A brief note on Hospital Statistics and measures of Hospital Performance, including 'Pabon Lasso Model' of Hospital Utilization.

1. Brig Gen Dr Zulfiquer Ahmed Amin
M Phil, MPH, PGD (Health Economics), Advance Course HA (AIIMS, Delhi), MBBS
North South University (NSU)

2. ● Data:
- Data is a set of values of qualitative or quantitative variables.
- Data is information in raw or unorganized form (such as
alphabets, numbers, or symbols) that refer to, or represent,
conditions, ideas, or objects.
● Information:
- Information is data that has been processed in such a way as
to be meaningful.
● Statistics:
- Statistics is a way to get information from data.
- The practice of statistics utilizes data from some population in
order to describe it meaningfully, to draw conclusions from it,
and make informed decisions.

3. Hospital Statistics
-It is the collection, processing, analyzing, and transmission of the
information required for the management of the hospital services.
-Hospital Information is an integral part of the hospital
administration. It is a basic Tool of management.
Definition
Information obtained from hospital indoor and outdoor facilities
regarding quality of care, utilization of services, quantity of services
delivered, workload, performance evaluation and other hospital
related administrative and logistic affairs is called ‘Hospital Statistics’.

4. Uses of Hospital Statistics
• Measure of health status of the community
• Measure of healthcare utilization
• Measure of evaluation of quality of care
• Guide for planning future development of the hospital
• Allocation of resources in different areas
• Identify deficiencies at various levels; ie. Input, process and
outcome of services
• Evaluate effectiveness and efficiency of the administration
• Re-orientation of health service delivery
• Efforts for improvement of hospital facilities
• Comparison of present and past performance of the hospital
• Appraisal of work performed by the medical, nursing and other
staff
• To conduct research

5. Tools of Measurements
In statistics, tools of measurements are rate, ratio and proportion.
Rate:
A rate refers to the frequency by which a certain event happens. eg,
Infant Mortality Rate (IMR).
A rate compares two quantities of different types and measuring
units. eg, Oil consumption of a car = 8 miles/liter.
Properties of Rate as measuring tool:
1. Numerator is part of denominator.
2. Compare measures of two different types of events.
3. Measuring units of comparing events are different.

6. Ratio:
Ratio a comparison of two numbers or quantities, measured in the
same units.
Properties:
-Numerator is not part of denominator.
-Compare two items/events with same measuring unit.
If a wall is made up of twelve blocks, five white blocks and seven red
blocks. The ratio of white blocks to red block 2:5, is a ratio.

7. Types of Hospital Statistics
1. Reports related to Hospital-Beds
-Daily Census
-Daily Average Attendance
-Bed Occupancy Rate
-Bed Turn Over Interval
-Bed Turn Over Rate
-Vacancy Rate
-Hospital Beds
-Sanctioned Beds
-Functional bed

8. • Admission:
-Daily Admission
-Total Admission over a period
• Discharge:
-Daily Discharge
-Total Discharge over a period
-Average length of stay
• Deaths
-Daily number of deaths
-Total deaths over a period
-Total deaths over 48 hours
-Total deaths under 48 hours
-Net death rate
-Gross death rate
-Post Operative death rate
-Anaesthetic death rate
2. Reports Related to Admission/ Discharge/ Death

9. 3. Work load statistics
-Total number of outputs
-New cases/ Repeat cases
-Total number of operations
-Total number of X-Rays
-Average OPD patients per day
-Total caesarean sections per day
-Average number of food served per day

10. 4. Hospital Care Evaluation Statistics
-HAI Rate
-Post Operative complication rate
-Autopsy rate
-Percentage of agreement between final and pathological
diagnosis
-Gross result of treatment; ie. Patients recovered, improved or
not relieved
-Caesarean sections rate
-Hospital Performance Index (eg, Pabon Lasso Model)

11. 5. Indices related to population at risk (Community Indices)
-Admission Rate
-Hospitalization Rate per person
-Bed-Population Index
6. Other types of classification:
• Patient movement statistics- Admission, discharge, deaths
• Morbidity statistics- Patients under various diagnosis
• Administrative statistics- Manpower, material, money-finance
• Hospital service statistics- No of operations, utilization indicators

12. Admission
The formal acceptance by a hospital or other inpatient health
care facility of a patient who is to be provided with room, and
continuous nursing service in an area of the hospital or facility
where patients generally reside at least overnight.
Admission Rate
Number of admission per 1000 population in a year.
Discharge
Discharge from the hospital is the point at which the patient
leaves the hospital and either returns home or is transferred to
another facility such as one for rehabilitation or to a nursing
home. Discharge involves the medical instructions that the
patient will need to fully recover.

