serves would be warranted.

The ultimate goal is to increase utilization of Hospital among women with

obstetric complications to 100 per cent. This indicator is not intended to promote

the delivery of all births in facilities. Many countries could not meet this

theoretical demand. Thus, women with normal deliveries may be better off

delivering at home or at facilities with fewer services.

Cesarean Sections as a Proportion of all Births: the proportion of

pregnant women who have a cesarean section in a specific geographical area

and time period. This is calculated as: Number of cesarean sections performed in

a specified time period and area divided by the number of live births in the same

specified time period and area. Data requirements are numerator: the number of

cesarean sections performed in a defined population during a specified time

period. Denominator: the total number of live births in the same area and time

period. Sources of data for numerator would be facility records, surgery log

books and for denominator: demographic surveys for crude birth rates; census

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for total populations. Household demographic surveys often produce national and

disaggregated estimates of the C-section rate.

This indicator demonstrates the extent to which a particular life-saving obstetric

service is being performed in emergency obstetric unit of hospital. It reflects the

availability, accessibility and utilization of services as well as the functioning of

the health service system. The appropriate use of a cesarean section leads to a

decrease in maternal mortality and morbidity, as well as decreasing prenatal

morbidity and mortality. While cesarean sections may be performed solely for the

health of the fetus or newborn, in developing countries the vast majority will be

done for maternal indications.

Case Fatality Rate (CFR): it is usually due to all complications. That is

good to take the example of obstetric complications which is defined as the

proportion of women with major obstetric complications who die in a facility. This

is calculated as: Number of deaths from specified obstetric complications in a

facility during a specified time period divided by number of women with specified

obstetric complications attended in the facility during the same time period.

Where deaths from the following complications are included:

• hemorrhage: ante partum, intra-partum or postpartum;

• prolonged/obstructed labor;

• postpartum sepsis;

• complications of abortion;

• pre-eclampsia / eclampsia;

• ectopic pregnancy; and

• Ruptured uterus.

All cases in the numerator also appear in the denominator and all complications

specified in the list above are included in both the numerator and denominator.

By definition, a CFR is cause-specific, but in this case a single facility may not

see but a small number of women with any one complication. Data requirements

are numerator: a count of the deaths from the specified complications in the

facility during the specified time period. Denominator: a count of women

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diagnosed with one or more of these complications attended at the emergency

obstetric unit of hospital during the specified time period. All data for numerator

and denominator would be received from facility records.

This indicator is used to measure facility performance, in particular quality and

promptness of care. It is most useful when comparisons are made over time for

the same facility. It is not useful for comparisons across facilities of different

types because of the different services they offer. Women with more severe

complications are more likely to present at referral hospitals while women with

less severe complications may access district hospitals or health centers. Even

comparisons among ‘same level’ or ‘like’ facilities may be difficult to interpret as

the population profile can vary dramatically due to socio-cultural factors or other

circumstances outside the control of the health sector, like transportation and

road systems.

Incidence rate (IR) (6 EPI target diseases, diarrhea, ARI): The

number of new cases of EPI targeted diseases in a specified time that occurs in

a population at risk of the disease in the same time period.

Rate of treatment or psychosocial intervention for symptoms of mental illness

It is the proportion of all people with symptoms of mental illness who requested

treatment. Numerator: Number of people requesting treatment or psychosocial

intervention for symptoms of mental illness during the past two weeks

Dominator: Number of people with symptoms of mental illness during the past

two weeks

Mortality rate under age 5 (U5MR): The ratio between the number of

deaths in children under 5 in a given year and the number of live births in that

year.

Numerator: Number of children who die before reaching 5 years of age

Denominator: Total number of live births in the given 1-year period

Post Operative Infection proportion: it is the proportion of infection

which is seen in patients after being operated. The numerator would be all those

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who have some sorts of infection related to their cases divided by the number of

cases that have been operated in a hospital in specific period of time.

External and Internal Monitoring “External monitoring” is monitoring conducted by someone from outside the

hospital. The monitor may be a representative of the Ministry of Health, a

neighborhood health committee, or an agency contracted to measure compliance

with specific standards; these standards are often established by the external

entity doing the measuring. Accreditation of the hospital, as conducted by Joint

Commission International Accreditation, is an example of an external monitoring

system. A discussion of external monitoring is not within the scope of this

module. “Internal monitoring” is a system set up by the hospital staffs who adopts

standards written by another credible group (e.g., the World Health Organization)

or by the hospital itself; the hospital can conduct a self-assessment to measure

the degree of compliance. An approach to developing an internal monitoring

system follows. Ongoing monitoring involves regularly measuring quality

indicators. Some indicators may be important enough (e.g., maternal mortality or

infection rates) to measure frequently and regularly (e.g., monthly): This concept

is often referred to as “trending.” However, because it is not feasible to measure

the hundreds of standards that are in existence, spot checks may be conducted

to measure specific standards during a specific period of time. A spot check may

be done on a one-time basis, or, as an example, the quality team may decide to

monitor the effectiveness of a new patient education program for six months.

Hospital Monitoring of Adverse Drug Reactions Adverse reaction to drugs poses as serious health hazards and has been

observed as long as the drugs have been used. There are some adverse

reactions of drugs which are related to ignorance of patients themselves and

health personnel in hospital or out of hospital. According to a survey which was

conducted in Singapore over dosage, intolerance, drug side effects,

hypersensitivity, idiosyncrasy was seen among patients admitted to hospitals.

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Due to low awareness concerning adverse reactions to drugs few attempts have

been made to measure the incidence of such reactions or their relationship to the

use of individual drugs. Since drug is any substance given as therapy or for

investigational purposes, thus, adverse Reaction to a Drug is any adverse

response to medication undesired or unintended by the physician.

Severity of Adverse Reactions is classified in three grades

• Severe: fatal or life threatening.

• Moderate: required treatment, admission to hospital, or prolonged the stay

in hospital by at least one day.

• Mild: incidental, required no treatment, and did not necessarily call for

withdrawal of any treatment.

A classification of the type of drug reaction which takes account of the dose and

the possible mechanism of the reaction was used.

• Overdosage. Excess intake of drug causing excess predictable

pharmacological action

• Excessive effect. Therapeutic dose but excess pharmacological action;

this might be: (a) a toxic extension of the action of the drug, or (b)

conditioned intolerance

• Side-effect. Unwanted predictable pharmacological action unrelated to the

therapeutic effect and not due to Overdosage.

• Hypersensitivity. Allergic sensitization to a drug by previous exposure to

the same drug or a chemically related substance, mediated by antigen-

antibody reactions

• Idiosyncrasy. Unrelated to known pharmacological actions of the drug and

not due to immunological mechanism; possibly genetically determined.

Taking into consider the reaction should keep close eye on drug reactions and

monitor it by some surveys and documental and prescriptions reviews from time

to time and develop some techniques for its mitigation.

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Monitoring of Absenteeism in Hospitals Absenteeism is defined as staff taking time off that has not been scheduled or

staff taking more leave than is necessary or reasonable. Many health service

managers are familiar with the problem of absenteeism in district hospitals. It

affects the running of the hospital and can seriously compromise the quality of

care which patients receive. Clearly there are many legitimate reasons for taking

sick or other types of leave. It is often debatable how much leave is “reasonable”.

It often depends on the pattern and circumstances, rather than the actual total

amount of leave that an individual takes. Managers have a responsibility to

balance the rights and needs of individual staff members, with the needs of the

hospital. High levels of absenteeism, both on the part of individuals or in the

whole hospital, are often symptomatic of underlying problems. Addressing these

issues can result in lower absenteeism levels that benefits staff, managers and

patients.

Why absenteeism

There are many causes why people are absent from work. They range from

unhappiness with management, to being bored with the work to a child-minder

being ill. The causes can be broadly divided into two groups – management

issues and staff issues.

Management issues:

• lack of coherent leadership in some hospitals

• lack of systems and processes in the workplace

• staff problems are not being dealt with quickly and appropriately

• low staff morale

• managers are not trained to manage staff and problems such as

absenteeism

Staff issues:

• unpleasant work environment – the work may be boring or staff may not

get on with other staff members

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• personal problems such as problems at home, substance abuse or

depression

• practical issues such as problems with childcare or caring for other family

members

• economic pressures – some staff may be holding down additional jobs to

supplement their income

Good hospital and human resource management practices will not necessarily

eliminate the problem, but can be expected to reduce the severity of the problem

How to deal with absenteeism

Step One: Establish the size and pattern of the problem. It means establish the

absenteeism patterns at your hospital over a period of time (e.g. three months)

by monitoring all the different kinds of leave taken by ALL staff.

Step Two: Make sure that everyone is aware of their rights and responsibilities.

Make sure that all staff members understand their rights and responsibilities

regarding leave and the consequences of breaking the regulations. It may be

useful to hold group workshops with ALL staff in the hospital on issues. Staff

should be aware what leave is legally allowed and what is not. They should know

the procedures required to have authorized leave. Each hospital should have

grievance and disciplinary policies and procedures that have been discussed

with staff and union representatives. Make sure that the hospital policies about

leave and employment, which are pertinent to absenteeism, are put into files

which are accessible to all staff.

Step Three: Address the problem as a whole. Improvements in the overall

management of the hospital with staff being more involved in decision-making

and feeling that their concerns are addressed is probably the best way to reduce

high levels of absenteeism. Agree on performance, provide sufficient support and

reward achievements. The hospital managers believe that this is due to the fact

that they have put a lot of effort into ensuring that issues affecting staff are

discussed with them and efforts made to accommodate their circumstances.

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Step Four: Dealing with individuals. In cases where one or more individuals

contribute substantially to the absenteeism rates, the approach needed may be

different.

• If it is a first offence, the staff member has an absence record no worse

than the average for the hospital, there are no other previous offences and

the explanation for unscheduled leave is feasible, then counseling should

be used.

• Counsel the staff member individually to ascertain their side of the story

regarding their leave patterns.

• Deal with personal/substance abuse problems in an individual capacity.

• Seek a second opinion from a hospital doctor regarding perceived abuse

of sick leave i.e. unreasonably long sick leave or frequent sick leave.

Some staff may be referred to social support or other agencies where they

can find help for their problems.

• Document the counseling and support offered

• Follow up.

• If it is not the first offence and the absence record is unsatisfactory or

previous warnings are on file, then the disciplinary process should be

used.

Step Five: Ongoing monitoring. The continuation of monthly monitoring will assist

managers to know if the absenteeism is being adequately addressed. Have

report-back sessions with your staff to applaud their efforts and carry on being

firm on the legal side of absenteeism, while remaining fair to the personal

problems which staff may have. Make efforts to have weekly sessions where the

unit meets as a team to share information, experiences and concerns.

Remember that in fulfilling the vision of the hospital, the rights of staff, the rights

of the hospital as employer and the patients’ rights to a quality service have to be

ensured.

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Session 7: SWOT Analysis of Hospital In general SWOT (strengths, weaknesses, opportunities, and threats) analysis is

a management tool for assessment an organization including hospitals and its

environment. It is the first stage of planning and helps the organization to focus

on key issues. Below is the S.W.O.T. analysis on a hospital which helps you very

much to think strategically in this regard.

Strengths:

Despite of having primary care services, our hospital is well known for its

provision of quality medical care. During the year the hospital has strived to

attract more members of staff especially nursing staff. The nursing staffing levels

have indeed been better this year than in recent years. The coming of young

Medical Doctors will further strengthen the clinical department of the hospital. We

are equipped with high technology services.

Weaknesses:

We are faced, as like other hospitals, a high nurse turnover of staff and it has

continued to affect nursing services at the institution. Due to inadequate funds

some planned activities especially in the Primary Health Care department have

not been undertaken. Although we have continued to receive support from our

partners for which we are very thankful, we are conscious that we have not made

any real progress in becoming fewer donors dependent. The hospital has been

discussing possibilities of embarking on income generating activities; however,

the poor prevailing economic situation makes such ventures risky. We are

working in a competitive environment.

Opportunities:

Our consumers are growing and the hospital continues to excel in its various

endeavors because of committed staff and a supportive working environment.

These factors offer opportunities for expansion of hospital services especially in

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Primary Health Care department. The hospital with financial, material and human

resources available would go a long way in strengthening community-based

interventions. The government is paying due attention to quality tertiary services.

Threats:

Hospital consultation is declining as compare to last quarter. Financial position of

the hospital has not been well during the year. Additionally while staff are

committed to working in the hospital, the rising costs of food and school fees

combined with more lucrative offers from external non-profit organizations for

highly skilled staff, often requires the hospital to pay top-ups to retain staff. The

hospital therefore struggles to meet the salary requirements. There is a real need

for the hospital to explore other means of sustaining the running of their

institutions through income generating activities and other donors especially for

community based activities.

Group work:

Process:

• Distribute participants into groups of 4- 6

• Invite them to assess their institution using the SWOT analysis

• The should report their finings in the plenary

• Collect comments of whole participant

• Close preventions by constructive feedback

Following table maybe used for group work.

SWOT analysis matrix to evaluate the institutions

Strengths

• Quality lab services

• Committed employees

• Advanced technology

Weaknesses

• Infrastructure

• Workforce force

• Low resources

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• Availability of nursing staff

• Availability of job descriptions

• Compliance code of ethics

• In-service education

• Good discipline

• Communications within

departments at the hospital

• Few specialists and registered

nurses

• No competition among staff

themselves

• Lack of work innovations and

creativity

• Understaffed departments

• High work load

Opportunities

• Vaccinations

• Surveillance

• Strategic plans

• Good relationship with

government

• Easy of the public transportation

to the hospitals

• Ability to expand the hospital

departments

• Opportunity to create training

programs

Threats

• Re-emerging disease

• Inflation

• Security

• Low staff income

• Lack of updated services

• Recruitment of staff through

MOH

• Lack of external fund resources

• Nursing shortage

• Lack of information technology

system

• Lack of internet resources

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Session 8: Medical Audit and Quality Assurance

Definitions The volume of literature on medical audit and the broader field of quality

assurance are expanding rapidly. Medical audit is now a requirement for all

medical practitioners; therefore, to perform it, they need to know something about

it.

Since audit was introduced in 1989 there have been many different definitions of

clinical audit. “Clinical audit is a quality improvement process that seeks to

improve patient care and outcomes through systematic review of care against

explicit criteria and the review of change. Aspects of the structure, process and

outcome of care are selected and systematically evaluated against explicit

criteria. Where indicated changes are implemented at an individual, team, or

service level and further monitoring is used to confirm improvement in healthcare

delivery”. Although this is an excellent technical definition of clinical audit it is also

68 words long and unlikely to inspire healthcare professionals to take part in

clinical audit work. Ironically, the 1989 White Paper Working for Patients provided

a far shorter and simpler definition of audit: “audit involves improving the quality

of patient care by looking at current practice and modifying it where necessary”.

Clinical audit is essentially all about checking whether best practice is being

followed and making improvements if there are shortfalls in the delivery of care.

A good clinical audit will identify (or confirm) problems and lead to effective

changes that result in improved patient care.

Basically clinical audit is a quality improvement process that involves reviewing

the delivery of healthcare to ensure that best practice is being carried out. In

recent times there has been a move away from “optional” clinical audit activity to

a more “obligatory” approach. It means that after development of medical audit

guidelines for all medical institutions including hospitals, they should be closely

monitored by MoPH to make sure that clinical audit work is being carried out.

The key component of clinical audit is that performance is reviewed or audited to

ensure that what should be done is being done, and if not it provides a

framework to enable improvements to be made.

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History of medical audit One of first ever clinical audits was undertaken by Florence Nightingale during

the Crimean of 1853-1855. On arrival at the medical barracks hospitals in 1854,

Florence was appalled by the unsanitary conditions and high mortality rates

among injured or ill soldiers. She and her team of 38 nurses applied strict

sanitary routines and standards of hygiene to the hospital and equipment.

Following this change the mortality rates fell from 40% to 2. Her methodical

approach, as well as the emphasis on uniformity and comparability of the results

of health care, is recognized as one of the earliest programs of outcomes

management. Another famous figure who advocated clinical audit was Ernest

Codman (1869-1940). Codman became known as the first true medical auditor

following his work in 1912 on monitoring surgical outcomes. Codman's "end

result idea" was to follow every patient's case history after surgery to identify

individual his / her errors on specific patients. Whilst Codman's 'clinical'

approach is in contrast with Nightingale's more ' epidemiological ' audits, these

two methods serve to highlight the different methodologies that can be used in

the process of improvement to patient outcome.

In 1989, the White Paper, Working for patients, saw the first move in the UK to

standardize clinical audit as part of professional healthcare. The paper defined

medical audit (as it was called then) as "the systematic critical analysis of the

quality of medical care including the procedures used for diagnosis and

treatment, the use of resources and the resulting outcome and quality of life for

the patient." Medical audit later evolved into clinical audit and a revised definition

was announced by the NHS Executive: "Clinical audit is the systematic analysis

of the quality of healthcare, including the procedures used for diagnosis,

treatment and care, the use of resources and the resulting outcome and quality

of life for the patient." The National Institute for Health and Clinical Practice

(NICE) published the paper Principles for Best Practice in Clinical Audit, which

defines clinical audit as "a quality improvement process that seeks to improve

patient care and outcomes through systematic review of care against explicit

criteria and the implementation of change. Aspects of the structure, processes,

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and outcomes of care are selected and systematically evaluated against explicit

criteria. Where indicated, changes are implemented at an individual, team, or

service level and further monitoring is used to confirm improvement in healthcare

delivery. "

Types of audit

Standards-based audit - A cycle which involves defining standards,

collecting data to measure current practice against those standards, and

implementing any changes deemed necessary.

Adverse occurrence screening and critical incident monitoring -

This is often used to peer review cases which have caused concern or from

which there was an unexpected outcome. The multidisciplinary team discusses

individual anonymous cases to reflect upon the way the team functioned and to

learn for the future. In the primary care setting, this is described as a 'significant

event audit'.

Peers review - An assessment of the quality of care provided by a clinical

team with a view to improving clinical care. Individual cases are discussed by

peers to determine, with the benefit of hindsight, whether the best care was

given. This is similar to the method described above, but might include

'interesting' or 'unusual' cases rather than problematic ones. Unfortunately,

recommendations made from these reviews are often not pursued as there is no

systematic method to follow.

Patient surveys and focus groups - These are methods used to obtain

users' views about the quality of care they have received. Surveys carried out for

their own sake are often meaningless, but when they are undertaken to collect

data they can be extremely productive.

Protocol for medical audit Health care is one of the most important issues facing our nation, yet the

standard of care received in private practices, hospitals and long-term care

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facilities can often be substandard. This is why medical audits are so important.

They play a pivotal role in meeting and exceeding health care standards by

evaluating the current level of care and setting goals that will help to improve it.

Step 1: Determine the reason for the audit. The determination process involves

gathering input from workers, patients and patients' families. Before

concentrating on a specific area that needs improvement, you must first know

what areas your hospital is weak in. Once you have this information, you can

concentrate on the most important areas of care that require improvement.

Step 2: Collect available data and evidence to support the problems mentioned.

Go through health records, nurses' notes and care plans for the patients. This will

give you a better idea of where you are currently at and help you better focus on

specific problems needing immediate attention.

Step 3: Focus on specific problem. If you are writing an audit for a private

practice, one problem might be the amount of time a patient has to wait to be

seen. If you are working for a hospital, you might focus on the amount of time it

takes to answer a call light (the light above the door indicating a patient needs

assistance). If the standards set for this is within 2 minutes and patients say it

takes the staff 5 minutes to reach them, then you need to concentrate on ways

for the staff to get to the patient quicker. If you work in a nursing home and find

that incontinent patients are not being changed promptly, causing rashes or skin

breakdown, you will focus on what can be done to avoid these unnecessary

health problems.

Step 4: Set your desired standards. Ask the staff members what they think are

acceptable standards. If it's the private practice, the staff may suggest spacing

appointments out so that the patients are seen in a more reasonable time frame.

For the hospital, the staff may suggest improving teamwork so that they are all

working together to meet the patients' needs. Many times in health care, the main

reason for patient neglect is the unwillingness of the staff to care for patients they

are not assigned to. In the nursing home, a suggestion may be to begin the

patient on a toileting schedule to cut down on the amount of accidents they have.

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Unfortunately in nursing homes, many patients are incontinent when they are

capable of being toileted, even through the use of bedpans.

Step 5: Write the plan for improvement. After you have discussed the problems

and possible solutions with your staff, write out a plan describing which

improvements need to be made and a reasonable resolution for the problems

identified. It helps to take into consideration the input of the direct care staff and

incorporate some of their ideas into the plan of action. This will put them on the

offense and motivate them to make the necessary changes by feeling as though

their opinions count.

Step 6: Reveal the plan and discuss it with your workers. Begin to set goals to

improve the standards of care. Discuss short-term and long-term solutions you

have decided upon. The short term will have a definite effect on the long term, so

set your goals within a reasonable time frame. If anyone feels a goal is

unobtainable, they will not reach for it at all. Also set a time for re-evaluation. This

will help in determining if the changes made have been effective and beneficial

for the patients.

Step 7: Write your conclusion--a short and concise closing that summarizes the

findings and the solutions that have been decided upon. Once you have

completed this, save the audit so you can compare your next audit to it. It will

help in determining which improvements have taken place and which areas still

require attention from the health care team.

Process of clinical audit

The clinical audit process seeks to identify areas for service improvement,

develop & carry out action plans to rectify or improve service provision and then

to re-audit to ensure that these changes have an effect.

Clinical audit can be described as a cycle or a spiral, see figure. Within the cycle

there are stages that follow the systematic process of: establishing best practice;

measuring against criteria; taking action to improve care; and monitoring to

sustain improvement. As the process continues, each cycle aspires to a higher

level of quality.

