Presentation given by Dr. Rajesh Harshvardhan, Department of Hospital Administration, AIIMS on August 1st, 2011 at eWorld Forum (www.eworldforum.net) in the session Sharing Good Practices in eGovernance

1. Challenges before Hospital Management & it’s Solutions Dr. R. Harsvardhan MBBS, MHA(MD-HA), DNB, DGM, DMLE, MPH (Hons & Gold Medalist) Department of Hospital Administration AIIMS, New Delhi drrharsvardhan@yahoo.co.in; +91 9350597571

2. Challenges are what, we live for . . . . 8/27/2011 2

3. Background Hospitals dominate health care in most parts of the world and for a variety of reasons, are likely to continue being a key factor in the overall performance of the health care system. Any effort to improve this performance must therefore, give greater hospital efficiency the highest priority. 8/27/2011 3

5. And further it absorbs a vast proportion (50 to 80 %) of health budget; it is not people-oriented; its procedures and styles are inflexible; it overlooks the cultural aspects of illness (treating the disease without treating the patient); the treatment is expensive; it is intrinsically resistant to change, and so on. . . 8/27/2011 4

6. Background The relative isolation of hospitals from the broader health problems of the community, which has its roots in the historical development of health services, has contributed to the dominance of hospital model of health care. 8/27/2011 5

7. Introduction 8/27/2011 6

9. A very high proportion of the population in many developing countries including India, and especially in rural areas, do not have any access to health services, which can be used by only the privileged few and urban dwellers.8/27/2011 7

10. Introduction Although there is the recognition that health is a fundamental human right, there is a denial of this right to millions of people who are caught in the vicious circle of poverty and ill-health. In short, there has been a growing dissatisfaction with the existing health services and a clear demand for better health care. 8/27/2011 8

12. Among many consequences, for example, syringes and surgical equipment are repeatedly used on different patients without adequate sterilization allowing spread of deadly infections among unsuspecting patients.8/27/2011 9

14. Sweepers, medical technicians, nurses and even physicians have been reported to be absent for months at a time and have been referred as “ghost workers”.8/27/2011 10

15. A Case Study 8/27/2011 11

17. As every person has his own opinion about these problems so a study was performed to analyse the reasons for the problems faced by patients.8/27/2011 12

18. Objective To assess the reasons for the problems faced by patients in the government hospitals to make an emphasis on higher authorities for identification of problems and implementation of effective measures. 8/27/2011 13

20. Out of all the reasons listed, 84% doctors favored the reason of inadequate salary to doctors & paramedical staff by government.

21. While other two reasons favored by 80% doctors were lack of facilities and security for doctors and illiteracy and poverty of patients.8/27/2011 14

23. Out of six reasons, "lack of facilities & security of doctors" was marked true by 80% of doctors. Other reasons were in the range of 30% to 60%.

24. The reasons for the problems related to doctors were four. Out of four reasons, "Inadequate salary to doctors and paramedical staff by government" was marked true by 84% of doctors. Other reasons were in the range of 30% to 50%.8/27/2011 15

25. Observations The reasons for the problems, related to patients, were three. Of these three reasons, "Illiteracy and poverty of patients are factors that create problems for them in government hospital" was marked true by 80% of doctors. Other reasons in a range of 30% to 60% . 8/27/2011 16

26. Conclusion This hospital based study showed that the causes were related mainly to hospital management, doctors' attitude and responsibility and also to patients' illiteracy and poverty. 8/27/2011 17

27. Changing Paradigm 8/27/2011 18

29. Rising hospital management costs, an aging population, a shortage of healthcare workers, challenges in accessing services, timely availability of information, issues of safety and quality, and rising consumerism are some of the facts of today’s healthcare system. 8/27/2011 19

30. Changing Paradigm The industry has reached a point of chasm, where they need to decide how services could be delivered more effectively to reduce costs, improve quality, and extend reach. The critical questions facing the industry today include: 8/27/2011 20

32. How can we provide care in a cost-efficient manner at a time when healthcare spending is rising; and

33. How do we most efficiently use our resources and support front-line staff in order to reduce medical errors and enhance quality of care.8/27/2011 21

34. Hospital Management Faces Many Challenges 8/27/2011 22

36. Assess emergency and surgery capacity management practices.

37. Look for opportunities to improve patient flow, treatment pathways, length-of-stay and case management based on leading practices. 8/27/2011 23