13. Hospital Beds
A hospital bed or hospital cot is a bed specially designed for
hospitalized patients in need of some form of health care.
WHO defines a ‘hospital bed’ as a bed that is regularly maintained
and staffed for the accommodation and full-time care of a
succession of inpatients and is situated in wards or a part of the
hospital where continuous medical care for inpatients is provided.
Total number of beds excludes bed compliments of the hospital for
normal, healthy newborn babies in maternity ward; but includes
incubators used for premature babies.

14. Sanctioned Bed
It is the official bed capacity of the hospital.
CMH Dhaka: 1500 beds
BSMMU: 1900 Beds
Functional Bed
This is the actual functional status of beds in a hospital.
Observation patients in observation locations:
An “observation” location (e.g., 24-hour observation area) is
considered an outpatient unit, so time spent in this type of unit
does not contribute to any inpatient counts.

15. Bed-Days or Patient-Days
A day or part of a day that a patient is admitted to receive hospital
treatment.
A bed-day is a day during which a person is confined to a bed and in
which the patient usually stays overnight in a hospital. Each day
represents a unit of time during which the services of the institution
or facility are used by a patient; thus 50 patients in a hospital for 1
day would represent 50 patient-days.
One full day is counted when admission before mid-day and
discharge after mid-day.

16. Calculation of Bed-day/ Patient-day

17. Vacancy rate is the ratio of beds not rented versus the total number
of beds in the hospital.
vacancy rate is:
For example, let's assume that CMH Ghatail has bed-capacity of 300
units. Of those units, 25 are not occupied. Using this information and
the formula above, we can calculate that vacancy rate of CMH
Ghatail is:
Vacancy rate = 25/300 = 8.33%
Vacancy Rate

18. Bed Supply Rate (Bed to population ratio)
BSR = (No of Beds available ÷ No of population served) x 1000.
Bangladesh: 0.79/ 1000 population (2021).
India: 0.50/ 1000 population (2020)
Global average of 2.9 beds/ 1000 population.
Developed countries: 3-10 beds/ 1000 population.
WHO standard: 3 beds/ 1000 population.
The number of hospital beds available in public hospitals in Bangladesh amounted to 54,660, whereas the same figure
in private ones amounted to 91,537, bringing the total number of beds to 143,394 at the end of 2019.
Bed : Population Ratio

19. Hospital Admission Rate
• Number of hospital admission per 1000 population per year
• All admissions including re-admission for the same condition
are counted

20. Per Capita Hospitalization Rate
• Per capita days of hospital care given for a particular geographical
area, during a particular period.
• Range varies from 0.3 to 1.5
• In Bangladesh approximately 0.3
Number of days of hospitalization per person in a year in a defined area.

21. Hospital Utilization Statistics
Hospital Utilization Statistics are the information that shows the
performances of hospitals. Both, under and overutilization of
hospital resources are wastage of valuable resources. From hospital
utilization statistics, causes of underutilization can be identified and
remedial measures can be taken. Again, reducing unnecessary
hospital admission can result in a leaner, more efficient system with
lower costs and greater health outcomes. The opportunities to save
money and improve care are extraordinary. Indicators are:
-Bed Turnover Ratio
-Bed Turnover interval
-Average Length of stay
-Bed Occupancy Rate

22. Bed Turnover Ratio
Bed turnover rate (BTR) measures productivity of hospital beds, and
it represent the number of patients treated per bed in a defined
period, usually 1 year.
eg, Number of patient cared in 2009= 2358
Number of beds in that hospital in 2009 was 300.
Hospital Bed turnover rate = 2358/300 = 7.86
In India (2018)= 39
Significance of BTR:
It indicates the productivity of a hospital.
Turn-over ratio in acute care is higher than chronic care hospitals.
This is the indicator of hospital efficiency.
Quick turn-over indicates better care, quick recovery and discharge.
Delayed turn-over indicates delayed recovery, and delay in discharge.

23. Bed Turn Over Interval (TOI)
Turnover interval (TOI):
It is the average period in days, that a bed remains empty. Average
length of time (in days) that elapses between the discharge of one
inpatient and the admission of the next inpatient to the same bed.
The ideal turnover interval is suggested to be 1–3 days.
Significance:
-It indicated productivity of the hospital
-More bed vacant reflects bad reputation of the hospital
-It shows non-utilization of hospital beds.