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Stage 1: Identify the problem or issue

This stage involves the selection of a topic or issue to be audited, and is likely to

involve measuring adherence to healthcare processes that have been shown to

produce best outcomes for patients. Selection of an audit topic is influenced by

factors including:

Stage 2: Define criteria & standards

Decisions regarding the overall purpose of the audit, either as what should

happen as a result of the audit, or what question you want the audit to answer,

should be written as a series of statements or tasks that the audit will focus on.

Collectively, these form the audit criteria. These criteria are explicit statements

that define what is being measured and represent elements of care that can be

measured objectively. The standards define the aspect of care to be measured,

and should always be based on the best available evidence.

A criterion is a measurable outcome of care, aspect of practice or capacity. For

example, ‘parents are involved in negotiating or planning their child’s care’.

A standard is the threshold of the expected compliance for each criterion (these

are usually expressed as a percentage). For the above example an appropriate

standard would be: ‘There is evidence of parent in care planning in 90% of

cases’.

Stage 3: Data collection

To ensure that the data collected are precise, and that only essential information

is collected, certain details of what is to be audited must be established from the

outset. These include: the user group to be included, with any exceptions noted;

the healthcare professionals involved in the users' care; and the period over

which the criteria apply. Data to be collected may be available in a computerized

information system, or in other cases it may be appropriate to collect data

manually depending on the outcome being measured. In either case,

considerations need to be given to what data will be collected, where the data will

be found, and who will do the data collection. Ethical issues must also be

considered; the data collected must relate only to the objectives of the audit, and

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staff and patient confidentiality must be respected - identifiable information must

not be used. Any potentially sensitive topics should be discussed with the local

authorized committee (Institutional Review Board at APHI).

Stage 4: Compare performance with criteria and standards

This is the analysis stage, whereby the results of the data collection are

compared with criteria and standards. The end stage of analysis is concluding

how well the standards were met and, if applicable, identifying reasons why the

standards weren't met in all cases. These reasons might be agreed to be

acceptable, i.e. could be added to the exception criteria for the standard in future,

or will suggest a focus for improvement measures. In theory, any case where the

standard (criteria or exceptions) was not met in 100% of cases suggests a

potential for improvement in care. In practice, where standard results were close

to 100%, it might be agreed that any further improvement will be difficult to obtain

and that other standards, with results further away from 100%, are the priority

targets for action. This decision will depend on the topic area – in some ‘life or

death’ type cases, it will be important to achieve 100%, in other areas a much

lower result might still be considered acceptable.

Stage 5: Implementing change

Once the results of the audit have been published and discussed, an agreement

must be reached about the recommendations for change. Using an action plan to

record these recommendations is good practice; this should include who has

agreed to do what and by when. Each point needs to be well defined, with an

individual named as responsible for it, and an agreed timescale for its

completion. Action plan development may involve refinement of the audit tool

particularly if measures used are found to be inappropriate or incorrectly

assessed. In other instances new process or outcome measures may be needed

or involve linkages to other departments or individuals. Too often audit results in

criticism of other organizations, departments or individuals without their

knowledge or involvement. Joint audit is far more profitable in this situation and

should be encouraged by the Clinical Audit lead and manager.

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Re-audit: Sustaining Improvements

After an agreed period, the audit should be repeated. The same strategies for

identifying the sample, methods and data analysis should be used to ensure

comparability with the original audit. The re-audit should demonstrate that the

changes have been implemented and that improvements have been made.

Further changes may then be required, leading to additional re-audits.

This stage is critical to the successful outcome of an audit process - as it verifies

whether the changes implemented have had an effect and to see if further

improvements are required to achieve the standards of healthcare delivery

identified in stage 2. Results of good audit should be disseminated widely.

While clinical audit makes great sense, there can be an issue around persuading

hospitals and clinicians to undertake and apply clinical audit to their everyday

work. All the process which is described above is sometimes expanded to more

steps to be elaborated effectively. Such a detail is brought to your attention by

following chart.

1. Selected Topic

7. Implement

Change

8. Re-audit

2. Agree Standards

of best practice

3. Define Methodolog

y

4. Pilot and data Collection

5. Analysis and

Reporting

6. Make recommend

ations

Action

Planning

Audit

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Evaluation, Research, Medical and Clinical Audit Some times there is a confusion regarding the above terminology. It is better to

clarify them a bit for your understanding. Clinical audit’ tends to be used as an

umbrella term for any audit conducted by professionals in health care. Audits

conducted by doctors are often referred to as medical audits, although the term

‘Clinical audits’ could also be used. It is important to stress that very few health

care procedures involve just one professional discipline and that non-clinical staff

such as receptionists, secretaries, porters, managers, etc. play a vital role in the

quality of the service provided. Clinical audit, therefore, is usually a multi-

disciplinary activity. Many clinical audits are also ‘multi-sectoral’, that is, they may

involve health and social services, primary and acute care providers, education

and health.

Service evaluation may be defined as: “A set of procedures to judge a service’s

merit by providing a systematic assessment of its aims, objectives, activities,

outputs, outcomes and costs” (NHS Executive, 1997). There are many different

approaches to service evaluation. Whichever method is used, the process should

provide practical information which helps to inform the future development of a

service. Clinical audit may be one activity which takes place during a service

evaluation, alongside other activities such as routine data gathering, incident

reporting, and interviews with staff and service users. In order to conduct an

evaluation, services need to consider their aims, objectives and then identify their

key evaluation questions. Further texts to assist in service evaluation are listed at

the end of this book.

Clinical audit is not research, but it does make use of research methodology in

order to assess practice Key differences between clinical audit and research is

outlined in the coming table. Although research and clinical audit are two distinct

activities with different purposes, they are interrelated in several ways, as

described by Black (1992):

• Research provides a basis for defining good-quality care for clnical audit

purposes.

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• Clinical audit can provide high-quality data for non-experimental evaluative

research.

• Research into the effectiveness and cost-effectiveness of clinical audit is

needed.

• Research needs to be audited to ensure that high-quality work is

performed.

Differences between research and clinical audit - Adapted from Madden (1991)

and Firth-Cozens (1993)

Research Evaluation

• Aims to establish what is best practice

• Is designed so that it can be replicated and so generalized to other results are not transferable to other settings similar groups

• Aims to generate new knowledge/increase the sum of knowledge

• Is usually initiated by researchers Is usually led by service providers

• Is theory driven • Is often a one-off study • May involve allocating service

users randomly to different treatment groups

• May involve administration of a placebo

• May involve a completely new treatment

• Aims to evaluate how close practice is to best practice and to identify ways of improving the quality of health care provided

• Is specific and local to one particular patient group – that its results can be

• Aims to improve services

• Is practice-based

• Is an ongoing process • Never involves allocating

patients randomly to different treatment groups

• Never involves a placebo treatment

• Never involves a completely new treatment

How to Write an Audit Report

Writing the report often makes up the most difficult portion of the audit process;

while you want a comprehensive report, you also want to make it user-friendly so

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management and others looking at your audit can make the best decisions based

on its findings.

Step 1: Include a front page with the name of the organization, project title, audit

lead and date. For reports longer than 5 pages, include a table of contents.

Step 2: Start with an executive summary relating your findings with a brief

abstract of the issues, state of the findings and conclusions.

Step 3: Include a background summary. This should provide the background for

why you conducted the audit. Discuss how your organization assembled audit

team and why it made the audit a priority.

Step 4: Provide objectives and standards. The objectives detail the project's

goals, and standards inform the reader what format you used to conduct the

audit. If you conducted the audit with the goal of setting standards, state this

here.

Step 5: Include a section on methodology. This should provide the reader with

the population for the sample, rationale for how you chose the sample, the size of

the audit and the time period in which you conducted it.

Step 6: End with results and conclusions. Use charts and percentages to help

readers to visualize your findings. Put the conclusion in terms anyone in the

organization can understand, and make sure the conclusion directly ties back to

audit objectives.

Hospital Standards in Afghanistan The MOPH National Hospital Standards Policy for Afghanistan which is

developed and revised in June 2006. It consist the following main headings,

subheadings and standards which are not possible to mention all in this module.

For each standards there are criteria for verification and there level of ordinal

scores .Anyway I would like to just outline them with the number of standards in

each one. If needed reader is requested to refer to the original document at

MoPH.

Section 1: Governance

1.1 Community Hospital Board (9 standards)

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Section 2: Clinical Care

2.1 Pediatric Care

• Acute Febrile Illness in a Child 2 Months to 5 Years of Age (8 standards)

• Acute Respiratory Distress in a Child 2 Months to 5 Years of Age (9 standards)

• Diarrhea and Dehydration in Children (6 standards)

• Malnutrition—Severe in a Child 0 to 5 Years of Age (7standards)

• Facilities and Equipment for Pediatric Department and Ward (4 standards)

2.2 Surgical Care

• Management of Abdominal Pain Patients (9 standards)

• Burn Patients—Initial Management (4 standards)

• Operating Room/Theater Practices (5 standards)

• Fluids and Electrolytes in Surgical Care (4 standards)

• Organization of Surgical Department (4 standards)

2.3 Surgical Emergencies

• Management of Trauma Patients (8 standards)

• Management of Shock (3 standards)

• Management of Brain Injured Patients (8 standards)

2.4 Anesthesia and Post-Anesthesia Care

• Anesthesia and Trauma Care (6 standards)

• Anesthesia and Post-Anesthesia Care Unit Practices (10 standards)

• Anesthesia Care Documentation (6 standards)

• Patient Information and Education (3 standards)

• Facilities and Physical Environment for Anesthesia and Post-Anesthesia Care

Unit (4 standards)

2.5 Obstetric Care

• Management of Complications during Pregnancy (20 standards)

• Care During Normal Labor, Delivery, Postpartum and Newborn (27 standards)

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• Drugs for Obstetrics (2 standards)

• Information, Education, and Communication (5 standards)

• Human, Physical, and Material Resources (18 standards)

• Management Systems (13 standards)

Note: Standards in italics have not been developed as of June 2006

2.6 Infection Prevention

• Central Sterilization and Supply Department (14 standards)

• Surgical Unit (23 standards)

• Isolation Systems (10 standards)

• Labor and Delivery (19 standards)

• Casualty, Surgical, and Medical Wards (33 standards)

• Maternal and Child Health and Family Planning Clinics (24 standards)

• Dental Department (13 standards)

• Laboratory (17 standards)

• Blood Bank (20 standards)

• Post-Mortem Care (6 standards)

• Administrative Functions (8 standards)

• Patient/Client Education (4 standards)

• Food Service and catering (8 standards)

• Laundry (5 standards)

• Waste Management (9 standards)

2.7 Internal Medicine (No standard available now)

Section 3: Nursing Services

3.1 Patient Wards (No standard available now)

3.2 Operating Theater/Room (No standard available now)

3.3 Central Service and Sterilization (No standard available now)

Section 4: Ancillary and Support Services

4.1 Laboratory (12 standards)

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4.2 Blood Bank (19 standards)

4.3 Hospital Pharmacy Management (8 standards)

4.4 Radiology/X-Ray (No standard available now)

Section 5: Administration and Management

5.1 Hospital Maintenance of Facilities and Equipment (11 standards)

5.2 Human Resource Management in Hospitals (13 standards)

5.3 Medical Records (No standard available now)

5.4 Housekeeping (No standard available now)

5.5 Catering/Food Service (No standard available now)

5.6 Laundry (No standard available now)

5.7 Purchasing/Medical Stores (No standard available now)

5.8 Business Office and Administration (No standard available now)

Standards and Performance at Hospitals

According to hospital policy in Afghanistan and EPHS the following standards

have developed and promoted. It is mentioned there that standards are required

to improve the clinical and managerial performance to attain an acceptable level

of operations for hospitals. Standards establish what is expected of hospitals and

their staff at all levels of operation. It is the establishment of such reasonable

standards which permits the monitoring of hospital operations against which

hospital performance can be measured. This is required to improve the standard

of care and management of hospitals in

Afghanistan. The following provide the framework of the basic standards.

Specific details, elements and components of each standard must be developed

and specified in greater detail by the MOH. The following provides a structure

and direction for development of detailed standards for hospitals, which will be

used for accreditation, ultimately.

1. Responsibilities to the Community

1.1. The hospital is responsive to the community’s needs

1.2. Hospital services will be accessible to the community.

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1.3. Hospitals will have a proper disaster preparedness plan so it can properly

respond in the event of natural or man-made disasters.

2. Patient Care

2.1. Patients will be treated with dignity and have a right to be treated in a

respectful manner.

2.2. Quality of clinical care to the patient that the hospital serves is high and

appropriate for Afghanistan, including the proper staffing, equipment and

supplies.

2.3. Quality of care will be monitored and measured by agreed indicators (e.g.

wound infections, length of hospital stay, operations per patient, mortality rates

etc).

2.4. Women and children will receive the basic package of health services at

hospitals, including immunization, outpatient care for conditions, such as

pneumonia and diarrhea, as well as appropriate assistance at the time of

delivery.

2.5. Hospitals will be “mother and baby friendly” and encourage “rooming-in” and

immediate, exclusive breast feeding.

2.6. Care delivery is monitored by the hospital’s health care team to ensure that

care meets the needs of patients and to assist in the improvement of care.

2.7. Medical records are maintained for each patient and are kept confidential

and secure.

3. Leadership and Management

3.1. The hospital is effectively and efficiently governed, organized, supervised

and managed to ensure the highest quality of care possible for patients.

3.2. To ensure the responsiveness of hospitals to the community, a hospital

board of directors or board of management will be established at each hospital to

govern and oversee the proper operation and management of the hospital.

4. Human Resource Management

4.1. Staff planning ensures a properly trained hospital staff and the appropriate

number of staff.

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4.2. Staff is appointed through a recruitment, selection and appointment

procedure that is consistent with the MOH human resources policy.

4.3. In performing their duties, staff adheres to high ethical standards and a code

of conduct.

4.4. A comprehensive program of staff development and in-service training

meets individual and hospital needs.

4.5. Effective workplace relations are developed through use of teams

5. Management Systems

5.1. Financial management policies and procedures are developed and adhered

to in order to ensure accountability of the hospital’s finances from all sources.

5.2. Management information systems meet the hospital’s internal and external

needs

5.3. Patient care, management of services, education and research are facilitated

by the timely collection and analysis of data

5.4. Information technology enhances the hospital’s ability to gather, store and

analyze information and to communicate.

5.5. Appropriate logistics and purchasing systems are maintained to ensure

clinicians have the proper equipment, supplies and pharmaceuticals to provide

patient care.

5.6. Buildings and grounds are maintained to ensure a safe patient care and

work environment for patients, staff and visitors.

6. Hospital Environment

6.1. Infection is effectively controlled throughout the hospital

6.2. The physical environment of the hospital and its equipment are properly

maintained to ensure patient and staff safety and that there are no physical

barriers for those with disabilities.

6.3. The hospital is accessible to all patients with including those with physical

disabilities.

6.4. Buildings, grounds, plant and equipment are regularly maintained to ensure

a safe environment for all persons in the hospital.

6.5. Waste from the hospital is handled, contained and disposed of safely and

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Efficiently

6.6. Occupational health measures are adopted to ensure the safety of staff,

especially those dealing with direct patient care.

6.7. Clean water of sufficient quantity and quality is available for patients and

staff and for proper hospital functioning.

6.8. Toilets in the hospital are kept clean for use by patients, staff, and visitors.

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Hospital Standards for Accreditation for Afghanistan: Assessment of Progress in Achieving the Standards

Hospital Department or Area: Infection Prevention: Patient/Client Education Hospital Facility: _____________ Assessor: __________________ Date of assessment: ____________________

Infection Prévention: Patient/Client / Education

Compliance in

meeting standard

(score)

Standa

rd #

Standard Criteria for

Verification of

meeting

standard Full Partial non

e

Bases for

evaluation

Grads/Comme

nts/Action Plan

Observe if: • There are posters or stickers visible and in good condition about hand washing and hygiene located in:

• Corridors

• Waiting

areas

• Toilets

• wards

There are signs saying “no littering” to encourage patients/clients and relatives to avoid littering on the grounds

1 There are educational posters for patients/ clients about infection prevention (IP) measures.

There are posters or stickers visible and in good

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condition about visiting hours and number and age of visitors There are posters or stickers visible and in good condition about “cough etiquette”

Observe if there are posters visible and in good condition informing patients/clients about the critical IP practices (e.g., hand washing, injection safety, use of gloves during invasive procedures) that should be followed by providers during the provision of care, located in: • Outpatient

facilities

• Wards

• Causality

areas

• Laborator

ies

2 There are informational posters about patients’/clients’ rights concerning IP during the provision of care.

• Dental

Departm

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ents

Observe if there are signs in these areas: • Laboratory

Isolation areas

Central supply and Sterilization Department and operating room

Lab and delivery

areas

Nursery

Mortuary

3 There are signs to alert patients/clients about restricted or risky areas.

Waste storage

areas

Verify with the hospital director/manager if: • There is a written plan to conduct educational activities on IP for the community and for the relatives who accompany patients/clients

4 The hospital works with community organizations on IP education.

There is a record of activities implemented

Importance of Clinical Audit

If we come once more to definition, them “clinical audit involves systematically

looking at the procedures used for diagnosis, care and treatment, examining how

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associated resources are used and investigating the effect care has on the

outcome and quality of life for the patient” (Department of Health, 1993).

‘Audit’ is a word which has acquired different meanings over time in relation to

health care quality. The above definition, provided by the Department of Health,

emphasizes the fact that clinical audit can be used to examine all aspects of

patient care from assessment through to outcomes. In brief, clinical audit

provides a method for systematically reflecting on and reviewing practice

In the literature about clinical audit methods, the following terms are often

mentioned: criteria based audits; adverse occurrence screening; critical incident

audits; peer reviews; and case note analysis. These are used inconsistently by

different authors and tend to add to the general confusion about the clinical audit

process. We would recommend ignoring this labyrinth of terminology since there

is only one clinical audit method – the clinical audit cycle. This method involves

completing a number of stages and activities as described.

The overarching aim of clinical audit is to improve service user outcomes by

improving professional practice and the general quality of services delivered

There are a number of reasons why clinical audit is an important activity. The

main reason is that it helps to improve the quality of the service being offered to

users. Without some form of clinical audit, it is very difficult to know whether you

are practicing effectively and even more difficult to demonstrate this to others.

The benefits of clinical audit are that it:

• identifies and promotes good practice and can lead to improvements in

service delivery and outcomes for users

• can provide the information you need to show others that your service is

effective (and cost-effective) and thus ensure its development

• provides opportunities for training and education

• helps to ensure better use of resources and, therefore, increased

efficiency

• Can improve working relationships, communication and liaison between

staff, staff and service users, and between agencies.

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Areas and Time of clinical audit

There are numerous topics which are suitable and relevant for clinical audit.

Several ways of subdividing clinical audit topic areas have been devised. A

useful framework has been provided by Donabedian (1966) who classified topics

under three headings:

Structure: The availability and organization of resources and personnel.

Process: The activities undertaken, that is, what is done with the service’s

resources?

Outcome: The effect of the activities on the ‘health/well-being’ of the service

user, that is, changes for the individual which can be attributed to the clinical

intervention they received.

For some clinical audit projects, data collection, analysis and action plans can be

carried out in an hour or two. Similarly these audit stages can take one or more

years to complete. What is important is to design a clinical audit project which will

produce meaningful data and which can be finished within the budget and time

available. The most time-consuming element of any clinical audit project is the

implementation of required changes. It is suggested that projects be kept simple

and cover areas in which changes can be achieved. Clinical audit can be both

simple and quick

A clinical audit project is more likely to be successful and beneficial to service

users if all of the key stakeholders are involved from the outset. These may

include: clinical and non-clinical staff providing the service, service users and

people whose support may be required to implement resulting changes in

practice (e.g. managers, referrers, and trust board members).

As many of the above groups as possible should be represented on the clinical

audit project team. If individuals are unable to attend team meetings, then they

will need to be consulted and kept informed about the clinical audit project

throughout the process. Key stakeholders should be involved in the clinical audit

project from the start.

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Quality Care in Hospitals Quality assurance and medical audit are processes which seek to improve the

quality of care by addressing differences between accepted good care and actual

practice. Nowadays more or less hospitals are very much concerned of quality in

their services. A revolution is taking place in the field of healthcare. The concept

of “quality of care,” is now speeded by the advent of healthcare reform in many

countries. Providing quality healthcare within the constraints of available

resources is a challenging undertaking. Nonetheless, even in an environment

with limited resources, methods are available to regularly monitor the quality of

care by collecting and analyzing a core set of health indicators, and thereby

laying the groundwork for improvement.

Main approaches for quality improvement in hospitals are quality monitoring,

providing feedback to healthcare workers, training and supporting staff to

undertake improvements leading to quality care, and designing solutions for

closing identified quality gaps. It means that there is no shortage of evidence to

support the argument for the introduction of quality assurance into clinical

practice. Many published studies, which have assessed the quality of care with

measurable criteria, have shown wide gaps between actual care and accepted

good practice. For example, in a large proportion of deaths from asthma there is

evidence of lack of appropriate medication or referral or physiological

measurement, similar findings were reported in studies of routine care given to

patients admitted to hospital with acute severe asthma.' Underuse of a blockers

and aspirin for patients who have had myocardial infarction and of streptokinase

for those admitted with myocardial infarction has been described.

Variation in use of procedures and demonstration of inappropriate use of invasive

investigations such as coronary angiography and of prescribed drugs such as

antibiotics" indicate a degree of uncertainty in clinical decision making - a factor

which may at least partly explain some of the differences between actual and

accepted practice.