38. Hospital Management Faces Many Challenges Workforce shortages, especially in nursing and primary care, grow worse. Analyze staffing to learn how to use the workforce more efficiently. Train staff in change management and leading practices. Reduce staff turnover by facilitating and respecting their patient care responsibilities. 8/27/2011 24

39. Hospital Management Faces Many Challenges Aim is to reduce the overall cost of medical care—and improve patient satisfaction—by offering wellness programs, palliative care, and disease management. Evaluate such programs carefully, since their effectiveness in improving long-term costs or outcomes is difficult to measure. 8/27/2011 25

41. Analyze your clinical and business processes and publicize the results.

42. Use them to identify opportunities to streamline workflows, eliminate unneeded procedures and improve management of your supply chain and revenue cycle.

43. Collaborate better with employers and payers. 8/27/2011 26

44. The Road Ahead 8/27/2011 27

45. The Road Ahead An aging population and chronic illnesses are straining hospital management as much as nurses and doctors. The problem has been highly publicized, yet hospital management shortages are still a reality. What’s more, the shortage of nurses and doctors is putting additional strain on hospital management that is charged with filling those positions. 8/27/2011 28

47. Recent studies demonstrate that about one third of facilities don’t have enough staff available, putting a dam in the flow of operations of hospital management.

48. Even if hospital management attracts the right talent to fill the shifts, turnover is a major issue in the healthcare industry, especially nursing staff. 8/27/2011 29

50. Effectively designed enterprise wide risk management also enables the ability to provide transparency to key stakeholders, such as community boards, public authorities, government regulators and valued employees and patients.8/27/2011 30

51. My View Point 8/27/2011 31

53. Making a commitment to becoming a risk resilient organization includes a rigorous assessment of an organizations current activities and their alignment with business processes and strategy. 8/27/2011 32

55. Risk resilient organizations will have to ensure that traditional internal barriers are eliminated to ensure effective risk mitigation. 8/27/2011 33

56. My View Point Consumer choices, reimbursement restrictions and investments in information and medical technologies are squeezing already-slim operating margins. One can no longer stay competitive by delivering traditional models of patient care. 8/27/2011 34

58. The growth strategy must address them better, faster than the competitors.

59. Quality differentiates the organization in a competitive marketplace.

60. But quality care is more than a business strategy.

61. It is the organization’s mission and reason for being.8/27/2011 35

62. Thank You !! 8/27/2011 36 “We face a challenge -- no matter how great -- because we know that on the other side there is always hope.”

64. Many times the medical miracles in India lie in the fact that some patients actually survive their hospital stay. 8/27/2011 37

65. Introduction How can we help to implement this declaration, while at level of tertiary health care especially government hospitals, poor patients that are the major population of India, are still facing problems for obtaining proper facilities for their treatment ? 8/27/2011 38

67. "Senior doctors including professors, who are paid meager salaries of up to 20,000 rupees a month, are involved in lucrative private practice in order to lead a decent life and thus have no time or drive to care for patients or mentor medical trainees.

68. Several physicians in the government hospitals solicit business and lure patients into seeing them in their private clinics.

69. Moreover, doctors charge fees for their services without following any particular fee schedule. Job dissatisfaction and stress among doctors affect the quality of health care.

70. Majority of doctors working at these teaching hospitals of Karachi had a poor satisfaction level and higher levels of job stress. This suggests that immediate steps should be taken for rectification.8/27/2011 39

72. Patients usually don't observe the follow-up probably owing to overload in govt. hospital.

73. Sometimes after initial response and feeling better they ignore doctor's advices.

74. So measures should definitely be taken to improve the understanding, the importance of follow-ups and the doctor's advice.

75. The results of this study warrant a prompt corrective action by the all concerned. 8/27/2011 40

77. All the doctors were asked questions related to the problems created by hospital management, due to the irresponsibility and concerns of the doctors and also due to the patients themselves. The responses were evaluated separately. 8/27/2011 41

78. Observations The study was conducted to deduce certain root causes of major problems. Though a vast variety of problems were considered, three most significant ones emerged drew full attention. The third query of the questionnaire which was regarding facilities and security of doctors was marked "true" by almost 80% responders, which is itself an indicator of still lasting fear regarding security probably due to killings of doctors in the recent past. 8/27/2011 42