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Choice of Quality Healthcare

Quality health care means doing the right thing, at the right time, in the right way,

for the right person—and having the best possible results. Although people would

like to think that every health plan, doctor, hospital, and other provider gives high

quality care, this is not always so. Quality varies, for many reasons. Fortunately,

there are scientific ways to measure health care quality. These tools, called

measures, have mostly been used by health professionals. They use measures

to check up on and improve the quality of care they provide. But there is some

quality information that can be used to help you compare the health care choices

for consumers. And more and more is becoming available all the time. Many

public and private groups are working to improve and expand health care quality

measures. The goal is to make these measures more reliable, uniform, and

helpful to consumers in making health care choices.

There are two main types of quality measures that can help you choose quality

health care are consumer ratings and clinical performance measures. Both types

are based on "outcomes research." Outcomes research measures the end

results of health care practices and treatments. For example, after treatment, is

the pain gone? Can the patient carry out his or her daily activities? Is he/she

satisfied with his or her care?

Consumer Ratings (or "consumer satisfaction" information): These look at health

care from the consumer's point of view. For example, do doctors in the plan

communicate well? Do members get the health services they need? Many

consumer ratings of health plans are based on a survey called the Consumer

Assessment.

Clinical Performance Measures (also sometimes called "technical quality"

measures): These measures look at how well a health care organization prevents

and treats illness. For example, one clinical performance measure looks at

whether children get the immunizations (shots) they need when they need them.

Research shows that people want and value quality health care. And that's a

good thing. Because when you make health care choices that offer the best

possible care, you are most likely to get the best possible results. So when it

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comes to making major health care decisions—about health plans, doctors,

treatments, hospitals, and long-term care—how can you tell which choices offer

quality health care, and which do not? Fortunately, more and more public and

private groups are working on ways to measure and report on the quality of

health care. This means there is more and more information to help one make

choices that improve the quality of his or her own care.

Here are some important things which make individuals to choose hospital care

and make such choices:

• Quality matters. It can be measured, and it can be improved.

• Patient and doctor should see each other as a team. You need to work

together to get the best care.

• The patients should ask questions, and make they understand the

answers. The only "bad" question is the one you wish you had asked.

• Remember that "more" is not always "better." It is always a good idea to

find out why a test or treatment is needed and how it can help you.

• Customers want to find and use reliable health care information. They will

ask the doctor or nurse, to library, and explore the internet

Checklist for choice of Quality Healthcare

The following checklists summarize the major ways you can check for quality in

health care. The information in it comes from research about the information

people want and need when making decisions about health plans, doctors,

treatments, hospitals, and long-term care.

• The hospital has been rated highly by its members on the things that are

important to you.

• The hospitals do a good job of helping people stay well and get better.

• It is accredited, if that is important to you.

• Ii has the doctors and hospitals you want or need.

• The center provides the benefits you need.

• The hospitals provides services where and when you need them.

• Meets your budget.

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• Medical personnel Is rated to give quality care.

• They have the training and background that meet your needs.

• They try to takes steps to prevent illnesses for example, talks to you about

quitting smoking.

• It is part of your health plan, unless you can you afford to pay extra.

• The staff encourages you to ask questions.

• They are listening to you.

• They are explaining things clearly.

• Treats you with respect.

• The hospital makes it clear what your diagnosis is.

• It will predict whether treatment is really needed at this time.

• Suggestion will be given what your treatment options are.

• Whether the treatment options are based on the latest scientific evidence.

• The benefits and risks of each treatment is clearly explained

• It is affordable for you to incur the cost of each treatment.

• It is accredited by the Joint Commission on Accreditation of Healthcare

Organizations.

• The hospital is rated highly by government or consumer or other groups.

• It is one where your doctor has privileges, if that is important to you.

• The hospital has experience with your condition.

• Checks and works to improve its own quality of care.

• Its quality has been approved by other institutions

• It provides the services you need.

• It has qualified staff that meets your needs.

The way forward Apparently the quality assurance activities are not well documented or well

developed and are seen as the purview of the medical staff. Although some sorts

of standards are developed for QA which is usually partially applied in lower

public health facilities which are controlled by MoPH and implemented by NGOs.

If you review them and evaluate quality control processes, it is not widespread.

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We can conclude that few formal QA function exists, and little attention is given

to these activities.

Quality assurance activities should become a higher priority at the hospitals and

the process of accreditation and QA capacity-building should be implemented

and should include hospital line administrative managers as well as the medical

staff. It is time to begin such activities with some alleged quality private hospitals.

> QA standards should be developed and implemented. Possible Technical

Assistance is capacity-building and developing and implementing accreditation

standards. Technical assistance is recommended in the education, training, and

implementation of the accreditation process for hospitals under the Hospital

Reform Project. One hospital department, possibly OB/GYN, could be selected to

work with HSR as a model for the development of standards and for

implementation of the accreditation process for QA capacity-building.

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Session 9: Financial Management in Hospitals

Assessment of hospital financial performance starts with some basic questions

such as how does a hospital get and spend its money? Is the hospital in good

financial health (able to cover its basic financial requirements and)? What types

of government policies and regulations affect the hospital’s financial health?

What are the market trends and how are these forces shaping the decisions of

the hospital leadership? These are just a few of the questions that are needed to

be answered when one is evaluation the financial status of the hospital.

The health services industry includes many providers of service. To understand

the flow of funds, or how money flows through a hospital, it is important to know

the key players in the hospital industry. These include physicians and ancillary

providers, skilled nursing facilities, long-term care providers, home health care,

and pharmacies, as well as hospitals.

Health Providers in Hospital System Hospitals are registered with different health system maybe seen as general,

special ones. General Hospitals provide patient services, diagnostic and

therapeutic, for a variety of medical conditions while in specialty related ones

they provide diagnostic and treatment services for patients who have specified

medical conditions, both surgical and nonsurgical. In addition hospitals are

organized as public, private and not-for-profit entities. In general, public hospitals

provide substantial services to patients living in poverty. There are some public

hospitals such as those run by the military. Public Hospitals are often funded by

local and central government through taxes which is collected from people.

Private, not-for-profit hospitals are nongovernment entities organized for the sole

purpose of providing health care. Non for profit hospitals are exempt of paying

taxes to government. Their number is very low in Afghanistan. We can name the

French Medical Institute for Children (FMIC) one of such hospital which is

running by Aga Khan University in Kabul. There are some health centers and

hospitals which are controlled by government but not through channel of MoPH.

They are also included in public Hospitals.

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Other Providers are physicians may practice general medicine or specialize in a

particular area. We call them medical examination room which is very common

in the country. Some physicians are employed by private hospitals while others

may have private practices in the community. Home care services are, as the

name implies, provided in the patient’s home usually by a home health aide.

These services may include nursing, nutritional and therapeutic aid, and the

rental and sale of medical equipment. As patients are discharged to their homes

sooner—due to hospitals’ economizing strategies— home care plays an

increasingly more important role in the health services industry. This is less

common in a country like Afghanistan but mostly it is seen in developed countries

and even in it has been started in developing countries. Pharmacies are found in

hospitals as integrated portion and they are working in private pharmacies which

are partially controlled by the MoPH as well in the community. They are providing

pharmaceuticals to that patient who request for and have become more

important in the health care delivery sector as they may supplant treatments.

If we assess the types of hospital ownership they can bye classified to groups of

hospitals of public and private sectors. Public hospitals are further classified into

hospitals under the MOPH, under the Universities, and under various Ministries.

The determined categories of private hospitals are not-for-profit hospitals, for-

profit hospitals and other types of private hospitals. The public hospitals are

providing more wide ranges of services concerning comprehensive care

including curative, promotive, preventive and rehabilitative care. The private

hospitals are emphasizing mostly on curative care and they are less likely

providing promotive and preventive care from which they were able to make

profits. They show low interest in provision of those services which include the

public goods.

Based on constitution public hospitals in Afghanistan are bound to provide free of

cost services which is hindering the modern and state of art technology. Payment

system in the private hospitals is market salary based or it is related to staff’s

work productivity in terms of quantity and quality while the public system is

basically a salary system in which promotion is likely to link with work years.

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However, training and development for public hospital staff is more formalized

than the private hospitals. Public Hospitals consider information system as a key

element to enhance evidence-based decision making while the culture is less

supported in private hospitals. More number of qualified employees with specialty

of current and modern financing and accounting are employed in the private

hospitals. Their roles are relevant for providing inputs to make decisions while

the public hospitals do have limited qualified staff leading to limited inputs-based

decisions. They are mostly based on traditional lengthy procedures. Auditing

system is performed in the public hospitals as obliged to the law of Ministry of

Finance while there is no approved auditing system for private hospitals. As an

autonomous hospital is increasingly considered as an alternative to improve

efficient use of health resources in public hospitals, some recommendations of

general management for transforming the public hospital into the autonomous

hospital are made as follows:

• Comprehensive care should be provided,

• three levels of management composed of the hospital board, the hospital

management team and functional units should be established,

• Internal and external auditing system should be carried out to improve

management transparency,

• incentives system should be designed to encourage health workers to

work more productively,

• Qualified people whose backgrounds are accounting and financing should

be more recruited,

As a fundamental structure of the hospital management, the information system

should be developed to produce beneficial inputs for decision making,

The accounting system should be based on the accrual system, used for auditing

and estimating care costs to facilitate more equity of resource allocation.

Payers in Hospital System To understand how hospitals generate revenue for patient services, it is

important to understand the “payers” in the healthcare industry. Public payers

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include government which fund hospitals in MoPH and other public institutions.

Private payers are insurance companies which is not common in the country.

Both public and private payers are often referred to as third-party payers. We can

allege that all population in the country is not insured just in some very rare

cases. The efforts have been started lately. There are some payment which is

done by external donors and the channels maybe indirectly through involvement

of government and or directly by non governmental organizations.

Out of pocket payment is by consumers themselves pay the costs of medical

expenses out of their own pocket. Typically, hospitals “charge” these patients a

higher fee than what they actually expect to collect from the organized payers

described above. If an individual does not have adequate resources to pay the

bill, providers will not deliver the services to them. Nevertheless the welfare

system and exemption schemes are there in some hospitals. Hospital policies

are required to put the issue in attention of private hospitals.

Hospital Revenues: How Hospitals are earning money? Typically, hospitals get their revenue in a variety of ways: by providing medical

services; by providing nonmedical services; through donations and grants from

individuals, foundations, or the government; through investments and so on.

There are various sources of revenue for hospital in different countries. Some of

them are discussed here.

Operating revenue is the income earned by delivering patient care and it is the

first and primary way that hospitals make money. This revenue is further

categorized in hospital finance terms as gross and net: Gross Patient Service

Revenue (GPSR). The amount of money that hospitals would make if they were

paid in full (that is, the non-discounted rate) for the care they deliver (total

inpatient and outpatient revenues before deductions). However, hospitals provide

most patient care at less than full charge and never actually collect their gross

patient service revenue. Net Patient Service Revenue (NPSR) is the total amount

of money the hospital actually collects after deducting charity care and

contractual adjustments.

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We should understand here the difference among charge, payment and cost. A

charge is the amount the hospital lists as the price for services. Only self-payers

and some private insurers pay this “sticker price.” Payment is the amount the

hospital actually receives in cash for its services. Private insurers, public

insurers, and the uninsured all pay different amounts for the same services.

Payment can be either more or less than what it costs the hospital to provide a

given service. Cost is what it actually costs the hospital to provide the services.

Costs are reported in aggregate, so you will not be able to find cost for individual

Procedures on financial statements. The payment-to-cost ratio illustrates the

amount of revenue a hospital receives relative to its costs. A payment-to-cost

ratio of 1 means that the hospital is receiving payment that exactly covers its

costs. A ratio greater than 1 means that the hospital is receiving more money

than the cost of the service it is providing.

Table: Payment methodology and incentives created in Hospitals Payment method Definition Incentives Fee for Service (FFS) Providers are paid a fee

for every service performed.

The FFS method rewards hospitals for providing more care. The more they provide, the more they are paid. Under this method, there is concern that FFS payments will lead to additional and unnecessary services which is called supplier induced demand

Discounted FFS Providers are paid a fee for every service performed, but at a discounted rate.

This method offers incentives similar to those described above. Although hospitals are not paid as much per service, there are still incentives to provide additional services in order to get additional payments. There is also an incentive for providers to mark-up charges to offset the discount.

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Capitations Providers are paid a certain amount per patient for a predetermined set of services.

Hospitals receive the same monthly fee whether they treat a patient or not. The capitation method of payment leads to a common concern that hospitals and other providers will not provide necessary services, since providing additional services will not increase the amount of money they receive.

Per diem Providers receive fixed daily payments that do not vary with the level of services used by the patient.

Since a hospital is paid by the day and not by individual case, the hospital can make more money by keeping a patient in the hospital for more days than are necessary.

Diagnostic Related Grouped (DRG

Providers are paid a lump sum to cover inpatient acute care operating costs. Patients are sorted into groups according to principal diagnosis, type of surgical procedure, presence or absence of significant co-morbidities complications, and other relevant criteria.

DRG payments will create an incentive for hospitals to provide services at lower cost and to shorten lengths of stay. They will also benefit from an increase in the volume of admissions.

Charges Hospital’s posted price for services.

In most states there are no limits (other than “market forces”) as to what a hospital can charge. The incentive is to establish charges as high as possible to get the most from the indemnity.

Other operating revenues in Hospitals also make money by providing services

that are ongoing business activities, but that are not directly related to the

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hospital main mission of delivering patient care. While these activities bring in

significant and continuous streams of funds, the money resulting from these

services and activities is called other operating revenue. Some typical categories

that make up other operating revenue include:

• Cafeteria sales

• Gift shop sales

• Parking garage fees

• Space or equipment rentals

• Research grants

While it is probably obvious how a hospital benefits financially from rentals,

cafeteria, gift shop, and parking garage fees, funding from research grants

deserves a little more explanation. Hospitals are a valuable arena for researching

new drugs, treatments, and procedures, and outside agencies fund hospitals to

perform such research. Such a fund was provided to Maiwand Teaching

Hospital for cohort (clinical trial) of affecting vitamin D in occurrence of

pneumonia in children. It was supported and conducted by London School of

Hygiene and Tropical Medicine. Hospitals also receive funding from

pharmaceutical companies to test new drugs and products. Money from research

grants can be a significant source of funds for a hospital, particularly if it is a

teaching hospital.

Hospital Expenses: How Hospitals are spending money? Hospitals must spend money to function and provide patient care. The main

categories of expenses include salaries, supplies, depreciation, amortization,

interest, and bad debt expenses.

Wages and salaries paid to employees are usually the largest category of

expenses for hospitals. In many hospitals, salaries make up about 60 percent of

total expenses. Only physicians who are employees of the hospital are included

in the category. Most community hospitals do not employ physicians except in

the emergency department, the radiology department, the laboratory, and often

in the anesthesiology department.

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Supplies usually make up the second largest category of hospital expense and

typically account for 30 percent of a hospital’s expenses. “Other” includes a

range of expenses, but often represents contract labor and lease expenses.

When any entity (including hospitals) buys equipment, buildings, or other fixed

assets, it does not expense, or write off, the entire cost of purchasing that fixed

asset in one accounting period. Instead, it recognizes the cost over the estimated

life of the good, and records the appropriate portion as an expense during the

current accounting period. The process of expensing a fixed asset for its

expected length of use is called depreciation. For example, if a hospital bought

an x-ray machine for $100,000 and expected it to last 10 years, using the

straight-line depreciation method the hospital would record the expense of the

machine at $10,000 per year for 10 years. Similarly, when a hospital purchases

an intangible asset the process of expensing its cost over the expected length of

its life is called amortization. Intangible assets consist of the nonphysical assets

of a business, such as goodwill, copyrights, and patents. The entire cost is

spread over the anticipated life of the asset instead of recognizing it all at once in

the first year.

Hospitals often borrow money for mortgages and other large purchases. Interest

expense is the amount a hospital must pay in the current accounting period for

borrowing funds.

Bad debt represents service charges for which a hospital expected to collect but

does not receive payment. Bad debt is valued at charges. For example, a patient

is billed $1,000 for a procedure. If the patient is only able to pay half of the cost

($500), the hospital must write off the other $500 as bad debt and record it as an

expense.

Financial Information in the Hospitals After knowing how a hospital makes and spends money, now you need to learn

where you can find this information. All hospitals must have complete financial

statements.

Hospitals, like other businesses or organizations, issue financial statements.

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Financial statements are reports that show the type of financial actions an

organization has taken and the impact of these actions. For example, statements

show where and when a hospital’s money has been spent and whether the

hospital is financially successful. They answer questions such as: What is the

financial picture of the organization in any given year? How well did the hospital

do during a given period of years?

There are three major financial statements: the income statement; the balance

sheet; and the cash flow statement. Each statement has a distinct focus and use.

The Income Statement The income statement (also referred to as the Profit and Loss Statement or

Comparative Statement of Operations) focuses on performance over a

designated period of time, usually one year. This statement provides important

information about the profitability of a hospital, including information on how the

hospital gets its money and how the hospital spends its money. Here is an

example of income statement.

Table: income statement in 1000

OPERATING REVENUES 1998 1998 Gross Patient Service Revenue $258,125 $263,469 Free Care 5,800 6,024 Contractual 69,320 67,985 Net Patient Service Revenue 183,005 189,460 Other Operating Revenue 14,600 14,843 Total Operating Revenue $197,605 $204,303 OPERATING EXPENSES Depreciation 13,152 13,805 Interest 3,222 5,026 Bad Debt 5,163 6,866 Other Operating Expenses 168,585 173,634 Total Operating Expenses $190,122 $199,331 Net Operating Income $7,486 $4,972 NONOPERATING REVENUE Investment Income $2,530 $ 3,328 Gains/Losses 159 0 Other Income (Expenses) 470 1,112 Total Non-operating Revenue $3,159 $4,440 Excess Revenues over Expenses $10,645 $9,412

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OTHER GAINS (LOSSES) DUE TO: Extraordinary Gains (Losses) 0 –748 Total Surplus/Deficit $10,645 $8,664

The purpose of the income statement is to provide information on hospital

performance, including how much profit the hospital makes. So that it is

necessary to know what does profit means.

What Is Profit?

Profit is the difference between revenue and expenses in addition to non-

operating gains and losses. Profit is sometimes referred to as the hospital’s

“bottom line,” because the bottom line of the income statement shows the excess

revenues remaining once expenses have been subtracted. Profit may also be

called “total margin.” For example, a 2 percent total margin means that the

hospital keeps as profit 2¢ for each dollar of revenue. In addition to looking at the

bottom line to gauge profit, financial analysts also measure the difference

between operating revenue and operating expenses without non-operating gains

and losses. This measure of profit is referred to as net operating income and is

used to measure how much profit comes from a hospital’s central mission of

delivering patient care. A “not-for-profit” designation does not mean a hospital

can’t make money. A nonprofit may make a “profit,” but it does not distribute its

profit to individuals or shareholders as a for-profit organization might.

A hospital may be conservative in its estimate of how much money it will earn

from patient revenues. Because these numbers usually require a certain amount

of estimation, bad debt and contractual settlements might be much less (or more)

than the hospital’s reported figures. For example, a hospital may not recognize

all Medicare patient revenue because of the uncertainly regarding whether the

hospital will be permitted to keep this revenue. When a hospital “settles” with an

insurer at the end of the financial reporting period and it is found that the insurer

overpaid the hospital, the hospital may have to give back some of the money to

the insurer.

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The Balance Sheet The balance sheet gives a snapshot of the organization’s financial health at a

particular point in time, for example, as of June 30, 2000. It is also known as the

statement of financial position or statement of financial condition. In general, the

organization’s total assets should be greater than its total liabilities, or it cannot

survive for long. The kinds of assets and liabilities an organization has also affect

its financial health. For instance, current assets (such as cash, receivables, and

securities) should cover current liabilities (such as payables, deferred revenue,

and current-year loan and note payments). Otherwise, the organization may face

immediate solvency problems. On the other hand, if an organization's cash and

equivalents greatly exceed its current liabilities, the organization may not be

putting its resources to the best use.

There are several major elements on a balance sheet.

• Assets are economic resources that are expected to provide future

benefits by helping to increase cash inflows or reduce cash outflows.

Property, plant, and equipment (PPE) are considered assets.

• Liabilities are economic obligations of the organization to outsiders, or

claims against its assets by outsiders. Accounts payable is as example of

a hospital liability.

• Net assets, fund balance, or owners’ equity are all different names for

the same thing: they all refer to the residual interest in, or remaining

claims against, the organization’s assets after all liabilities have been

deducted. This may be expressed as: assets – liabilities = net assets.

Balance Sheet Equation shows that the balance sheet has two counterbalancing

sections which form the balance sheet equation:

Assets = Liabilities + Equity (or Net Assets)

The Liabilities + Equity portion of the balance sheet equation represents outsider

and owner “claims against” the total assets shown on the assets portion of the

equation.

Hospital Balance Sheet

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Assets Liabilities and Net Assets

Current Assets Cash and Investments– Unrestricted Cash and Investments– Board Designated Cash and Investments– Trustee Held Net Patient Accounts Receivable Due from Affiliates

A list of resources which will most likely be used within the year Cash, cash equivalents, and short-term investments on which no special restrictions are imposed on how they may be spent Cash, cash equivalents, and short-term investments internally designated for use by the board of trustees Cash, cash equivalents, and short-term investments designated as trustee-held to be used to repay specific obligations (usually long-term debt) Payments due from patients minus amounts subtracted for estimated uncollectible accounts and “discounts” to large purchasers Contractual obligations of affiliates due this year

Current Liabilities Current Portion of Long-term Obligations Accounts Payable and Accrued Expenses Current Portion of Accrual for Settlements with Third-Party Payers Due to Affiliates Total Current Liabilities Noncurrent Liabilities Long-Term Obligations, Less Current Portion

Short-term obligations to outside parties who have provided resources (liabilities) Principal payments due this fiscal year on long-term obligations Includes accounts payable, accrued salaries payable, wages, payroll taxes, interest, vacation (earned time) and other accrued liabilities Current portion of amounts received from third-party payers which the hospital expects to be due back to third parties in the current year Current amounts owed to related entities Sum total value of all of the current liabilities listed above Long-term obligations which are not due within one year Noncurrent portion of long-term debt, capital leases, and mortgage

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Third-Party Settlements Receivable Other Accounts Receivable Inventories Prepaid Expenses Total Current Assets Noncurrent Assets Long-Term Investments Pledges Receivable Over a Period Greater Than One Year

Estimates of settlements to be received this fiscal year Includes other receivables not related to patient services, third-party receivables or amounts due from affiliates Goods being held for sale, and material and partially finished products that will be sold upon completion Intangible assets that will become expenses in future periods when the services they represent are used up Sum total value of all the current assets listed above Assets that are expected to be of use to the hospital for longer than one year Long-term resources A promise to give (pledge) by a donor which has not yet been received and will not be received within one year’s

Other Noncurrent Liabilities Net Assets Unrestricted Temporarily Restricted Permanently

notes payable All other noncurrent liabilities, including reserves for self-insurance, accrued pension and post-retiree health benefits, noncurrent amounts due to affiliates, amounts due to restricted funds, notes payable, deferred gift annuities, construction and retain age payable, etc Net assets represent the difference between assets and the claim to those assets by third parties or liabilities; increases in this account balance occur from either contributions or earnings Includes all net assets that are not temporarily or permanently restricted by donor or grant Includes funds temporarily restricted by donor or grantor stipulations. Includes funds

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Net Property and Equipment Other Noncurrent Assets

TOTAL ASSETS

time Value of land, buildings, equipment, construction in progress, and capitalized leases All other noncurrent assets not listed above, including amounts due from restricted funds; deposits; other noncurrent unrestricted receivables; deferred financing costs and deferred charges; pension and insurance obligations or retirement programs; Organization costs, etc. The sum total value of all current and noncurrent assets

Restricted Total Net Assets TOTAL LIABILITIES AND NET

ASSETS

called for a specific purpose; property, plant and replacement; or endowment funds Includes funds permanently restricted by donor or grantor stipulations Sum total value of all net assets Sum total value of all liabilities and net assets raised

by issuing stock

The Cash Flow Statement The cash flow statement shows the cash that has come into and gone out of an

organization, after operating expenses have been met, during the accounting

period. Cash flow analysis provides a reliable, valuable perspective on hospital

financial performance. Because cash is not estimated, it cannot be hidden or

misleadingly labeled. Over the long term, multi-year cash flow analysis provides

an accurate and objective perspective of hospital financial performance.

Statement of Cash Flow

CASH FROM OPERATING ACTIVITIES

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Net Income $10,645

Noncash Expenses (Depreciation & Amortization) 13,152

Working Capital Changes:

Increase Accounts Receivable 6,480

Increase Accounts Payable –4,295

Total Cash from Operating Activities $25,982

CASH USED FOR INVESTING ACTIVITIES

Property, Plant, and Equipment Purchases –7,854

Increases or Decreases in Marketable Securities 2,702

CASH FROM FINANCING ACTIVITIES

Issuance or Repayment of Long-Term Debt –7,087

Transfers to and from Affiliates –4,300

NET CHANGE IN CASH $9,443

This sample shows the standard items listed on the cash flow statement. One

piece of valuable information that can be gleaned from the statement is transfers

to and from affiliates. Hospitals that are affiliated with other hospitals or entities

often transfer funds to and from one another. For example, many hospitals are

now merging or creating alliances with other hospitals. Suppose Hospital A

created an alliance with Hospital B and created a parent company called Parent,

Inc., to handle certain operations and other business ventures. In this typical

situation, Hospital A might transfer funds to Parent, Inc., to run business

operations for them. CCESS PROJECT

Hospital A would then record this transaction as a transfer to an affiliated entity

and record it as a negative change in net assets (equity), separate from the

hospital’s bottom line on the income statement. The hospital would also record

the transfer of funds on the cash flow statement. It is important to understand this

flow of funds between entities, as a hospital’s profitability can be affected if the

hospital is transferring resources to affiliates instead of investing in its own

operations.

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Evaluation of Hospital Financials conditions Three types of performance indicators are used to measure a hospital’s financial

condition: Ratio analysis, Multi-year cash flow analysis, Affiliate charts

Ratio Analysis

The purpose of a ratio is to relate several pieces of information through one

summary measure that is more meaningful. Ratios can be looked at across time,

called a trend analysis, and can be compared to other hospitals or industry

standards. Ratios should be used together to understand the full story of a

hospital. Ratios address three aspects of financial performance: profitability,

liquidity, and solvency.

Profitability: how much profit has a company made? Is the hospital rolling in

dough or just breaking even and covering its costs?

Liquidity: A company’s ability to meet its short-term obligations. Does the

hospital have enough cash to pay its bills?

Solvency: A company’s ability to meet its long-term obligations. For example,

can the hospital pay back its mortgage? The following table shows a list of

common ratios used to evaluate financial performance.

Ratio Definition What it shows? Profitability Total Margin Operating Margin Markup Ratio Deductible

Revenues in excess of expenses / Total Revenues Net Operating Income/ Total Operating Revenue (Gross Patient Service Revenue + Other Operating Revenue)/ Total Operating Expense Contractual Allowance/ Gross Patient Service Revenue

Shows the percentage of revenues collected from central and peripheral activities that is kept as profit. For example, a 5% Total Margin means that for every $1.00 collected as revenue, $0.05 is kept as profit. Shows the percentage of revenues collected from central activities that is kept as profit. For example, a 3% Operating Margin means that for every $1.00 collected of patient revenues, the hospital keeps $0.03 as profit. Measures the percentage by which charges are increased above cost. For example, if the hospital’s cost for providing a particular service was $10,000 and they charged $15,000 for the service, they would have a markup of 1.5.

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Ratio Measures the percentage discount that third-party payers get, on average, from listed charges. For example, a 25% ratio would mean that the average third-party payer received a 25% discount off listed charges.

Liquidity Current Ratio Days Cash on Hand, Short-Term Sources Only Days Cash on Hand, with Board- Designated Investments

Current Assets/ Current Liabilities Current Cash and Investments/ (Other Operating Expenses/365) (Current Cash and Investments + Board-Designated Investments)/ (Other Operating Expenses/365)

Measures how many times the hospital is able to meet its short-term obligations with short-term resources. A ratio of two would show that the hospital could pay its current liabilities twice over. Illustrates the number of days the hospital could continue to operate without collecting any additional cash. For example, a ratio of 150 would mean that the hospital could stop collecting revenues today and be able to continue operations for an additional 150 days before running out of cash. Considering all sources of unrestricted cash available for operations, this ratio illustrated the number of days the hospital could continue to operate without collecting any additional cash.

Solvency Equity Financing Cash Flow to Total Debt

Unrestricted Net Assets Total Unrestricted Assets (Revenues in excess of Expenses + Depreciation) (Total Current + Total Noncurrent Liabilities)

Shows how much of the hospital’s assets were paid for using equity, and how much of its assets were paid for using debt. For example, a ratio of 60% would indicate that the hospital financed 60% of its assets with equity, which means the remaining 40% were paid for by debt. Illustrates financial risk: Given the firm’s source of total funds for the current year, how much of their total debt could they pay off this year? For example, a ratio of 30% means that a hospital would be able to repay a third of their total debt in the current year, if they used all of their available funds.

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Cash Flow Analysis

A cash flow analysis aggregates cash inflows and outflows over time to illustrate

a pattern of cash sources and uses. Hospitals can provide services (operating

activity), borrow (financing activity), or buy and sell assets (investing activity). A

healthy hospital generates cash mainly from operating activities, especially

operating income, non-operating income, and depreciation. An unhealthy hospital

uses debt financing as a large source of cash and uses cash for unprofitable

operations. Depreciation expense is the largest source of operating cash for

many hospitals.

Affiliate Charts Affiliate charts help to explain the organizational structure of the system to which

the hospital belongs. The chart may illustrate if the hospital supports other

entities or is supported by the other entities. The charts may help interpret trends

in ratios and explain impacts on cash flows. The tax status of the affiliates is also

important to assess.

Financial report and information system A hospital administrator must be conversant with the financial status on a week

to week and month to month to basis and in a long perspective. It is the duty of

the finance officer to provide reports on financial performance and explain the

situation on regular basis to the administrator.

The assessment end result can not be possible without accurate data provided

on timely basis. Information about actual outcomes should be available through

the management information system in standardized format.

Daily Reports:

• Inpatient census, admissions, discharge

• Outpatients visits— new and repeat

• Tests carried out in laboratory, X-Ray, etc.

• Daily bank and cash positions

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Monthly Reports:

• Monthly statement of income and expenditure with department wise

break-p

• Budget versus actual cash positions— detailed comparison of actual to

budget sources and the application of the cashes

• Free and concessional care

• Operating indicators

Quarterly Reports:

Budget performance of all departments

Yearly Report:

• Balance sheet

• Income and expenditure statement

• Departmental income and expenditure statement

• Cost analysis

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Session 10: Grievance and complaint Management in Hospitals Complaint is an expression of grievance or resentment. It is a pleading

describing some wrong or offense; "he was arrested on a charge of larceny"

In general use, a complaint is an expression of displeasure, such as poor service

at a hospital, or from a local government, etc. in addition complaint is he first

step taken by an employee who believes he or she has been discriminated

against. A complaint is an allegation of illegal discrimination that is handled

through an administrative procedure or the document which, when filed with the

court, initiates a lawsuit. It sets forth the plaintiff's claims against the defendant.

Therefore a complaint is the legal document that is filed in court to begin a

lawsuit. (Web definitions)

Over the years, the hospitals faces thousands of complaint cases, derived from

all areas of hospital activities. However, attention has to be focused mainly on

the handling of individual complaint cases—some of which could be very

complex, involving more than one hospital or department, and encompassing

comments relating to varied aspects of hospital care. Whilst the satisfactory

resolution of individual cases is important, it is also important, particularly from

the viewpoint of a hospital authority to try to discern whether there are particular

trends, or systemic problems. Focusing only on dealing with individual complaints

also means that the chance is lost to prospectively and systematically learn from

circumstances that have led to complaints in the past, in the hope that proactive

action or precautions may be taken to minimize the chances of similar complaints

arising again in the future. The Hospital management should be, therefore,

aiming to enhance proactive mining of the complaint cache that exists in the

Hospital authority, so as to develop a system to more sensitively monitor system

failures and to achieve organization-wide enhancements.

As most medical colleagues are aware, the term ‘clinical iceberg’ is used to

describe the phenomenon whereby the visible part of a disease—that which is

detected or diagnosed— is only the ‘tip of the iceberg’. What may matter even

more is that there might be a significantly greater part which has not yet been

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uncovered. We may perhaps use the same analogy to consider what may be

usefully gained from the complaints process. It may be that what we can see

from the complaints received is only the tip of the ‘complaints iceberg’.

Nonetheless, just as it is useful to work from what is visible to try to discern

pointers as to what is happening in the greater, unearthed portion, so there may

perhaps be useful ‘lessons to learn’ from a sampling of the cases which have

been received over the years.

Importance of facing complaints as challenge Better management of grievance and complaints in the hospital improves the

quality of care. As a hospital you should be a customer focused organization and

highly value patient and family rights. The Hospital is supposed to establish a

complaint handling process that fully assists its valuable customers in reporting,

investigating and responding to their raised concerns. You should encourage our

patients and their family members to freely raise and discuss their concerns with

the concerned health care team members of doctors, nurses, and service

coordinators in the wards, who always try to address and resolve these issues on

the spot. In case the ward staff is unable to resolve such issues, the patients and

families have the right to make a formal written complaint. The prescribed forms

and drop boxes should be available in all patient care areas.

The staff in the Health Complaints Office (HCO) should be available from in

working hours for a personalized complaint reporting mechanism and assistance

in resolving the raised concerns. If desired, representatives from senior medical,

nursing, and administrative leadership should be always more than willing to

meet the complainants in order to explore timely resolution of raised issues. The

hospital should be a learning and quality driven organization, and always

welcomes its valuable customers to freely raise their concerns or complaints and

views these as opportunities for improvement. Some hospitals are fearful of

grievance and complaints and try to conceal or resolve it without awareness of

other staff and costumers.

The potential value of clinical complaints as a means of improving quality of care

is accepted in overseas health care systems. In the United States, the Joint

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Commission on Accreditation of Health Care Organizations, in its publication

Using Quality Improvement Tools in a Health Care Setting, sets out a ten-step

model for monitoring and evaluation of health care quality including the collation

of patient complaints as an important step in carrying out a full evaluation of

health care quality standards. In the quality process as set out, it was also noted

that while the collation of complaints as an initial step was important, just as

important was the communication of results of the evaluation back to the source

of the feedback and/or complaint, thereby ensuring that the loop was closed and

that there was a genuine continuous quality ‘cycle’ at work. This is particularly

relevant to a health care organization. It is one of the most complexes of

professional organizations as professionals have a large degree of control over

such an organization a result, the ability of managers to influence decision-

making is more constrained than in other organisations5 and ways have to be

found to generate change from the bottom up, not just the top down. Hospital

doctors are unwilling to make changes unless they see benefits for their own

practices and patients. Similar recognition of the value of complaints can be

found from various studies in the United Kingdom, for example, the study by Bark

et al7 where 1007 complaints in 24 hospitals in the North West Thames region of

England were surveyed and various aspects of each of the complaints were

examined, including the nature of the complaint, the reasons for making a

complaint, and factors that could have prevented complaints. The authors

concluded that a better response to complaints at the clinical level by the staff

involved in the original incident was needed, staff training in responding to

complaints was essential, and monitoring complaints must form part of a more

general risk management programme. As a further recognition of the value of

complaints Good medical records and thorough documentation are very

important.

So that there is a dire need to establish procedure and envisage that there would

be a full investigation for each complaint case. So that individual complaints

could be satisfactorily responded to, and hospitals must vigorously investigate

and learn effectively from complaints and that investigation of complaints and

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incidents should be coordinated under a single senior manager. It would be

better to establish and strengthen the office and Health Complaint Office which is

mentioned in Human Resource Policy for Health in Afghanistan. The quality

officer or any other appointed one can follow and take action in this regard in

hospitals. Following please review the complaints, investigation and

recommended action to strengthen your learning in this regard.

Complaint case 1: Informed consent for teaching purposes

In a patient complaint which happened at a teaching and clinical session of the

gynecology clinic of a public hospital, the complainant was dissatisfied with the

hospital’s arrangement whereby she had to undergo vaginal examination 3 times

(one by the specialist and the others by two medical students). She alleged that

no prior consent for the vaginal examination for teaching purposes was sought

from her.

Observations and conclusion

The case was subsequently submitted to the Hospital Authority (HA) Public

Complaints Committee (PCC)—the final appeal body for patient complaints

within the HA— which ruled that:

• the specialist did not clearly inform the patient that the vaginal examination

by the medical students was for teaching purposes;

• no prior consent was sought from the patient for the vaginal examinations

by the medical students; and

• the medical students were not clear about the concept of patient informed

consent as reflected in their statements submitted during the complaint

investigation

Recommendations and follow-up actions

Following the PCC’s recommendations, a review was conducted by the HA on

the issue of patient consent for physical examination by medical students for

teaching purposes as part of the Authority’s risk management initiatives. Since

the review, the concerned medical staff has been reminded that prior patient

consent must be obtained. The case was also shared by all frontline staff through

the Risk Management Release (a corporate electronic publication on risk

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management) to prevent recurrence of similar problems. The PCC Secretariat

has also formally written to the deans of the medical schools drawing their

attention to the case and suggesting that they alert medical students of the

importance of patient consent for physical examination.

Complaint case 2: The importance of good medical records keeping

In a complaint against a public hospital for inappropriately discharging a patient

who was suspected to be suffering from peritonitis, the PCC noted that the

patient had had a history of Sjogren’s syndrome complicated by

thrombocytopenia and hyper viscosity for 8 years. She also suffered from

nephritis and was maintained on immunosuppressive therapy. She was admitted

to hospital A for fever and abdominal distension and was discharged 2 days later

upon stabilization. Six days later, the patient was admitted to hospital B through

the Accident and Emergency Department for a similar complaint and it was

treated as peritonitis. She was subsequently transferred back to hospital A for

further treatment.

Observation and conclusion

The complaint was received 2 years after the incident. During the course of

investigation, the patient’s medical records during the first episode of

hospitalization at hospital A were found to be missing. This had posed great

problems for the PCC in reconstructing the chronology of events and what

transpired when the patient was hospitalized. The hospital had made tremendous

efforts to retrieve other available evidence, including medical information in the

computerized laboratory results report, the prescription records during her

hospital stay, and the discharge summary. These records revealed that

abdominal parencentesis was not indicated during the patient’s hospitalization,

that her condition at the time of discharge was stable, that she was not on

antibiotics during her hospital stay nor upon discharge and that a follow-up

appointment was only scheduled for 3 weeks’ time. Based on expert advice, the

available medical information and circumstantial evidence during the patient’s 2-

day stay in hospital A, the PCC concluded that it was unlikely that the patient was

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suffering from peritonitis at the time. The allegation of inappropriate discharge of

the patient was unsubstantiated.

Recommendations

Good medical records and thorough documentation are essential in responding

to complaints and claims. They provide an objective record of treatment of a

patient. Arising from this case, the PCC had made a general recommendation to

remind management and staff of all HA hospitals on the importance of proper

record management.

Complaint case 3: Use of less flammable disinfectant

In a complaint against a public hospital for causing a burn injury to the patient

during an emergency appendectomy operation, the PCC noted that the patient

was suffering from acute appendicitis. Emergency appendectomy under general

anaesthesia was arranged. After induction and intubation, Hibitane, a

disinfectant, was used to prepare the patient for operation. Bleeding was noted

during the operation. To stop the bleeding, coagulation diathermy was applied.

When diathermy was applied for the second time, smoke was noted coming out

beneath the drapes covering the patient. A longitudinal burn was subsequently

found on the patient’s right loin and upper part of the right buttock.

Observations and conclusion

Although the blue flame generated by fire involving Hibitane would normally not

be visible under operating theatre lighting, the Committee considered that the

patient’s injury was caused by accidental diathermy burns as a result of

inadvertent collection of excessive Hibitane beneath the drapes covering the

patient.

Recommendations

Since Hibitane is an inflammable disinfectant used to prepare patients for

operation, the Committee recommended that extra care should be exercised

when applying the disinfectant and diathermy in any operative procedure.

Follow-up actions taken by the hospital

Following the Committee’s recommendation, the hospital reviewed and

considered the use of an alternative and less flammable disinfectant other than

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Hibitane for preoperative preparation of patients to prevent future recurrence of

similar incidents.

Six rules for pursuing hospital complaints through patient’s perspective

Rule 1: Know your patient rights - before you file your complaint. It is believed

that you should familiarize yourself with your hospital's patient rights policy before

you file your complaint. You can then cite the patient right that applies to your

particular complaint, should you choose to do so.

Rule 2: Be pro-active and persistent when pursuing hospital complaints. Many

patients are reluctant to complain because they fear "retaliation" by hospital

employees. This is unfortunate. Hospitals want to maintain a positive reputation,

and avoid potential negative publicity. More importantly, it is your health that's at

stake - far better to be pro-active and persistent as a means of getting action for

you or your loved one, than it is to be passive and never get the complaint

properly addressed.

Rule 3: Act quickly - don't delay. Delaying the filing of your complaint is a

mistake. File the complaint when the information is still fresh in your mind.

Rule 4: Be thorough, and clearly state the facts. Be tactful. Explain your

complaint thoroughly - what exactly is the complaint, who was involved, what are

the time frames. Whether you are writing or speaking, state the facts in clear,

understandable terms. Also, be tactful.

Rule 5: Start your complaint process directly with the hospital. Patients are

encouraged to first file their complaints directly with the hospital. It’s believed that

it is best to resolve your complaint locally, if possible.

Rule 6: File your complaint with external organizations, if necessary. If you get no

resolution after filing your complaint directly with the hospital, we suggest

promptly filing your complaint with one or more external organizations.

Patients’ rights It is very necessary for hospital staff to familiarize themselves with hospital's

patient rights. You should develop the patient’s rights base on your setting and

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just paste it in public area to be visible by all your costumers. Costumers can

then cite the patient right that applies to their particular complaint.

The Joint Commission, which is the national accrediting organization for most

hospitals in many countries, adopted patient rights standards many years ago.

All hospitals accredited by the Joint Commission are required to adopt their own

patient rights policies based on the Joint Commission's standards, and to provide

a copy to each patient. These patient rights policies are routinely provided by the

hospital to patients and their families during the pre-admission or admission

process. Here are the Joint Commission's patient rights standards.

• The hospital respects the rights of patients.

• Patients receive information about their rights.

• Patients are involved in decisions about care, treatment and services

provided.

• Informed consent is obtained.

• Consent is obtained for recording or filming made for purposes other than

the identification, diagnosis or treatment of the patients.

• Patients receive adequate information about the person(s) responsible for

the delivery of their care, treatment, and services.

• Patients have the right to refuse care, treatment, and services in

accordance with law and regulation.

• The hospital addresses the wishes of the patient relating to end-of-life

decisions.

• Patients and, when appropriate, their families are informed about the

outcomes of care, treatment, and services that have been provided,

including unanticipated outcomes.

• The hospital respects the patient's right to and need for effective

communication.

• The hospital addresses the resolution of complaints from patients and

their families.

• The hospital respects the needs of patients for confidentiality, privacy, and

security.

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• Patients have a right to an environment that preserves dignity and

contributes to a positive self image.

• Patients have the right to be free from mental, physical, sexual, and verbal

abuse, neglect, and exploitation.

• Patients have the right to pain management.

• Patients have a right to access protective and advocacy services.

• The hospital protects research subjects and respects their rights during

research, investigation, and clinical trials involving human subjects.