79. Observations This should of course, be a main sector of concern for the higher authorities as no one can do their best until they feel adequately secured. As the questionnaire also focused on the facilities for doctors, 80% responders were dissatisfied with the current privileges. This shows that peace of mind is an important factor for efficient working. This can be acquired by improving the facilities provided. 8/27/2011 43

80. Observations Improving health services in poor communities might involve changing the incentive structure for public providers. Introducing incentives in the public sector is often difficult due to non-flexibility of civil service rules. Incentives as paying extra allowances for hardship posts have been implied in many countries. All mechanisms of incentives have their own risks and none of them is problem free. 8/27/2011 44

82. This, indeed, reflects that doctors and paramedical staff are not satisfied or content with their current benefits rendered to them for their hard and diligent work.

83. The query elucidates that performance of doctors and paramedical staff can be enhanced by giving appropriate incentives to them. 8/27/2011 45

84. Case StudyThe Western Experience 8/27/2011 46

86. Following are the results of the survey, which was sent to 1,275 hospital CEOs in October and November 2009, of whom 525, or 41 percent, responded.8/27/2011 47

87. Outcomes Financial challenges ranked No. 1 on the list of hospital CEOs’ top concerns in 2009, making it their No. 1 issue for the last five years, according to the American College of Healthcare Executives’ (ACHE) annual survey of top issues confronting hospital CEOs. 8/27/2011 48

88. Outcomes Within each of their three top issues, respondents identified specific concerns facing their hospital. Following are those concerns in order of importance for the top three issues identified in the survey: 8/27/2011 49

89. Financial Challenges (n=393) 8/27/2011 50

90. Healthcare Reform Implications (n=275) 8/27/2011 51

91. Care for the Uninsured (n=187) 8/27/2011 52 *This item was derived from written-in responses. Frequencies for this variable should be taken as an underestimate of perceived importance.

92. 1Starting in 2008, this issue comprises both patient safety and quality. In prior years, they were two unique issues.2In 2008 this issue was broadened and changed from “biodisaster” to “disaster” preparedness. 8/27/2011 53

94. From inadequate reimbursement and productivity management to rising insurance costs and patient satisfaction concerns, recruiting hospital manager is becoming a greater and greater challenge.

95. Indeed, it’s not just nurses and doctors, but the hospital management that’s hard to come by these days. 8/27/2011 54

97. Hospital management also entails quality compliance and patient safety, managing premium labor costs, revenue enhancement and governmental regulations and mandates.

98. Concepts like universal healthcare could complicate matters for hospital management, according to recent surveys.8/27/2011 55

100. That would add to the already forecasted problems for hospital management. Hospital management is looking for strategies to stem the tide before it’s too late.8/27/2011 56

101. My View Point As they develop their response strategy and how to integrate it, they will need new methodologies, approaches and expertise than previously required. Competition is relentless and pressing. So are the demands from all quarters that you deliver better care for less money. 8/27/2011 57

102. Changing Paradigm These are just a few questions facing the industry. It looks bleak, but there’s hope. 8/27/2011 58

104. Computerization of services in the medical field.

105. Technological and telemedicine innovation.

106. The management of human resources.

107. The management of materials and equipment.

108. The relationship between hospitals and partners.8/27/2011 59

109. Changing Paradigm The management of medicines. The relationship with patients. Waste management within hospitals and medical centers. Financial management in hospitals. Health insurance. Medical staff facing bad practices and the law. 8/27/2011 60

110. Hospital Management Faces Many Challenges Hospital management is becoming increasingly difficult in today’s market. The demand is growing and the challenges are increasing. 8/27/2011 61

111. Hospital Management Faces Many Challenges Commercial payers are following the lead of the market & services in expanding the clinical scope and financial impact. Assess the benefits—and return on investment—of physician/hospital alignment strategies. 8/27/2011 62

112. The Road Ahead By integrating risk management, internal control and compliance systems, management decisions can be made with increased confidence and clarity. Risk-resilient organizations understand how to effectively align business processes to minimize compliance risks. 8/27/2011 63

114. Increasingly enterprise-wide assessments are indicating the need for integrated compliance programs that drive down risk while increasing value.

115. So for example, billing compliance remediation leads to more patient revenue, and preparation for recovery audit contractor reviews leads to operational and quality improvements.8/27/2011 64

117. As every person has his own opinion about these problems so a study was performed to analyse the reasons for the problems faced by patients, at Jinnah Postgraduate Medical Center, Karachi8/27/2011 65