• In hospitals that provide opportunities for work, a defined policy addresses

situations in which patients work.

Right to billing information: Under Organization Ethics, there is an "element of

performance" which states: "Patients receive information about charges for which

they will be responsible."

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Session 11: Hospital Information System

The HMIS is a system based on qualitative and quantitative indicators where

data is collected, processed, analyzed, interpreted, disseminated, and used to

improve the provision of health services according and ultimately to improve the

health of the population. In addition, the information generated can be used for

research and training purposes.

A hospital information system (HIS), variously also called clinical information

system (CIS) is a comprehensive, integrated information system designed to

manage the administrative, financial and clinical aspects of a hospital. This

encompasses paper-based information processing as well as data processing

machines.

It can be composed of one or a few software components with specialty-specific

extensions as well as of a large variety of sub-systems in medical specialties.

CIS are sometimes separated from HIS in that the former concentrate on patient-

related and clinical-state-related data whereas the latter keeps track of

administrative issues. The distinction is not always clear and there is

contradictory evidence against a consistent use of both terms.

The advance Hospital management system is a web based software system

which regulates each and every function of Hospital with 50-1000 beds. The

software registers a patient, recommends him the required treatment, and gets

admitted. That means right from Patient Registration, OPD, Ward Management,

Radiology, Pathology, Pharmacy, Store, Inventory, HR & Payroll, Finance &

Accounts, Help Desk, kitchen & Laundry, MRD, Dash board, MIS Reports you

have all the modules integrated and functional with our package. A person who

enters the cycle by getting registered and till the time he gets out of the cycle by

finally settling his/her bills and getting discharged from the hospital is all the

automated. All the process during his entry to exit is also performed by different

modules deployed at different locations which is all integrated and made

functional.

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Working principles for revising the HMIS

The working principles which is developed and applied are worth of mentioning

here and it should be taken into account when the hospital is collecting data or

health information.

1. Any data to be recorded at a service level must have a use (action) in

terms of case or community management by staff or community members

at that level.

2. Proposed changes should simplify the existing system.

3. Any changes or developments to data recording and reporting should be

made only to improve the provision of care at the patient and community

level, particularly for those populations most in need.

4. Great prudence should be applied when making changes to components of

health information systems that are working fairly well. If it is working well

now, don't fix it.

5. Efforts should be made to make better use of existing data at all levels

through practical analysis and improved presentation of data.

6. Modest use of computerization should be encouraged and supported for

data base maintenance and report generation.

7. Improvement in health data generation and use at the various service

levels should be undertaken in support of efforts to improve service task

performance and be seen as a by-product of such performance

improvement.

Criteria for Health Indicator selection

Health Indicators, in particular those obtained through routine reporting systems,

should be chosen for national use with the following criteria in mind:

1. Useful for action at the recording level - The data needed for the indicator

is useful for the person doing the recording (manager, staff, community

leader or patient) and the recorded data contributes to necessary action

being take with regard to the case, family, community or district being

served

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2. Valid, consistent, reliable and sensitive - The indicators should have been

proven capable of being recorded across the service with the necessary

degree of validity, consistency and reliability, and be sensitive to short

term changes in the variable of interest.

3. Ease of Generation and Measurement.

4. Understandable - The indicator should deal with a single clear idea which

everyone will see as an important measure.

5. Representative - Indicators should be selected that can be a measure of

health status or service performance beyond the immediate event or task

being reported.

6. Relevant for National and Program Monitoring

7. Ethical - Data collection, including the choice of the data source,

computation of the indicator and its use should not conflict with accepted

ethical values, and follow the values of the MOPH.

Importance of Health Information System

By increasing the population of the country and rising hospital management

costs, 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 today’s healthcare system. The critical questions facing

the hospitals and other healthcare institutions 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; and

how do we most 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 hospitals systems. The answers is

developing the new generation of Hospital Information System (HIS) or Hospital

& Information Management System (HIMS) that would be powerful, flexible and

easy to use and would have been designed & developed to deliver real

conceivable benefits to hospitals. The Health Management Information System

(HMIS) in Afghanistan has been conceived by a group of technical and

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professionals with rich and relevant experience in healthcare system. The system

incorporates the healthcare practices which is relevant to BPHS and EPHS and

is designed to deliver key tangible benefits to clients across the heath system

including governmental and non-governmental organizations.

Offering HIMS is comprehensively a revolutionary solution with end-to-end

features for simplifying hospital management. Access to the right information and

the automation of complex tasks & workflow is the key focus of the HMIS and

HMIS, enabling freeing the staff to spend more time on caring for patients and

extending the reach of services.

An HMIS for a hospital would require being very precise and must result in

operational cost reduction, process improvement and efficient management. We

should develop a HIMS solution which would be very accurate in its approach

and suits all environments including large, medium or small hospitals. That is a

need to be taken into account and accomplished by MoPH as an initiative. The

support maybe solicited from private sectors and donors. The new generation of

HIMS should be designed in such a way to cover a wide range of hospital

administration and management processes. It should be integrated to other

databases and with great stability and flexibility. It should be easily customized to

suit the requirements and reflect the priorities of a hospital management team.

By enabling a smooth flow of patient information, the HIMS will enable hospitals

and doctors to better serve their patients. Additionally, the HMIS provides a host

of direct benefits such as easier patient record management, reduced paperwork,

faster information flow between various departments, enhanced availability of

timely and accurate information, reduced length of stay, reduced test requests,

greater organizational flexibility, reliable and timely information, easier resource

management, minimal inventory levels, reduced wastage, reduced waiting time

at the counters for patients and reduced registration time for patients. The

indirect benefit would be an improved image of the hospital and increased

competitive advantage. The HIMS optimizes the resources to be deployed and

helps in prioritizing the developmental activities of the hospital. The system not

only provides an opportunity to the hospital to enhance their patient care but can

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also increase the profitability of the organization. The Return on Investment

coupled with an enhanced image of the hospital act as drivers for healthcare

providers to invest in the HIMS that will keep their patients satisfied. Based on

view points of scholars the patient satisfaction is quality.

Hospital Information System Forms in MoPH After development of HMIS in 2003, efforts have continuing to include secondary

and tertiary service delivery units in the system. Fortunate the second version of

HMIS manual has presented some forms for collection of data from Hospitals.

They are briefly described here. Following forms are used for data collection from

hospitals. For more detail please refer to actual forms at the annex of this

module.

• Monthly Integrated Activity Report (MIAR)

• Hospital Monthly Inpatient Report

• Hospital Status Report

Monthly Integrated Activity Report – Facilities OPD (MIAR)

Services Report 1. Purpose of the Form

This reporting form has been designed to consolidate into one document most of

the data about health services offered at the BHC/CHC level and the out patient

hospital level. This form is used by BHCs, CHCs, and Hospital outpatient

departments and emergency rooms.

2. Lay-out of the Form

This document is a 2-page form printed on A-4 paper, so that the different

sections are not separated. The form consists of the following main sections:

A. Morbidity of Priority Health Problems

B. Nutrition status

C. Maternal & Neonatal health

D. Stock-outs of Essential drugs and commodities

E. Immunizations

F. Laboratory Exams

G. Tuberculosis

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H. Community Health

I. Report Transmitted

J. Report received/Aggregated

K. Comments

3. Data Sources

The data for this report comes from 9 principal sources:

1. OPD Tally sheet

2. The Antenatal Care Register

3. The Maternity Register

4. EPI register

5. Nutrition Surveillance Register/Child Clinic Register

6. Stock Register

7. Family Planning Register

8. Lab Register

9. TB Register

Some organizations use different registers for each of these data sources; others

combine some of the data sources into one form. Use the form in your facility

which corresponds with the listed data source. The MOPH is testing a tally sheet

in conjunction with a patient card for the sections A, B and C of this report. If the

tally sheet is used, write totals in the corresponding boxes of the MIAR.

4. Person who prepares

Staffs responsible for the various services contribute the data related to their own

activities (e.g., the midwife for data on obstetric care, the Lab technician for

laboratory data, etc.). The senior staff member of the team reviews the report for

accuracy and completeness before signing it and sending it to the PPHO. OPD

attached to Hospitals should also complete a BHC/CHC Monthly activity report in

addition to the Monthly Inpatient Report. Hospital maternity wards (district,

provincial, regional) should use the MIAR for all obstetric services, except for

caesarean and other obstetric surgery services.

5. Definitions

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This form is the key data collection instrument to collect most data required to

calculate HMIS indicators for the BHC/CHC and outpatient hospital level. At the

provincial health office level, data from the forms of all facilities is aggregated to

calculate the indicators at the provincial level.

6. Instructions

This form has a total of 11 sections (A to K).

General information

Province name & code: Write the name and the Geocode of the province where

the facility is located. Use official reference lists to find the name and Geocode.

District name & code: Write the name and the Geocode of the district where the

facility is located. Use official reference lists to find the name and Geocode.

Facility name: Write the full name of the health facility reporting

Facility code: Write the ID code assigned by the MOPH to this facility

Month: Write the number of the month for which the data is being reported

(usually this will be the month prior to the current month)

Year: Write the 4 digit year (shamsi calendar) for which the data is being

reported.

Facility Type: Circle the type of facility, for hospitals, circle the type of hospital:

H1 for regional/national hospitals, H2 for provincial hospitals, H3 for district

hospitals.

Patients/clients: Totals for the corresponding row and column in the MIAR Tally

Sheet are written in each cell. Write the sum of the four preceding columns under

the column labeled “Total new.”

A. OPD Morbidity

In this section, record information about morbidity and visits to your facility during

the month. This information is gathered from the OPD tally sheet. Totals for the

corresponding row and column in the Tally sheet are written in each cell. Write

the sum of the four preceding columns under the column labeled “Total new.”

Use the comments section to highlight any unusual cases that you treated or to

explain any disease trends that you have noticed in the catchment area of your

facility.

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B. Nutrition Status

Write the totals of the corresponding cells of the tally sheet in each cell.

C. Maternal Health

Write the totals of the corresponding cells of the tally sheet in each cell.

D. Status of Stock of Essential Drugs

Go through the stock register (and check shelves where you may keep drugs for

day to day distribution) and place a cross (X) in the box to the left of any of the

indicator drugs (listed below) which was not present for one or more days during

the month. Situations, in which a couple of tablets of a drug remain, but not a

number sufficient to serve patients, should also be considered as the drug not

being present. If the drug was present every single day of the month, a tick-off

( ) should be placed in the box to the left of name of the drug name:

X = during the last month, this drug was not present one day or more

= during the last month this drug was present every single day

Although the stock position of all drugs should be monitored regularly, the

following is the list of essential drugs for which the stock status should be

reported monthly:

Oral contraceptive

Injectable contraceptive Acetyl Salicylic Acid/Paracetamol , Mebendazole

Amoxicillin/Ampicillin, INH, Rifampicin, Amp. Diazepam, Inj. Lidocaine

Metronidazole ,Co-trimoxazole, Anti-hypertensives, Condoms, IUD, TT vaccine

DPT vaccine, ORS, Vitamin A, Chloroquine, Sulfadoxine + Pyrimethamin

Ferrous Suplhate + folic acid, Oxytocin, Gloves, D2.

Comments about stock situation: Use this space to note any special drug stock

problems – this could include overstocks, understocks, expiring drugs that have

been destroyed, drugs that were received in bad condition.

E. Immunizations

E1. Childhood Immunizations: Record in the boxes the total number of doses of

DPT3 administered by age group. “Total” is the sum of all children who received

DPT3: 0-11 + 12- 23 + children two years and older. This information can be

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found in the EPI Monthly Vaccination Activity Report. Similarly, from the same

report note for each age group, the doses of vitamin A administered. “Total” is

the sum of all children:0-11 + 12-23 + older children who received vitamin A.

E2. TT Immunizations

Record the total number of Tetanus Toxoïd immunizations given to pregnant

women. In the column TT2, list the number of TT2 doses given. In the column

>TT2, list the sum of all TT shots given after the second shot (TT3,TT4, c) This

information should be calculated from the EPI monthly tally sheet.

F. Laboratory Exams:

Although many facilities conduct a number of other lab tests that should be

recorded in the laboratory register, only the following tests and test results should

be reported because they confirm diagnoses of priority health problems. If

necessary, use a tally sheet to abstract the data from the laboratory register.

F1. Blood

Total malaria slides examined: total blood slides examined from for

malaria

Total PF positive: slides positive for Plasmodium Falciparum

Total other Positive: slides positive for Plasmodium Vivax or other

plasmodia, but not for Plasmodium Falciparum

Total HIV examined: total blood specimen examined for HIV

Total HIV positive: number of blood specimen positive for HIV

F2. Sputum

Total AFB slides examined: all sputum slides examined for AFB

Total AFB positive: number of slides found AFB +

G. Tuberculosis

This section is only filled out if the facility is involved in tuberculosis diagnosis

and treatment.

G1. Case detection

Number of new smear (+) cases: from the Monthly Report on Tuberculosis

Case- Finding: Sum of male and female pulmonary smear (+) cases.

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Number that started treatment: from TB Treatment register: all smear (+)

patients with a treatment start date within the past month and a pre-

treatment positive lab result.

G2. Treatment success

Number of cases completed treatment and smear (-): from the TB treatment

register: all initially smear (+) patients that completed their treatment and tested

negative after they completed the treatment.

H. Community Health

1. No. of community meetings held with the community health committee:

number of meetings held in which the facility staff went to the village to meet with

the health committee

2. Number CHWs visited for supervision: obtained from the CHW supervisory

log.

I. Report Submitted

These details should be completed to trace the submission of the report. The

boxes should be filled by the health worker in charge of the facility who prepared

the report or checked the report for completeness before sending it to the PPHO.

Name: Enter the name of the health worker who was in charge of the facility at

the time the report was submitted,

Designation: Enter the designation of the person submitting the report.

Date: Write the date that the completed report was submitted (i.e., mailed or

dispatched by courier).

Signature: Sign the report.

J. Report received/aggregated

Date Received: The in-charge in the Provincial Health Directorate who receives

the report should note the date that the report was received at the office. This

should be recorded in the dispatch/receipt register.

Date aggregated: The person who completes the aggregation of the data on

paper or the entry of the data onto the computer should enter the date that the

report was aggregated / entered.

K. Comments

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Use this space to note special activities or problems in the BHC/CHC or

community during the reporting period or to explain significant trends or

anomalies in morbidity or service delivery. Add an extra sheet, if required. This is

an important mechanism to communicate important issues to your supervisor

and to explain your analyses of health problem and service trends.

7. Submission Guidelines:

This report is to be prepared by the staff member responsible for each of the key

service areas included: Ante-Natal Clinic, Maternity, Nutrition/Child Clinic,

Reproductive Health service, Laboratory, and Pharmacy. The data are reported

from all OPDs: Hospitals, BHC and CHCs. For hospitals, the emergency room

also fills out this form; the in-charge of the hospital combines the data of the OPD

and the emergency room into one MIAR. The in-charge of the health facility must

review the report for missing data and other anomalies, note any comments

about important trends or problems in the catchment area and dispatch it to the

PPHO within 7 days of the end of each month. A copy of each report should be

kept in a chronological file within the facility.

Hospital Monthly Inpatient Report (HMIR)

1. Purpose of the Form

The purpose of this form is to report about inpatient activities, services, morbidity

and mortality at district, provincial and regional hospitals. The primary focus is on

indoor patients and referral services.

The hospitals report maternity care, outpatient services, and laboratory services

using the same Monthly Integrated Activity Report (MIAR) that is completed by

Basic Health Centers (BHCs) and comprehensive Health Centers (CHCs.)

2. Lay-out of the Form

The form contains nine sections:

A. Indoor patients

B. Nutrition of under fives

C. Imaging services

D. Other Surgical services

E. Stock out of hospital drugs

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F. Cases and deaths of priority diseases

G. Comments

H. New inpatient cases

I. Report submission

3. Data Sources

The data for the form comes from:

• Indoor Patient Registers of each departments (including nutrition)

• Daily Indoor Patient Census of each departments

• Operating Theatre Registers

• X-ray and Ultrasound Register

• Pharmacy

4. Who prepares

This form is mainly used to report information about referral services provided at

district, provincial and regional hospitals. The document is prepared by the staff

of the various departments and then compiled under the supervision of the

Hospital Director. The report is sent to the PPHO by the 7th day of each month.

The PPHO enters all hospital data into the HMIS database and sends a quarterly

electronic copy to MOPH/HMIS

5. Definitions

Most of the terms on this form are self-explanatory. There are two calculated

entries:

Number of Patient Days: This number is an indicator of the volume of indoor

patients who are treated during a given month. An example for the calculation of

this indicator is included below in the Detailed Instructions.

Average length of stay: This number is an indicator of the efficiency of

hospitalization. To calculate this indicator, take the sum of the duration of

hospitalization for all patients who were discharged during the month and divide it

by the total number of patients discharged during that month. An example for the

calculation of this indicator is included below in the Detailed Instructions.

6. Detailed Instructions

General information

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Province Code & Name: Write the Geocode and the name of the province

where the hospital is located

District Code & Name: Write the Geocode and the name of the district where

the hospital is located

Hospital Name: Write the name of the hospital

Facility Code: Write the MOPH ID code that identifies the Hospital

Type of hospital: Tick H1 (National or specialized hospital), H2 (Regional or

provincial hospital, H3 (District hospital)

A. Indoor Patients

Using the Indoor Patient Register, provide a summary of patient movements

during the month in the categories listed below. For each of the listed categories,

write the total number of children under five, females over five and males over

five.

1. Admissions: all patients admitted as inpatients. Note that maternal and

neonatal data related to deliveries performed at the hospital are noted on the

MIAR. However, those hospitalized are included in the general admission

register and counted here.

2. Referred-in: count those who have been referred-in from other health

facilities, including those who originated in your hospital’s outpatient

departments.

3. Deaths: all inpatients who died in the hospital before being discharged

4. Number of Patient days: Add together the number of patients who stayed

each night during the month. See the box below or an example.

6 7 8 4 4 8 8 5 5 6 7 9 10 7 8 5 3 4 4 6 7 7 7 7 8 5 8 8 8 5 x total =191

For example, if there were 6 people on the 1st, 7 on the 2nd, 8 on the 3rd, etc.,

the number of patient days would be 6+7+8+etcc or at total of 191. In the

example, the month has only 30 days, so day 31 is not counted. The number of

daily inpatients should be obtained from the census conducted each morning.

The number of patient days per month when combined with the number of

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available beds during the same period allows calculation of the bed occupancy

rate.

Average length of stay: sum of the duration of hospitalization for all patients

who were discharged during the month divided by the total number of patients

who were discharged or died during that month. In the example given, 23

patients were discharged or died during the month and they stayed in the

hospital for a total of 191 days: an average length of stay of 8.3 days.

Average length of stay

Number of patients

discharged or died

Number of days for stays Average days

hospitalized

23 Total =191 ALS=191/23=8.3

5. Discharged: Note the total number of inpatients discharged. For the

discharged patients, write the total that corresponds to each category:

a. Recovered/improved: inpatients that were discharged because their status

improved, including those who need some further ambulatory care

b. Absconded/defaulted: patients that are no longer hospitalized, but whose

whereabouts are unknown. Ideally, this number should be zero.

c. Not Improved: patients who were discharged without improvement in status.

This includes patients whose status did not improve, for whom no further

treatment is useful.

d. Referred-out: those patients who have been referred to other medical

facilities for more specialized care.

B. Nutrition of under fives

Only malnourished children who need hospitalization are taken into account.

Ambulatory screening and treatment of the nutritional status of children under

five is noted in the MIAR.

1. Admitted: Number of malnourished children admitted into the hospital

2. Improved: Number discharged with improvement

3. Defaulter: dropped out, left the hospital before being discharged

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4. Referred out: Number of hospitalized malnourished children referred to other

facilities for more specialized care

5. Deaths: number of malnourished children who died

C. Imaging services

Using the imaging department records, report the number of images taken during

the month according to the following categories:

1. Chest x-ray

2. Abdomen x-ray

3. Skeletal x-ray

4. Other x-ray

5. Ultrasound

D. Other Surgical interventions

Using the operation theatre (OT) register, you record the total number of surgical

interventions of the following types that were performed during the month. Be

sure to sort them out by Major (under general anesthesia) and minor (under local

or regional anesthesia) interventions.

1. Gynecological: all gynecological interventions, except obstetric interventions,

which are already captured in the MIAR. This includes all interventions on the

female genital tract and breast.

2. ENT

3. Eye

4. Orthopedic: all orthopedic and traumatic surgery not pertaining to any of

those listed under 1, 2, 3.

5. Others: any surgical intervention, not listed under F1, F2, F3, F4.

6. Total: total of the above

7. Post operative deaths: number of patients who die within 10 days of surgery

8. Post operative complications: number of patients who have complications of

the surgical intervention: local or general infection; bleeding; re-intervention.

9. Blood transfusions: the number of patients who received a blood transfusion.

This also includes patients who undergo cesarean sections and other obstetric

surgery.

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10. Blood transfusion reactions: number patients with adverse reactions

following blood transfusion. This also includes patients who undergo cesarean

sections and other obstetric surgery.

E. Stock status of hospital drugs

Go through the stock register (and check the shelves where you may keep some

drugs for day to day distribution) and place a cross (X) in the box to the right of

any of the following indicator drugs that was not present for one or more days

during the month. Situations, in which a couple of tablets of a drug remain, but

not a number sufficient to serve patients, should also be considered as the drug

not being present. If the drug was present every single day of the month, a tick-

off X) should be placed in the box to the left of the name of the drug:

X = during the last month, this drug was not present one day or more

= during the last month this drug was present every single day

Although the stock position of all drugs should be monitored regularly, the

following is the list of essential drugs whose stock status should be reported

monthly:

Arthesunate inj

Atropine inj

Benzathine Penicilline inj

Digoxine

Ergometrine inj

Furosemide inj

Gentamycine inj

Iodine poluvidone

Ketamine inj

Lidocaine 5% spinal inj

Magnesium Sulphate

Morphine inj

Naloxone inj

Hydralazine inj

Oxygen

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Pethidine inj

Phenobarbital inj

Quinine inj

Ranitidine inj

Ringer lactate IV

Salbutamol inj

Sodium chloride IV

F. Cases and Fatalities for Priority Diseases

Using the indoor patients register, note the total number of admissions and

deaths for the following priority diseases/health problems. To simplify calculation,

record only the total deaths and total admissions during the month – even if

some of the deaths may have been from admissions during previous months. Be

sure to focus on admissions and death in <5 children for Diarrhoea, ARI with

pneumonia, Measles.

G. Comments

Note any particular issues or trends that you wish to highlight at the central level

H. New Indoor Cases of Morbidity

Using the indoor patient register, tally up the number of patients admitted during

the month for each of the priority health problems/diseases listed. Include only

inpatients, do not include outpatients. Cases definitions are given in Annex 3.

I. Report Submission

This section should be filled out by the person responsible for submitting and

receiving the report.

Report Submitted

These details should be completed to trace the submission of the report. The

boxes should be filled by the hospital in-charge who prepared the report or

checked the report for completeness before sending it to the PPHO.

Name: Enter the name of the hospital in-charge at the time the report was

submitted,

Designation: Enter the designation of the person submitting the report.

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Date: Write the date that the completed report was submitted (i.e., mailed or

dispatched by courier).

Signature: Sign the report.

Report received/aggregated

Received by: Initials of the person at the PPHO who receives the report

Date Received: The in-charge in the Provincial Public Health Office who

receives the report should note the date that the report was received at the office.

This should be recorded in the dispatch/receipt register.

Aggregated/computerized by: Initials of the person(s) who aggregates /

computerizes the report

Date aggregated: The person who completes the aggregation of the data on

paper or the entry of the data onto the computer should enter the date that the

report was aggregated / entered.

7. Submission Guidelines:

This report is to be prepared by the staff member responsible for each of the key

service areas included. The data are reported from all Inpatient departments. The

in-charge of the hospital must review the report for missing data and other

anomalies, note any comments about important trends or problems in the

catchment area and dispatch it to the PPHO within 7 days of the end of each

month. A copy of each report should be kept in a chronological file within the

hospital.

Hospital Status Report Form (HSR) R-2)

1. Purpose of the Form

The purpose of this form is to report on the physical facility and human resources

available at the Hospital. This form also captures some hospital activities that are

not directly clinical activities. The hospital staff and provincial level health

authorities use this information to assess the adequacy of physical facilities and

human resources to ensure uninterrupted health services at the hospital. While

usually required on an annual basis, during periods of rapid expansion of or a

change in the level of health services, the MoPH may require the report on a six-

monthly or quarterly basis.

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2. Lay-out

The form is an A4 two page (four sides) form, printed in landscape mode.

The report contains 7 sections:

A. General Hospital Information

B. Human Resources

C. Supervision

D. Equipment list

E. Services provided

F. Remarks and observations

G. Report submission

3. Data Sources

The data for the form comes from

1. Inventory Register

2. Visitor’s Book

3. Facility inspection

4. Various activity records (e.g. Health Education)

5. Staff records

6. Diary or register of IEC and other activities

If records are not available or are incomplete, the in-charge of the facility will

personally check the accuracy of the required information and complete the

information. If data is ultimately not available for a reporting period, the in-charge

will note “NA” in the corresponding entry.

4. Who Prepares

The in-charge of the hospital prepares two copies of this form. When reporting

annually, one copy is submitted to the PPHO by the 15th of Hamal each year, or,

when reporting six monthly or quarterly, submitted by the 15th of the month after

the last month in the reporting period. Another copy is filed at the hospital for

future reference.

5. Definitions

MD medical doctor

CHW community health worker

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6. Instructions

A. General Facility Information

1. Province Code & Name: Write the Geocode and the name of the province

where the hospital is located

2. District Code & Name: Write the Geocode and the name of the district where

the hospital is located

3. Hospital Code & Name: Write the MoPH ID code and the name of the

hospital

4. Type of hospital: circle H1 (National or specialized hospital), H2 (Regional or

provincial hospital, H3 (District hospital)

5. Period: Write the months (fromc to c.) and the year (ofcc) for which the

report is being prepared. Dates should reflect the Afghan Shamsi calendar.

When the report is prepared annually, note that this year is not the same as the

year you are preparing the report. When you are reporting more frequently, the

same is true for the first reporting period of the year. For example, if you are

preparing the report in the month of Hamal of 1381, write 1380 here because the

report you are preparing is for year 1380.

6. Building: A building is considered temporary if the building’s original and

permanent future intended use was/is use for something other than a health

facility.

Examples of temporary buildings are tents and prefab structures used while the

hospital building is being renovated or enlarged, schools or other public buildings

used as health facilities, rented houses, shops, or other buildings. A building is

considered permanent if the original or permanent future use is as a health

facility.

7. Main construction material: circle concrete or other. “Concrete” means

having at least a concrete base and concrete supporting beams for walls and

roof (in theory, earthquake proof. The “concrete” reflects the Dari term “ پخته ” and

the “other” reflects the Dari term “ .”خام

8. Main source of drinking water: this refers to the usual source of drinking

water. If a facility normally uses a water tap, except for the dry months, when it

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uses a well, the main source of drinking water is the water tap. Safe means water

obtained from a covered deep well, a tube well with a covered base, piped water,

and/or chlorinated water from closed containers. Other means all other sources.

9. Main source available: Write the number of months the main source of

drinking water is available; write “12” if the source is available throughout the

year.

10 Electricity: circle YES if available, even only a few hours a day, and NO if not

available at all.

11. If Electricity is YES, indicate the main source of electricity by ticking any

one of the options. If the facility relies usually on line electricity, and has

generator backup, only line should be ticked.

12. Indicate the Average hours per 24 hours that electricity from the main

source is available, e.g., if line electricity is available six hours a day and a

generator is used two hours a day on average, write “six”

13. On drivable road: Circle YES or NO to indicate whether or not the facility is

located on a drivable road.

14. If not, walking time from road: If the answer is “No,” write the number of

hours and minutes needed to walk to the nearest drivable road, e.g., 90 minutes,

note as 1 hour 30 minutes. A “drivable road” is any road regularly used by

motorized vehicles, regardless of its shape or condition.

15. Referral facility name & code: write the name and the MOPH ID code of the

most frequently used referral facility--the general facility (hospital) that is most

often used for complicated cases. Many facilities can use a specialized hospital

(e.g., eye hospital) for specific cases – do not write the name of this hospital.

16. Latrine for use by patients: circle YES if there are latrines for patients, NO

if not. If the facility has latrines for use by staff of the facility only, the answer

should be NO.

17. If Yes, type: If YES is circled, mark the type of latrine. Open means that flies

and other animals have access to the waste, e.g., the traditional Afghan latrines.

Closed means flies and other animals have no access to the waste, e.g., VIP

latrines, flush latrines, etc.

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18. Separate latrine for male and female: circle YES if there are separate

latrines for men and women, circle NO if there are not.

19. No. of Beds: Write the number of patient beds currently available at the

hospital for each of the wards. This includes both occupied and unoccupied

beds.

20. Waste disposal: Circle YES or NO as to whether the facility has a special

area for medical waste.

21 If YES, type: mark the type of waste disposal. Incinerator means a special

device to completely burn the medical waste. Burn and bury means a place

where waste is accumulated, then burned and buried at regular intervals.

(Beware that an oven-like construction is often referred to as “incinerator” in

Afghanistan when it really is a “burn and bury.” ) Other means any other than the

afore-mentioned or none.

24. Main source of support: write the name of the agency that delivers the

greatest regular support to the facilities’ activities. This can be the MOPH, a

specific UN agency, an NGO, a donor. If it is a UN agency, NGO or donor, write

the specific name.

25. Other sources of support: write the specific name of all other agencies that

support the facility in one way or another.

B. Human Resources

The staff categories listed is those listed in the BPHS for hospitals. Note that a

DH has staff required for BPHS and additional staff for the EPHS. Write down the

number of female and male staff of each category. Write the number of staff in

each category who are certified according to the new MOPH certification rules

and the number of staff who attended at least one refresher training during the

last reporting period.

B2. Physicians

11. Medical Specialist: any MD specialist who is not a Surgeon, Anesthetist,

Pediatrician or Dentist.

B5. Support Staff

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34. Administrative staff: any clerks, computer operators, accountants, etc. The

in charge of the administration of the hospital is listed under management: 4.

Administrator

C. Supervision

Write the number of supervisory visits to this facility performed during the last

reporting period by the PPHO and by others (NGO, UN agency, and donor).

Count only supervisory visits, not monitoring or evaluation visits.

D. Equipment list

For each of the listed types of equipments, mark the number that are present in

the facility. The actual number is useful for the in-charge of the hospital. For

several items, the actual number becomes less useful for provincial and national

analysis. For larger facilities, the in-charge will have to sum reports from different

departments.

Usable: The equipment is new and complete, or some parts or accessories may

be missing but the equipment can still be used for its basic functions, e.g., some

clamp or forceps of the Minor Surgery Kit may be missing, but the kit can still be

used; however, if only a scalpel and needle holder are left, the kit is no longer

usable.

Not usable: pieces are missing or broken to the extent that the equipment

cannot be used for its basic function.

E. Services provided

Mark for each of the listed services whether or not they were provided on a

regular basis during the past reporting period.

E1. General Curative

2. IMCI implemented means that all modules of the IMCI are being

implemented: ARI, Diarrheal, Fever & malaria case management, EPI, growth

monitoring. All of the separately mentioned modules need to tick off as well. If

IMCI is not completely implemented, IMCI should not be ticked off, but the

specific services (ARI, DD, malaria, EPI, Growth monitoring) that are provided

need to be ticked off.

E2. Child Health

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4. Management of severely ill child means the treatment of referred, severely

ill children (IMCI classification).

E10. Community services

1. CHWs supervised once: write the number of CHWs who were supervised at

least once this quarter.

2. Health Post Active: write the number of Health Posts active and reporting to

this facility

3. Health Posts Supervised once: write the number of Health Posts supervised

at least once this quarter

F. Remarks and observations

Write all notable achievements, observations or experiences regarding the

functioning of the facility during the last reporting period in this space. For

example, if the facility was closed for a period of time, mention this as well as the

reason for the closure, or, if a particular service was not delivered during the

reporting period, provide the reason it was not delivered and suggest a remedy.

G. Report submission

Finally, the person that filled out the report should provide his/her name and

designation, as well as the date of the report, and sign.

7. Submission guidelines

The in-charge of the hospital fills out two copies of this report. When reporting

annually, one copy is sent to the PPHO by the 15th of Hamal of each year; the

other copy is filed and kept in the facility. When reporting more frequently, the

report is sent by the 15th of the month after the last month of the reporting

period.

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Session 12: Waste Management in Hospitals

Hospitals produce many types of waste material, housekeeping activity

generates considerable amount of trash, and visitors and others bring with them

food and other materials which must in some way be disposed of. In addition to

the waste that is produced in many residential buildings, hospital generates

pathological waste— blood soaked dressings, carcasses and similar waste.

These waste material must be suitably disposed of immediately lest they putrefy,

emit foul smells, and as a source of infection and diseases, and become a public

health hazard. While in developing countries many of the public health problems

are also related to defective sewage and waste disposal.

Many of our hospitals neither have a satisfactory waste disposal system nor a

waste management policy and disposal policy. The disposal of waste in

exclusively entrusted to the junior most staff from the housekeeping department

without any supervision, and even pathological waste are observed to be

disposed off in the available open ground around hospitals with scant regard to

aesthetic and hygiene considerations.

Waste can be defined as any discarded, unwanted residual matter arising from

the hospital or activities related to the hospital. Disposal covers the total process

of collecting, handling, packing, storage, transportations and final treatment of

wastes. On an average, the volume of total solid waste in hospitals in India is

estimated to range between 1- 3 kg per day on per bed basis. While the quantum

of waste in advanced countries is six to ten times more. The average refuge in

hospitals in Denmark and Germany is 14kg per bed per day. Unfortunately in

Afghanistan it is still not studied and low attention is given to this critical issue in

hospitals.

Types of wastes

Hospital waste can be divided into two major groups. The first group comprises

of mainly solid waste, and the second group mainly liquid waste. Waste covered

under group I include the following.

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Table: solid waste of hospitals

# Main category Descriptions

1 Dry garbage Ordinary floor refuse, papers, flowers, trash

2 Wet garbage Waste from kitchen ( fruit peels, left over food,

etc)

3 We tissues and bones From operational theatres labor rooms,

mortuary, laboratory

4 Plaster casts From plaster rooms

5 Packing materials Cardboard cartons, paper packets, etc

6 Surgical wastes Dressings, cotton pads

7 Metal wastes The cans, bottle caps. Needles

8 Glass Broken bottles, syringes

9 Disposable plastic items From all areas in hospitals

The group II of hospital waste covers sullage and sewage which emanates from

bathrooms, lavatories, toilets, kitchen, pantries, operations theatre, dressing

rooms, laboratory and laundry. To this must be added the waste from radiology

department comprising of chemical developers and fixers solutions. The quantity

of total liquid waste is estimated at 300 to 400 liter s per bed per day.

A third group of hospital waste is the radioactive waste from radiotherapy and

nuclear department (if available), usually in large teaching hospitals. The

quantum of such waste per se is very little, but requires and understanding of

principles of disposal of such wastes produced in the department itself and also

that excreted by the patients.

Then hospital waste disposal covers solid waste— whether biological or non

biological— that is discharged and not intended for further use, including

materials generated as a result of direct patient care activities— such waste can

be termed medical waste, and includes infection waste that can transmit the

disease (e.g. microbiological waste, discarded laboratory glassware and

materials, intravenous tubes, syringes, needles and dressings).

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Characteristics of a good waste disposal system

Incidents of inappropriate waste disposal and the fear of AIDS and Hepatitis have

drawn medical attentions to hospital waste management practices. Any good

waste disposal system should be planned for:

• Good appearance

• Safety

• Pest control

• Odor control

• Public health safety

The system should also be sanitary, economical and convenient. During the

planning stage attention should have been given to the routes by which garbage

and infected material are to be removed. In principle firstly the garbage and

infected materials should be removed from this point of origin by direct (and

shortest) routes without using hospital corridors. In tall building a lift for garbage

is necessary.

Secondly the movement of dirty and infected material should be restricted to the

minimum. Thirdly, handling and transportation of the waste within the hospital

premises should also be minimized.

Collection and Removal of wastes

Whatever the final method of disposal, collection is an important aspect. The

method of collection will depend upon the method of disposal. Collection can be

done in waste baskets, wheel barrows or in trash carts. Waste baskets made of

metal are preferable to wicker or wood for ease of cleaning. Trash carts should

have two sets of containers wherein after collection of dirty filled container, and

empty clean container is replaced in its place. Timing of collection and removal

should be convenient to all departments. It should be avoided during normal

hospital routine or while the patients are resting. Collection of removal should be

free of noise to avoid disturbing the patients. Trash removed in cans should be in

covered containers to avoid and unsightly appearance.

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Disposal of waste

Waste disposal is a problem that is rapidly assuming alarming proportions.

There is no epidemiological evidence to suggest that most hospital waste is any

more infective than residential waste. There is no also epidemiological evidence

that hospital waste has caused disease in the community as a result of improper

disposal. Therefore, identifying wastes for which special precautions are

indicated is largely a matter of judgment about the relative risk of disease

transmission.

However, hospital wastes, for which special precautions appear prudent, include

microbiology and laboratory waste, pathology wastes and blood specimens or

blood products. Infected wastes in general should better incinerate or should be

autoclaved before disposal in a sanitary land fill. All blood, suction fluid, excretion

and secretions of infective cause maybe carefully pour down in a drain

connected to a sanitary sewer. Sanitary sewers maybe also used to dispose of

other infectious waste capable of hospital of being group and flushed in the

sewer.

Disposal of hospital waste has public health implications as compared to such

material from the community because of the potentially dangerous nature of such

waste as mentioned earlier. Whatever the method of disposal it has to be

carefully chosen and regularly supervised. The principle in the mode of disposal

of waste is to treat the waste appropriately at the source itself and then ensuring

its hygiene transportation to the site of final treatment, and that during the internal

transportation of the waste within the hospital, it should not come in close vicinity

of patients.

Classification of waste

From the final disposal point of view, based on their combustibility and moisture

content, waste has been classified into sic types.

1. Type 0 wastes: Trash: type 0 wastes is a mixture of highly combustible

waste such as papers, cardboard, cartons, wooden boxes, and

combustible floor seeping from commercial, industrial and housekeeping

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activities. These types of waste contain 10% moisture, 5% incombustible

solids and have a heating value of 8500 BTU/lb as fired.

2. Type 1 waste: Rubbish: rubbish consists of combustible waste such

as paper, cartons, rags, wood scraps, saw-dist, foliage, and floor

sweeping from domestic commercial and industrial activities. This type of

waste contains up to 25% moisture, up to 10% incombustible solids, and

has a heating value of 6500 BT/lb as fired.

3. Type 2 Waste: Refuge: refuge consists of an approximately even

mixture of rubbish and garbage by weight. This type of waste is common

to residential blocks, and contains up to 50% moisture ,7% incombustible

solids, and has a heating value of 4300 BTU/lb as fired

4. Type 3 Waste: Garbage: gar b age consists of animal and vegetable

wastes from restaurants, cafeterias, hotels, hospitals, markets and similar

establishments. This type of waste contains up to 70% moisture, up to 5%

incombustible solids and has a heating value of 2500 BT/lb as fired.

5. Type 4 Waste: Pathological: it is human and animal remains

consisting of carcasses, organs, and solid organic wastes from hospitals,

laboratories, abattoirs, animal pounds and similar source, containing up to

85% moisture , 5% incombustible solids and having the heating value of

1000 BTU/lb as fired.

6. Type 5 and 6 Waste: Industrial Operations: these types of waste

are byproduct waste, gaseous, liquid of semi liquid and solid from

industrial operations. Calorific values must be determined individually to

be destroyed.

Methods of disposal

In general, the methods available for disposal of refuge are as follows:

1. Storage at a central point in the hospital from where it is removed by the

local municipal authority. In most public hospital this method is being

followed. Needless to say, this is the most unsatisfactory method posing

public health problems.

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2. Refrigerated storage in cans in a walk-in-type of refrigerated facility has

the advantage of minimizing unpleasant odors.

3. Food scrap can also by flushed out

4. Sanitary land fill is a method is suitable for small hospitals where all types

of garbage is filled in pits, each filling being covered with layers of loose

earth.

5. Burning in conventional incinerators or electrical or oil-fired incinerators.

Infection Prevention and Waste Management in Hospitals MoPH in has developed the Procedures Manual for Infection Prevention and

Control in Hospitals and Health Centers with the aims to ensure a safe and clean

environment to protect people who handle waste items from accidental injury, to

prevent the spread of infection to healthcare workers who handle the waste, to

prevent the spread of infection to the local community, and safely dispose of

hazardous materials (toxic chemicals and radioactive compounds).

Policy:

Waste Segregation

• The doctor, nurse or any other person generating waste shall separate

hazardous waste from non-hazardous waste at source that is at the

ward bedside, operation theatre, laboratory or any other room in the

hospital where waste is generated.

• Disposable medical equipment and supplies like syringes, needles,

plastic bottles, drips, etc shall be disposed of at the point of use by the

person using them.

• Sharps including syringes and needles shall be placed in safety boxes

resistant to penetration and leakage and these containers shall be

designed in such a way that the items can be dropped in using one

hand.

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• All HCW shall be classified, colored and labeled appropriately

according to WHO standards.

• A Board of Survey shall be constituted to monitor treatment and

disposal of pharmaceutical waste.

• The pharmaceutical companies shall provide treatment and disposal

methods for their products.

• Distributed pharmaceutical products with shelf life less than six months

shall be returned to the supplier.

• Chemical waste and waste with high content of mercury or cadmin

shall not be incinerated but shall be placed in chemical resistant

containers and sent to specialized treatment facilities.

2. Waste Storage

• A separate central storage facility shall be provided for hazardous waste

at each health facility and be inaccessible to unauthorized persons and

animals.

• A hazardous waste central storage area shall have a sign clearly

mentioning that the facility stores hazardous waste.

• Hazardous waste shall be put in an appropriately color coded container

• The storage facility shall be located within the health facility premises

close to the incinerator (if available) and should be away from food

storage or food preparation areas.

• No waste shall be stored at the central storage facility for more than 1 day

(24 hrs) failing which the waste shall be refrigerated at a temperature of

3oC to 8oC.

• The central storage facility shall be thoroughly cleaned.

• Containers with chemical waste that are to be treated at a specialized

treatment facility shall be stored in a separate room.

• Waste should be stored in closed waste containers

3. Waste Collection

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• Ground staff, ward/patient attendants when handling HCW shall wear

protective clothing at all times including face masks, industrial aprons,

industrial boots and disposable or heavy duty gloves

• Ground staff, ward/patient attendants shall ensure that:

• Waste shall be collected daily.

• All bags shall be labeled before removal indicating the point of production,

time of production at the health facility and contents.

• Bags and containers that are removed are immediately replaced with new

ones of the same type.

• Where a waste bag is removed from a container, the container is

thoroughly cleaned before a new bag is filled therein.

4. Waste Transportation

• In the case where waste is transported on site (within the health facility

premises), the waste collection equipment (trolley, wheelbarrow) shall be

free of sharp edges, easy to load, unload and clean

• Hazardous waste shall be collected using separate trolleys, wheelbarrows

that shall be solely used for that purpose.

• The collection route shall be the most direct one from the final collection

point to the designated central storage area.

• Transportation off-site shall be the responsibility of the local authority or

legally permitted private agencies that shall follow the stipulated guideline.

5. Waste Treatment and Disposal

• Risk waste shall be inactivated or rendered safe before final disposal by

thermal, chemical, irradiation, incineration or filtration.

• Hazardous waste shall be disposed of by burning in an incinerator or by

burial in a landfill

• Radioactive waste shall be disposed by encapsulation

• Sharps containers not placed in yellow bags for incineration shall be

disposed of by encapsulation or any other method approved by

Afghanistan Bureau of standards.

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• Disposal methods (burning or incineration, burial in landfill) shall be

operated by a hospital after approval of its Environmental Impact

Assessment

• All hazardous waste delivered to an incinerator shall be burned within 24

hrs.

• Ash and residues from incineration and other methods shall be placed in

non-combustible containers and be disposed off appropriately according

to guidelines

• Landfills for HCW treatment shall be located at sites with minimum risk of

pollution of groundwater and rivers. Access to the site shall also be

restricted to authorized personnel only.

• Each HC shall have functional treatment and disposal facility in operation

at all times.

• Vehicles of the local authorities or permitted private agencies shall take

daily collection of hazardous waste from the health facilities immediately to

the designated landfill or incinerator.

• All liquid hazardous waste shall be discharged into a sewerage system

only after being properly treated and disinfected.

• In case of gaseous radioactive waste, portable filter assemblies shall be

used to extract iodine and xenon.

6. Accidents and Spillages

• In case of accidents or spillage, the following actions shall be taken

• The contaminated area shall be immediately evacuated.

• The contaminated area shall be cleared or disinfected.

• Exposure of the staff shall be limited to the extent possible during the

clean up operation and appropriate immunization carried out

• Any emergency equipment used shall be immediately replaced in the

same location from which it was taken.

• All health staff members shall be properly trained and prepared for

emergency response including procedures for treatment of injuries

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cleaning up of the contaminated area and all incidents of accidental

spillage reported appropriately.

• The responsible waste management officer shall immediately investigate,

record and review all such incidents to establish causes.

7. Health Care Waste Minimization and Re-Use

• To minimize health care waste, each health facility shall introduce

• Purchase and stock controls, involving current management of the

ordering process to avoid over- stocking.

• Waste recycling programs. This shall involve proper pre-packaging before

sending of un-used health care products or HCW to recycling unit for

reprocessing.

• Waste reduction practices in health facility departments.

8. Training and Capacity Building

• All health-training institutions shall in conjunction with the MOHP,

regulatory bodies and other stakeholders develop and strengthen their

curriculum on HCWM.

• All health – training institutions shall incorporate HCWM into their curricula

by introducing it or strengthening already existing related fields.

• All medical, paramedical, nursing and environmental health students shall

be trained in HCWM principles.

• Evaluation of the implementation of the training program in all health-

related training institution shall be carried out.

• The MOHP in collaboration with regulatory bodies and other stakeholders

shall develop a national training package for HCWM targeting all health

staff (including municipal and private staff working in solid waste

management) so as to enforce HCWM measures, knowledge and good

practices.

• The training package shall be adapted to various professional categories.

• Advocacy on risk awareness and their responsibilities related to HCW to

policy makers and health care facility managers shall be strengthened.

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• On going training in HCWM shall be ensured by the infection

prevention/HCWM team for each category of medical and non-medical

staff dealing with waste.

• An orientation shall be conducted to each new staff member working in

the health facility. It shall include a comprehensive briefing on HCW

segregation and handling as well as emergency measures to be taken in

case of accident or injury.

9. Community Awareness

• The MOHP (Health Education unit) in collaboration with stakeholders shall

outline requirements for HCWM messages for the community.

• The MOHP in collaboration with other stakeholders shall develop IEC

materials for the community

• The IEC materials on HCWM shall target all Afghans irrespective of their

gender, ethnic background and age.

• The IEC on HCWM materials shall respect cultural norms without limiting

the intended message

Some institutions have put color code for wastes in order to dispose are safely

and appropriately.

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Color coding: Clinical Waste Segregation

Hospital Setting

Examples

Waste Stream Colour Code Description and Method of Disposal

Examples of Containers

General waste. Personal Protective Equipment not contaminated with body fluids. Paper towels, disposable cups, newspapers, rinsed medicine tots, packaging from medication and uncontaminated dressings, bandages etc

Household Waste Can go to Landfill

Offensive Waste

Can go to deep

Incontinence pads, colostomy bags, urine bags dressings and PPE contaminated with body fluids NOT known to be infectious.

Landfill

Tiger Bag Order Code MVN 030

This waste must be tagged before disposal – and tag usage recorded in book

Items KNOWN to be contaminated with infectious pathogens E.g. Dressings from known infected wounds, and other items that have been in contact with infectious body fluids During confirmed outbreaks of infection dispose of incontinence pads, bedpans, PPE etc

Infectious Waste Can go to alternative treatments such as autoclaving then Landfill

This waste must be tagged before disposal – and tag usage recorded in book

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Sharps Needles, syringes, scalpels, stitch, cutters, razors, empty ampoules etc.

Sharps Waste Must go for Incineration

This waste must be tagged before disposal – and tag usage recorded in book

Full clinical waste containers must be placed into the corresponding colour

wheelie bins for collection by the waste contractor

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Session 13: Report writing Report writing needs good writing skills. A good report can help the decision

makers to take a sound decision; on the other hand, poor reports lead to poor

decisions. So, developing writing skills and knowing the methodologies of writing

a good and systematic report are much desired skills, which the organizations

look for in its employees.

There are reports, which are highly formal both in writing style and in physical

appearance. Again, there are reports, which display a very high degree of

informality. The objective quality of a report is its unbiased approach to the

problem. The basic ingredients of report, is factual information. Information is

based on events, records, data, and like. The report must serve the purpose for

which it is written.

This handout will provide a basic knowledge on report writing. The development

workers at all levels, who are involved in reporting, will be benefited from this

paper. The paper discusses the definition, rationale, Purpose and structure of a

standard report.

There are definitions of both extremities amongst the scholars of the subject.

Some define reports as ‘every written presentation, which contain information or

data’. The other extreme defines it as ‘only the most formal presentations’. The

middle ground definition is the definition, which has been widely accepted: ‘A

report is an orderly and objective communication of factual information that

serves a purpose.

Why report writing?

Report writing work is universal and used by all organizations for different

purposes. Sometimes reports are written by individuals or in collaboration with

others. All branches and departments have their own reporting systems and

such reporting is vital to the organization. Reports supply the decision makers

with the very vital ingredients of decision making i.e. information. Reports are

written for various reasons as following:

• If there is any discrepancy within the organization

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• If there is any problem, where identifying the causes are necessary for

decision making

• For routine reporting within the organization

• Following up previous issues

• Introduction / adoption of any new concept or idea

Written reports are useful and we also derive following benefits from written

reports:

• Written reports make permanent records.

• Those who need information can study at their convenience.

• Can reach a number of readers with minimum efforts.

• Maintains uniformity of contents throughout.

• Be used as reference at any later time.

Structure of Report Writing

Reports can be as simple as the standard memo format or as complex as a

formal report. The inclusion of all the items of the formats may not be necessary

or similar in all types of reports, as it will vary depending on the situation. A

formal report might have following parts:

• Cover

• Title page

• Letter / Memo of Transmittal

• Acknowledgement

• Table of Content

• List of Illustration

• List of abbreviations and acronyms

• Executive Summary

• Introduction

• Main body of the report

• Conclusions

• Recommendations

• Appendices

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• References / Bibliography

Now let us look at each of the parts in detail and see how to present them so that

we have an effective report:

a. Cover

The cover is the first encounter with the reporter and has to be eye catching.

The cover also serves to further the corporate image of the organization. In case

of reports prepared by the students the cover page and the title page is usually

the same.

b. Title page

The title page should contain the following information:

• Subject

• Recipient /prepared for

• Writer / Prepared by

• Date

The title should be precise and convey the main objective of the study or the

project. This page could also include subtitles, which gives more information

about the projects.

c. Letter / Memo of Transmittal

This is the memo through which the report is forwarded to the recipients.

d. Acknowledgement

The persons, organizations or institutions who contributed in the process of

preparation by information, data or other resource material, should be

acknowledged in this section. Authors own establishment and staffs need not be

included here.

e. Table of Content

This section gives the broad contents of the report and the flow of information in

the report. The arrangement of topics and the flow of information should be as

logical as possible and ideas should naturally follow each other.

Do not include ‘Table of Content’ in the list

Use lower case Roman numerals for all documents that precede the introduction

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f. List of Illustration

If the report includes only figures, title this section ‘List of Figures’

If the report includes only Tables, title this section ‘List of Tables’

If the report includes Both, title this section ‘List of Illustration’

g. List of abbreviations and acronyms

The definitions of unfamiliar words, abbreviations and acronyms used in the

paper must be provided. Common and universally used ones may not be

included.

h. Executive Summary

This is the most important part of the report. The summary should contain the

gist of the report. The entire information carried in the report must be conveyed

in its essence. This is going to be the section, based on which a reader will

decide whether to read the whole report or not.

The summary must convey the results. One must inform the readers what they

want to know immediately. Ideally, the first paragraph must itself satisfy their

curiosity.

The summary must be precise and one must use as much non-technical

language as possible. This is especially relevant in case of organizations, as the

users of the reports in other departments may base their decision on the

summary. For e.g. finance manager may take a decision on the technical

feasibility report based on the summary as he may not be well versed with the

technicalities and it could be difficult for him.

• The executive summary summarizes the report, and it is also called

Synopsis, abstract, epitome, précis, digest etc.

• This is primarily prepared for the busy executives, but other readers can

also use it as the preview of the report.

• It includes highlights of the facts, analyses, conclusions and

recommendations in proportion.

• As a general rule, the executive summary is one eighth of the original

report.

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• No unnecessary details should be incorporated in the executive summary.

• Follow indirect-order or direct-order executive summaries. Any one is all

right but to put more emphasis on the conclusions / recommendations the

direct-order executive summaries are popularly used.

i. Introduction

(a) The ‘Introduction’ Paragraph should include following:

• Purpose/objective

• Rationale

• Scope

• Preview / Background

• Introduce the major topics of the report.

• Limitations / Constraints / Assumptions

• Methodologies

(b) Finally, the introduction must lead the writer to the main report and prepare

him for the information he is about to receive.

j. Main Body (Report Proper):

• Data / Information / Analysis

• Summarize the data with major findings

• Cause / Reason against rationale (if any)

In case of data, the following should be noted: In case the data is less and

manageable then the data can be included in the main body of the report.

However, if the data is large, it can be included as appendices.

Similarly, any reference material, which is to be quoted, or any concept is to be

explained, it can be attached as appendices if it is too large

k. Conclusions

• Reports that seek an answer end with a conclusion to the question.

• Structure of the conclusion might vary on problem.

• Suggestions and recommendations may also be included here if not

specifically asked to provide a recommendation.

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This section must give the results of the report. This should be very objective

section. This section must contain only the conclusions.

l. Recommendations

• When the goal is not to draw a conclusion but to recommend a / set of

solutions.

• In some report, it may be a part of conclusion, but if the objective is to

provide recommendation then it should be a separate section following the

conclusion.

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Annexes:

Annex A: Quiz on Organizational Structure of Hospitals

Select the best answer and write the corresponding letter on line beside numeral.

______ 1. Understanding the organizational structure of a hospital is important to

because it lets the hospital personnel know who is responsible for each area of

the hospital.

a. True b. False

______ 2. Policies and procedural activities would be in which hospital service?

a. administrative services c. therapeutic services b. informational services

d. diagnostic services e. support services

______3. Diagnostic Radiology is a part of what service?

a. administrative services c. therapeutic services b. informational services

d. diagnostic services e. support services

______ 4. Therapeutic Services functions to:

a. diagnose patients c. treat patients b. admit patients d. maintain patient record

______ 5. The department that often assigns patient rooms is:

a. information services c. transportation b. administration d. admissions

______ 6. In some facilities, Nursing is a service by itself.

a. True b. False

______ 7. A patient’s first contact with a hospital is generally with:

a. nursing c. medical records c. admissions d. billing

______ 8. Central Supply is part of which service?

a. administrative services c. therapeutic services b. informational services

d. diagnostic services e. support services

______ 9. Support Services is sometimes referred to as:

a. accommodation services c. environ mental services b. organizational services

d. foundation services

______ 10. This service determines the causes of illness or injury.

a. administrative services c. therapeutic services b. informational services

d. diagnostic services e. support services

Key: 1. a ,2. a ,3. d ,4. c ,5. d ,6. a ,7. c ,8. e ,9. c ,10. d

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Annex B: Sample of strategic plan (partially)

King Faisal Hospital, Kigali Strategic Plan 2006-2010

The strategic directions:

Vision Statement: “King Faisal Hospital, Kigali will be a centre of excellence in

health services provision and clinical education in Africa”.

Mission statement: “We, King Faisal Hospital, Kigali, are committed to providing

cost-effective, self-sustaining, high quality and specialized health services in

collaboration with our clients. We do this with an empowered workforce in an

environment that values professionalism respects patients’ rights and upholds

human dignity at all times. With our partners and within available resources, we

contribute to the development of health services, research and education in

Rwanda”.

Value statement: All employees must relate to these values and they will be

instilled to each and every employee and we all shall always LIVE by them.

These values are: Quality Care, Compassion and Accountability

Key Success Factors: Key Success Factors (KSF) was agreed upon as central

to the achievement of this vision and mission and these are as follows:

a) Effective leadership

b) Financial sustainability

c) High involvement & commitment of all stakeholders in the change process

d) Quality systems that promote best practices in everything we do

e) Optimal utilization of available resources

f) Superior marketing and public relations

g) Effective capacity building

h) Shared vision and values

SWOT Analysis: An analysis of the Hospital Strengths, Weaknesses,

Opportunities and Threats at both organizational and departmental levels and

these were identified as follows:

Strengths

1. Endowment of resources: Strong physical facility, committed staff

2. Clear vision, mission and values for the hospital

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3. Stakeholders commitment to quality improvement

4. Demonstrated ability to provide training

5. Availability of substantial capital funding

Weaknesses

1. Obsolete and ill-functioning equipment, with a history of poor maintenance

2. Inadequate management systems

3. Financial un-sustainability

4. Insufficient specialized and trained staff

5. High dependency on external resources

Opportunities

1. Strong commitment of GoR

2. Teaching hospital and higher level of care status

3. Not for profit status

4. Emerging healthcare financing schemes

5. Land available for expansion

Threats

1. Erratic power and water supply

2. A degree of skepticism towards the hospital services held by certain segments

of the public

3. Potential loss of Government subsidy

4. Insufficient local suppliers of goods & services

5. Insufficient specialized skills in Rwanda

KEY STRATEGIC ISSUES: These include ten strategic areas around which

Strategic Goals have been developed and include the following:

1) Clinical services

2) Training & education

3) Research

4) Human resources management

5) Financial management

6) Administrative support management services

7) Facilities management

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8) Quality and safety

9) Information and communication technology

10) General management & Corporate Governance

Key Operational Areas (existing and new services) in line with Strategic

Issues identified and guided by the strategic issues identified above, a process of

identifying services that will require to be consolidated (existing services) and

those that require to be developed (new services) was undertaken. See the

following table for clinical services.

Services Current Planned

Surgery Surgery General

Surgery

Orthopedics

Ophthalmology

Neurosurgery

Dentistry

Ear Nose & Throat

Paediatric

Cardio-Thoracic

Vascular

Maxillo-Facial

Urology

Plastic Surgery & Burns Unit

Internal Medicine General Medicine

Dermatology

Cardiology

Pulmonology

Nephrology

Gastroenterology

Neurology

Endocrinology

Oncology

Rheumatology

Hematology

Infectious diseases

Peadiartices General Paediatrics

Neonatology

Cardiology

Nephrology

Haematology/Oncology

Endocrinology

Neurology

Infectious Diseases

Neonatal ICU (independent)

Obstetrics and

Gynecology

Obstetrics and

Gynaecology Services

Fertility Services

Oncology

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Utrasonography

Ante Natal Care

Obstetrics theatre

Midwifery post natal services

Baby friendly hospital initiative

Well women clinic

High dependency Ante- Natal

Care

Accident &

Emergency

Reception and triage Poison management services

Host the Ambulance Services

base

Anesthesia General

Regional

Recovery

Pain Management services

Intensive Care Unit Non –Invasive

monitoring

Invasive monitoring

High Dependency Care

Radiology CT Scanning

Ultrasonography

Fluoroscopy

General radiography

Mammography

Angiography

Dental Panoramic X-Ray

Pathology Haematology

Chemistry

Parasitology

Microbiology

Serology

Cytology

Histology

Immunology

Blood Transfusion Unit

Drug Monitoring Assays

Molecular Biology

STRATEGIC GOALS AND OBJECTIVES: There exists a logical link between all

strategic components. Information from one component provides input into the

next level, the logic cascading down to lower level components in a hierarchical

fashion. In CLINICAL SERVICES we have following goal and objectives:

To strengthen existing and develop new clinical services that are responsive to

the needs of the people of Rwanda and beyond

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To have:

• Implemented a vibrant clinical governance program by end of 2009 and

maintain it thereafter.

• improved existing medical services in line with accreditation standards by

August 2010

• consolidated and developed clinical support services that are responsive

to the needs of clinical care and that are able to meet international

standards by the end of 2009

• developed non-existing medical services while sustaining the achieved

quality level by 2009, resulting in a at least 50% decrease of 2004 number

of patients referred abroad

• strengthened the quality of nursing care for all existing clinical services

within two years and corresponding emerging services by 2010

STRATEGY IMPLEMENTATION: Inherent to this strategy are numerous

departmental operational plans. They contain more detailed and specific

information to guide implementation at each operational level. Each departmental

plan contains objectives, activities with time lines, the responsible person,

performance indicators and expected results. All these are aligned to the hospital

implementation plan.

FUNDING REQUIREMENTS: The implementation of this strategy will by any

means not be possible unless the necessary funding is secured in time. It is

indeed crucial for its successful implementation.

Descriptions Year 1 Year 2 Year 3 Year 4 Year 5 total

Medical equipment

Non medical equipment

Facilities

HIS&ICT

Training

Grand total funded required

Funded available

Fund needed

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PERFORMANCE MONITORING AND EVALUATION: The monitoring and

evaluation framework is an important aspect of this strategic plan. It provides the

mechanisms for monitoring, reviewing, and evaluating progress towards

attainment of the strategic objectives and goals.

CONCLUSION: We hold the strong view that this strategic plan is a road map

that will guide King Faisal Hospital, Kigali achieve an internationally recognized

status. The plan crystallizes the numerous thoughts and aspiration of the

members of the King Faisal Hospital, Kigali’s community.

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Annex C: Patients’ Rights and Responsibilities at Aga Khan University Hospital

Patient Rights and Responsibilities

Dear Patient,

Welcome to Aga Khan University Hospital (AKUH) and thank you for selecting

our Hospital for your healthcare needs. We are grateful to you for the level of

confidence you have placed in us.

At this academic medical centre, we are all committed to providing the highest

standards of quality care and are striving to not only meeting but exceeding your

expectations. The facility personnel who care for the patient are qualified through

education and experience to perform the services for which they are responsible

as per set standard and policies. The patient's bill of rights and responsibilities is

another pioneering initiative to ensure high-quality patient care services. It is

expected that observance of these rights will contribute to more effective patient

care and greater satisfaction for you, your family and our staff and the facility as

a whole caring for you.

Your Rights:

1.0 Accessibility to Care:

You will be provided with the best possible care available, regardless of age,

gender, nationality, ethnic background, religious origin or financial means. The

care will be respectful of your culture, religion and beliefs.

2.0 Guidance:

You will be provided with proper guidance in seeking financial assistance if you

are in need of such help in connection with your care and treatment at AKUH.

Such financial assistance is subject to the availability of resources in the

institution.

3.0 Communication:

You will be informed of your rights in a manner that you can understand. In

addition, other relevant information such as services available in the faculty, the

mechanism to lodge a complaint, making a suggestion, accessibility to ethics

consults, etc. will be provided to you and/or to your family.

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4.0 Patient education:

You and/or your family will be provided with education about our disease process

after assessing your learning needs. Upon discharge, you will be provided with a

discharge summary. On your request, a clinical summary under the signature of

the treating physician will be provided.

5.0 Privacy and confidentiality:

Care will be provided with full recognition of the individual need for privacy in

treatment and care along with protection of confidentiality of your health

information. Disclosure of information will be made as per the Hospital's policy

and Government regulations.

6.0 Involvement:

Depending on your ability or that of your next of kin, you and/or your immediate

family will be involved in decisions regarding admission, treatment, referral

and/or transfer and discharge. You and your next of kin have a right to be

informed about the benefits and risks of the proposed investigative and treatment

procedures.

7.0 Informed consent:

An informed consent will be administered to you/your next of kin prior to

undergoing treatment procedure according to the Hospital policy. The

organization will follow the established process, within the context of existing law

and culture, when persons other than you grant consent.

8.0 Refusing treatment:

You and/or your family have a right to refuse treatment and to seek discharge.

We will advise you/your family regarding the medical consequences of such a

decision. However the Hospital will not be held responsible for any

consequences resulting from such a decision made by you/your family.

9.0 Seeking second medical opinion:

We will respect your right to seek a second medical opinion, which in most

instances will be provided by an AKUH credentialed specialist. A request for

consultation from an outside non-credentialed physician will be honored with the

concurrence and approval of the treating physician and of the Medical Director of

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AKUH. In case of genuine dissatisfaction with treatment, you are entitled to

request a change in your treating physician. The concerned chair/section head

will assist you in this regard

10.0 Transfer

A critical care patient being considered for transfer to an alternate treatment

facility will be provided with all possible support and facilities.

11.0 Participation in research:

You have the right to be informed, to agree to or to refuse to participate in any

research/educational projects affecting your care or treatment. Your refusal will

not in any way affect the quality of care available to you. An informed consent

must be obtained from you and/or from your next of kin prior to your being

enrolled in a research project. This should include explanation of benefits and

risks or discomfort from participating in the project. All research project involving

patients and/or review of their medical records should be undertaken after

approval of the research protocol by the Ethical Review Committee of Aga Khan

University (AKU).

12.0 The Hospital Ethics Committee:

In case of conflict or ethical concern arising from care and treatment given to

you, consults from The Hospital Ethics committee can be sought by you/your

family through the physician/nurse in charge of your care.

13.0 Patient’s Complaints/Suggestions:

The Hospital will provide for and welcome the expression of grievances or

complaints and suggestions by you at all times either by speaking directly to the

team leader, supervisor, service coordinator or manager assigned to your care.

You may file a formal complaint in writing by filling the “Complaint/Suggestion

Form”, which is available at all service counters, and depositing it in the

complain/suggestion boxes available at several locations throughout the

Hospital. Our staff on each floor will be happy to assist you in this regard.

Your and / Or Your Family Responsibilities

1. You and/or your family members are responsible for:

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• Providing complete and accurate information necessary for your medical

treatment.

• Abiding by Hospital rules and regulations regarding admission, treatment,

safety, privacy and visiting etc.

• Refraining from the use of violent and disruptive behaviors or language

abuse. In case of any dispute, query or grievance, you are requested to

bring the matter directly to the attention of team leader, supervisor, service

coordinator or manager assigned to your care.

• Seeking complete and accurate information and/or explanation regarding

Hospital services and charges and for ensuring payment of Hospital bills

in full and in a timely manner.

• Exercising care and caution in using Hospital facilities and equipment.

• Complying with all discharge instructions and keeping follow-up

appointments.

• Being considerate towards the rights of other patients and of Hospital

staff.

2. Smoking is not allowed anywhere in the Hospital premises except designated

areas.

3. You are advised not to bring valuable personal belongings to the Hospital.

4. It is expected that you and your family will cooperate with nursing staff,

consultants, housekeeping staff, trainees/residents and students in carrying out

assessment, investigations and treatment procedures.

5. In case of gross misbehavior by the patient and his/her family and friends,

AKUH reserves the rights of admission to its facility, transfer out of the Hospital

and further action.

We wish you a complete and speedy recovery.

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Annex D: HMIS form (Monthly Integrated Activity Report- MIAR) Monthly Integrated Activity Report GOVERNMENT OF THE ISLAMIC REPUBLIC OF AFGHANISTAN

MIAR – Facilities, Page 1 MINISTRY OF PUBLIC HEALTH

District Name & Code Province Name & Code

Year Month Facility Code Facility Name

Monthly Integrated Activity Report GOVERNMENT OF THE ISLAMIC REPUBLIC OF AFGHANISTAN

MIAR – Facilities, Page 2 MINISTRY OF PUBLIC HEALTH

D. Stock status Essential

Drugs/commodities

Referred

Out

Referred

In

Reatten-

dance

New

Cases

C. Maternal & Neonatal Care

Acetyl Salicylic Acid/Paracetamol ## C1. Family planning

Mebendazole 1. Oral

Amoxicillin/Ampicillin 2. Injectable

INH 3. IUD

Rifampicin 4. Condoms

Amp. Diazepam 5. Permanent

New BHC

>= 5 < 5 CHC

Referred Out Referred

In

Reatten-

dance Total

New F M F M H1 H2 H3 OPD

Facility Type

Patients/Clients

A1. OPD Morbidity

1. COUGH &

COLD

2. ENT

3. PNEUMONIA

ARI

4. ACUTE

WATERY

5. ACUTE

BLOODY

6. W

DEHYDRATION

DIARRHEA

7. SEVERELY ILL CHILD

8. VIRAL HEPATITIS

9. MEASLES

10. PERTUSSIS

11. DIPHTHERIA

12. NEONATAL TETANUS

13. TETANUS

14. ACUTE FLACCID PARALYSIS

15. MALARIA

16. URINARY TRACT INFECTIONS

17. PSYCHIATRIC DISORDERS

18. TRAUMA

19. TB SUSPECTED CASE

99. OTHERS/UNLISTED DIAGNOSES

A2. Remarks

B. Nutrition

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249

Inj. Lidocaine C2. Pre- and Post-Natal

Metronidazole 1. First Antenatal Visit

Co-trimoxazole 2. Other Antenatal Visit

Anti-hypertensives 3. Postnatal Visit

Oral contraceptive C3. Obstetric Care

Injectable contraceptive 1. Normal Delivery

Condoms 2. Assisted Delivery

IUD 3. Major complication

TT vaccine 4. Other Complication

DPT vaccine 5.Maternal Death due to Major

ORS 6. Maternal Death due to Other

Vitamin A 7. Cesarean section

Chloroquine 8. Other obstetric surgery

Sulfadoxine + Pyrimethamin C4. Neonatal Care

Ferrous Suplhate + folic acid 1. Newborn Alive

Oxytocin 2. Low Birth Weight

Gloves 3. Neonatal Complication

4. Neonatal Death D2. Comments about stock

5. Stillbirth

E. Immunizations G. Tuberculosis

Total 12-23 months 0-11Months E1. Childhood G1. Case detection

1. DPT3 1. Number of new smear (+) cases

2. Vitamin A 2. Number that started treatment

G2. Treatment success

>TT2 TT2 E2. TT Immunization 1. Number of cases completed and smear (-)

1. Pregnant Women H. Community Health

F. Laboratory Exams

F1. Blood

1. Number of meetings with

community health committee

1. Total malaria slides examined 2. Number of CHWs seen for supervision

2. Total PF positive I. Report Transmitted

3. Total other positive Name

4. Total HIV examined Designation

5. Total HIV positive Date

F2. Sputum Signature

1. Total AFB slides examined J. Report Received/Aggregated

2. Total AFB positive Date Received

Data aggregated/computerized

Any special activities or problems, significant anomalies or trends in morbidity and service delivery K. Comments:

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250

Annex E: HMIS form (Hospital Monthly Inpatient Report- HMIR) Hospital Monthly Inpatient Report GOVERNMENTOF THE ISLAMIC REPUBLIC OF AFGHANISTAN

HMIR - Page 1 of 2 MINISTRY OF PUBLIC HEALTH

District Name & Code Province Name & Code

Year Month Facility Code Hospital Name

� Regional (H1) � Provincial (H2) � District (H3) Hospital Type

B. Nutrition of under fives A. Indoor patients

1. Admitted =>5M =>5 F <5

2. Improved 1. Admissions

3. Defaulted 2. Referred-in

4. Referred out 3. Deaths

5. Deaths 4. Number of patient days

C. Imaging services 5. Average length of stay

1. Chest x-ray 6. Total Discharged

2. Abdomen x-ray a. Recovered/Improved

3. Skeletal x-ray b. Absconded/defaulted

4. Ultrasound d. Not improved

5.Other e. Referred-out

E. Stock of essential hospital drugs D. Other surgical interventions

Arthesunate inj Total Minor Major

Atropine inj 1. Gynecological

Benzathine Penicilline inj 2. Orthopedic/trauma

Digoxine 3. ENT

Ergometrine inj 4. Eye

Furosemide inj 5. Others

Gentamycine inj 6. Total

Iodine poluvidone 7. Post operative deaths

Ketamine inj 8. Post operative complication

Lidocaine 5% spinal inj 9. Blood Transfusions

Magnesium Sulphate 10. Blood transfusion reactions

Morphine inj F. Cases and deaths of priority diseases

Naloxone inj Deaths Admissions Health Problem

Hydralazine inj 1. Diarrhea <5

Oxygen 2. Pneumonia <5

Pethidine inj 3. Measles <5

Phenobarbital inj

Quinine inj

Ranitidine inj

Ringer lactate IV

Salbutamol inj

Sodium chloride IV

G. Comments (any particular observations or issues that you want to highlight to the central level)

Hospital Monthly Inpatient Report GOVERNMENTOF THE ISLAMIC REPUBLIC OF AFGHANISTAN

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251

HMIR - Page 2 of 2 MINISTRY OF PUBLIC HEALTH

Year Month Facility Code Hospital Name

H. New Inpatient Cases

>= 5 < 5 Death Referr.

Out

Referr. In Total

F M F M Priority health problem/disease

Injuries and trauma

1. Weapon wounded

2. Road traffic accidents

3. Occupational injuries

4. Burns and scalds

5. Other injuries

Cardiovascular

6. Cerebro-vascular accidents

7. Rheumatic heart disease

Nervous system

8. Meningitis/encephalitis

9. Epilepsy

Endocrine & metabolic

10. Diabetes

11. Micronutrient deficiencies

Gastro-intestinal

12. Acute appendicitis

13. Peptic ulcer syndrome

14. Inflammatory bowel syndrome

15. Liver & gall bladder disease

Gynecology

16. Urinary tract infections(no STD)

17. Pelvic inflammatory disease

Infections (other than Notifiable)

18. Dysentery (all types)

19. Diarrhea (except dysentery)

20. Malaria

21. Tuberculosis

22. Hepatitis

23. Typhoid

Mental diseases

24. Depression

25. Psychosis

Respiratory

26. Pneumonia

27. Asthmatic disease

28. All other new inpatient cases

I. Report submission

Report Received/aggregated Report Submitted

5. Received by 1. Name

6. Date received 2. Function

7. Aggregated/computerized by 3. Date

8. Date aggregated/computerized 4. Signature

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252

Annex F: HMIS form (Hospital Status Report- HSR)

Hospital Status Report GOVERNMENT OF THE ISLAMIC REPUBLIC OF AFGHANISTAN

HSR - Page 2 of 4 MINISTRY OF PUBLIC HEALTH

B. Human Resources

Refresh Cert Female Male Type Refresh Cert Female Male Type

B4. Technical staff B1. Management 23. Psychologist 1. Hospital Director

24. Physiotherapist 2. Medical Director

25. Pharmacist 3. Chief nurse

26. X-ray technician 4. Administrator

27. Lab Technician B2. Physicians

Hospital Status Report GOVERNMENT OF THE ISLAMIC REPUBLIC OF AFGHANISTAN

HSR - Page 1 of 4 MINISTRY OF PUBLIC HEALTH

A. General Facility Information 2. District Code & Name 1. Province Code & Name

3. Hospital Code &Name

……..To…….From

……………Of

5. Period H1 National/specialist H2 Provincial/regional H3 District 4. Type of Hospital

Stone Mud Concrete 7. Main construction material Temporary Permanent 6. Building

9. Main source available ….….. months per year Other Safe 8. Main source of drinking water

……..12. Average hours/day Wind Solar Generator Line 11. Main sources of electricity Yes No 10. Electricity

15. Referral facility name & code …..Hrs ……..Min 14. If not, walking time from road Yes No 13. On drivable road

No Yes 18. Separate latrine for male and female Open Closed 17. If Yes, type: Yes No 16. Latrine for use by patients

19e. Other 19d. Surgery 19c. Adult Internal 19b. Ob&Gyn 19a.Pediatric 19. No of beds

Other Burn and Bury Incinerator 21. If yes, type No Yes 20. Medical waste disposal

22. Other sources of support 21. Main source of support

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253

28. Blood bank technician 5. Surgeon

29. Dental Technician 6. Ophthalmologist

30. Vaccinator 7. ENT

31. Nutritionist/cook 8. Anethesiologist

32. Technical assistants 9. ObGyn

33. Community Health Supervisor 10. Pediatrician

B5. Support Staff 11.Radiologist

34. Administrative Staff 12. Medical Specialist

35. Storekeeper 13. General MD

36. Technical maintenance 14. Dentist

37. Cleaners, waste & grounds B3. Nurses & Midwives 38. Laundry 15. Midwifes

39. Cook 16. Nurse operating theatre

40. Drivers 17. Nurse surgical ward

41. Guards and porters 18. Nurse internal ward

42. Tailor 19. Nurse pediatric ward

43. Mullah 20. Nurse anesthetic

B6. Community Health 21. Nurse ER and OPD

44. CHWs ever trained 22. Assistant Nurse

45. Trained CHWs active

C. Supervision 1. Number of supervisory visits received from MOPH

2. Number of supervisory visits from grantee agency

Hospital Status Report GOVERNMENT OF THE ISLAMIC REPUBLIC OF AFGHANISTAN

HSR - Page 3 of 4 MINISTRY OF PUBLIC HEALTH

D. Equipment list

Not Usable Usable Type Not Usable Usable Type

27. Autoclave 1. Computer

28. Ob/gyn table 2. Printer

29. D&C set 3. Stabilizer

30. Wound set 4. Radio

31. Minor surgical set 5. Telephone

32. Laparatomy set 6. Water purification

33. Caesarean/hysterectomy set 7. Fire extinguishers

34. Obstructed labour set 8. Vehicle, 4 wheel drive

35. Episiotomy set 9. Ambulance, 4 wheel drive

36. Suture set 10. Vaccine Refrigerator

37. Amputation set 11. Blood refrigerator

38. Laryngoscope set 12. Food refrigerator

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254

39. Endo-tracheal introducer 13. Cooking stove

40. Vacuum extractor (childbirth) 14. Water heater

41. Neonatal incubator, van Hemel 15. Sphygmomanometer

42. X-Ray machine 16. Stethoscope

43. Ultrasound machine 17.Vision Chart

44. Brown frame 18. Thermometer

45. Microscope 19. Child scale

46. HB meter 20. Height measuring scale

47. Urine sticks 21. Suction machine

48. Blood transfusion set 22. ECG machine

49.Cross match test 23. Fetal stethoscope

50. Blood HIV test 24. Ambubag & Guedel

51. Blood Hepatitis B&C test 25. Operating table & accessories

52. VDRL test 26. Mayo Stand

Hospital Status Report GOVERNMENT OF THE ISLAMIC REPUBLIC OF AFGHANISTAN

HSR - Page 4 of 4 MINISTRY OF PUBLIC HEALTH

E. Services provided

E7.Surgery E4. Maternal Health E1. General Curative

1. Closed fractures and dislocations (minor) 1. Antenatal care 1. Curative OPD

2. Lacerations and soft tissue injury 2. TT immunization 2. IMCI implemented

3. Acute osteomyelitis 3. Basic EmOC 3. ARI Case Management

4. Rheumatoid arthritis 4. Comprehensive EmOC 4. DD Case Management

5. Amputation 5. Blood transfusion 5. Malaria Case Management

6. Burns 6. Blood storage 6. Minor surgery (I&D, suture)

7. Superficial abscesses, cysts and tumors 7. Neonatal resuscitation 7. Major surgery

E8. Mental health E5.Family planning E2. Child Health 1. Acute confusion 1. Oral contraceptives 1. Routine Growth Monitoring

2. Depression 2. Injectable contraceptives 2. Nutritional rehabilitation

E9. IEC Actvities 3. IUD 3. Child Immunization

4. Condoms 4. Management of severely ill child (IMCI) 1. Obstetric complications & birth preparedness

5. Tubal ligation E3. Infectious Diseases

2. Family Planning 6. Vasectomy 1. TB detection & referral

3. Nutrition E6. Radiology 2. TB labdiagnosis

4. Child health 1. Thorax x-ray 3. TB treatment (excl. DOTS)

5. Injection Safety 2. Abdomen x-ray 4. DOTS

E10. Community Health Worker Supervision 3. Extremities x-ray 5. Malaria lab diagnosis

1. CHWs supervised once 4. Ultrasound 6. ITN distribution

2. Health Posts active 7. HIV/AIDS diagnosis

3. Health Posts supervised once

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F. Remarks and observations

G. Report submission

Designation Signature

Date Name

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256

Annexé G: Waste Colour Coding

Waste Receptacle

Description Example Contents

Yellow with purple stripe

Infectious waste contaminated with cytotoxic and /or

cytostatic medicinal products

Dressings / tubing from cytotoxic and/or cytostatic treatment

Yellow purple lid

Sharps contaminated with cytotoxic and /or cytostatic medicinal

products

Sharps used to administer cytotoxic products.

Amalgam waste

Dental amalgam waste

Yellow/orange

Infectious waste,

category A – yellow

category B – orange

see section 4.1.2

Soiled dressings from infected wounds and other items contaminated with infectious body

fluids

Orange top

Non- medicinally

contaminated sharps

Sharps from phlebotomy

minor surgery instruments scalpel blades, razor blades

Yellow top

Medicinally

contaminated sharps

Ampoules, vaccine syringes and needles Local anaesthetic syringes and needles

WHITE

CONTAINER

T

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257

Yellow/black stripe

Offensive waste

Human hygiene waste

and non-infectious disposable equipment, bedding

plaster casts, etc

Black bag or clear bag is acceptable

Domestic waste

General refuse, including, flowers, etc

Green/clear

Mixed recycling Paper, cardboard, tins, cans, plastic, Glass

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References: 1. Overview of Hospital and Health Services in 2002. Embangweni Malawi

Website (http://embangweni.com ) access date: 06/01/2010

2. Minnesota Department of Health: MDH SWOT Analysis. Website

(http://www.health.mn.gov) updated: 12/09/2006 and retrieved:

06/01/2010

3. Rufino L. Macagba. Hospitals and Primary Health Care: International

studies from the international hospital federations. Health Development

International (eBook). 126 Albert Street postage London NW1 7NX England

4. Miller, T.S. (1997) the Birth of the Hospital in the Byzantine Empire.

Baltimore, MD: Johns Hopkins University Press

5. Martin, M, Healy, J. European Observatory on Healthcare system Series.

Hospital in a changing Europe (2002) Open University Press, Buckingham

- Philadelphia

6. Wikipedia, the free online encyclopedia. History of Hospitals and clinical

audits (http://en.wikipedia.org)

7. University of North Texas: Health Science Technology Education.

Organizational Structure of a Hospital website: http://www.texashste.com

8. Allison, Michael and Judy Kaye, Strategic Planning for Nonprofit

Organizations: A Practical Guide and Workbook, 2nd edition, Englewood

Cliffs, NJ: John Wiley & Sons, 2005.

9. Washington State Hospital Association. Government Board Manual

Strategic Planning. Website: http://www.wsha.org

10. King Faisal Hospital, Kigali Strategic Plan 2006-2010. 2nd Edition

February 2009. King Faisal Hospital, Kigali website: www.kfh.rw

11. Hospital Policy for Afghanistan Health system. Islamic Transitional

Government of Afghanistan, Ministry of Public Health. Policy Statement.

February 2004

12. CIVICUS. World Alliance for Citizen Participation. Monitoring and

Evaluation Toolkit. Website: http://www.civicus.org

Page 259: Hospital Management Module Final Version

259

13. Teoh P.C. Hospital Monitoring of Adverse Drug Reactions in Singapore.

Singapore Med. Journal. vol 15, No 4, December 1974, PP 268-272

14. Barmford B. et al. How to Monitor and Address Absenteeism in District

Hospitals. Institute for sub-district support. Kwik-Skwis No25.The press

Gang. February 2000

15. Hurwits N. Papers and Originals: Intensive Hospital Monitoring of Adverse

Reaction to Drugs. Brit. med. J., 1969, 1, 531-536

16. Hospital Standards Manual. Ministry of Public Health (MoPH), Kabul-

Afghanistan. Supported by: USAID. 1385/2006

17. The Essential Package of Hospital Services for Afghanistan (EPHS).

Islamic Republic of Afghanistan. Ministry of Public Health. 2005 / 1384

18. Clinical Audit: What is it is and what it is not? The Royal College of

Psychiatrists. file format pdf (pp 1-4) Website: http://www.rcpsych.ac.uk

19. Joanne Ashton, Health Managers’ Guide: Monitoring the Quality of

Hospital Care. Quality Assurance Project. Center for Human Services.

USAID. Website: www.qaproject.org

20. Fiona Moss. Achieving Quality in Hospital Practices. Qual Health Care

1992 1: 17-19.

21. Grays Harbor Community Hospital. 2008-2009 Operational Plans.

Website: http://www.ghchwa.org

22. Sara G.L. et al, A Community Leaders Guide to Hospital Finance.

Evaluating How a Hospital Gets and Spends its Money? The Access

Project

23. David Collins. Planning, Costing and Budgeting Framework. A user

Manual. August 2007. Management Science for Health (MSH)

24. World Health Organization. Cost analysis of Primary Healthcare: A training

Manual for Programme Managers. WHO- OMS. 1994

25. The evolution of complaint management in the Hong Kong Hospital

Authority. Part 2: The ‘complaints’ iceberg. Doctors and Society. Hong

Kong Med J Vol 10 No 5 October 2004 pp: 362-3654

Page 260: Hospital Management Module Final Version

260

26. Six rules for pursuing complaints in Hospitals. Hospitalcomplaints.com.

retrieved 27/01/2010

27. Aga Khan University Hospital, Karachi (AKUH). Patients’ Rights and

Responsibilities. For patients and visitors. Retrieved 26/01/2010. Website:

www. aku.edu

28. Anand RC. Modern Approach for Management of Hospitals as a System.

Seminar on Hospital Administration: AIIMS New Delhi, 1984.

29. Shakharkar, BM. Principles of Hospital Administration and Planning.

Jaypee Brothers Medical Publishers, New Delhi India.

30. Procedures Manual for Infection Prevention and Control in Hospital and

Health Centers. General Directorate of Diagnostic and Curative Services.

Ministry of Public Health, Kabul Afghanistan. 2005

31. Kim Ormsby. Johanna Hill. Lynn Leaver. Clinical waste policy: Sharps,

Infectious and Offensive Waste arising from Healthcare Activities. Brent.

NHS. Website: www. brentpct.nhs.uk