24. Interpretation of TOI:
- Negative TOI indicates scarcity of beds and over-utilization.
- Long positive TOIs indicative of under-utilization because of
defective admission procedures or poor quality medical care.
- Short positive TOI is indicative of optimum utilization.
- TOI is ‘zero’ when Bed Occupancy Rate is 100%.

26. Length of stay is a term which is used to calculate a patient's day
of admission in the hospital till the day of discharge i.e. the
number of days a patient stayed in a hospital for treatment.
Given,
Number of patients = 4
Total Length of stay = 6 + 11 + 5 + 8
= 30 days

27. Salient of ALS
Average Length of Stay
= Total length of stay / Total
number of discharges
= 30 / 4
= 7.5 days

28. Importance of ALS
-The normal length of stay is 7 to 10 days.
-It helps identify essential and unnecessary length of stay.
-More ALS reflects inadequate functioning of the hospital and quality
of care
-Indicator of efficiency.
-All other things being equal, a shorter stay will reduce cost per
discharge.
Factors influencing ALS are:
-Character of the patient
-Disease character
-Hospital Acquired Infection (HAI)
-Habit of doctors and staff
-Hospital functioning

29. Habit of doctor and staff:
-Delay in case examination
-Delay in investigation
-Delay in starting treatment
Unnecessary admission to increase bed occupancy
Poor nursing care.
Hospital Functioning:
-Delay in special investigation
-Inadequate sanitation
-Improper disposal of Hospital Waste
-Quality of Central Sterile Supply Services
-Attendants controlling.

30. Bed Occupancy Rate (BOR)
It is the ratio between beds used and beds provided. The beds
occupancy rate is calculated based on the midnight bed census at
each hospital.
- A method of assessing hospital performance
- 80-85% BOR is ideal for good quality of patient care.
- 15-20% beds are vacant for emergency, maternity, isolation,
intensive care (Dead Space Beds).
- 100% occupancy means over-utilization.
- Occupancy less than 80% is under-utilization.

31. Example :
In June 2022, 4000 inpatients-days were served in a hospital with 150
beds .
Given,
Total number of inpatient-days = 4000. Available beds = 150. June
has 30 days. So, number of days in the period = 30
= 4000 x 100 / 150 x 30
= 400000 / 4500
= 88.889 %

32. Gross Death Rate:
Ratio of total deaths to total discharges including deaths.
EU average of GDR= 7.9 deaths per 100 cases
Autopsy Rate:
-Patients who are Dead on Arrival (DOA) at the hospital and Fetal
Deaths are excluded from both the numerator and the
denominator.
-Autopsy Rate more than 15-20% indicates enquiry type of medical
staff, progressive in outlook.

33. - Net Death Rate indicates the quality and efficiency of system
Net Death Rate:
A death rate, also known as the institutional death rate, that does
not include deaths, which occur within 48 hours of admission (24
hours of admission in some countries).

34. - As per WHO the ideal rate for caesarean sections to be between
10 to 15%.
- C-section rate in Bangladesh increased from 31% (2021).
- A higher CS should be enquired into.
Caesarean Section Rate:

35. Interpretation:
- Rates less than 5% may indicate inadequate availability and/or
access to emergency obstetric care.
- Rates above 15% suggest overuse of the procedure for non-
emergency reasons.
- Excessive use unnecessarily exposes women to anesthesia and
surgery with their concomitant risks.

36. Postoperative Death Rate:
The ratio of deaths within 30 days after surgery to the total number
of patients operated on during that period.
Global overall postoperative mortality from all causes is 1.85 % (1-2%)

37. Anesthesia Death Rate:
1. Anesthesia-Associated mortality:
Mortality in the context of an operation that was performed under
anesthesia (general or regional anesthesia). A causal association
between the anesthesiological measures and the patient’s death
cannot be established.
2. Anesthesia-Related mortality
Mortality that is caused directly by anesthesiological measures.
-Global death rate from anesthesia complications is about three per
10,000 procedures.
-Expected mortality rate from anaesthetic administration is less than
1:100,000.

38. For performance measurement of any hospital, any of the following
3 indicators are used:
-ALS = inpatient days / Number of admissions
This measures the average number of days the patient stays in the
hospital.
-BOR = (Patient-days / Bed-days) x 100
This is the measure of utilization of beds among available bed
capacity.
-BTR = total patient admissions / number of beds
This measures the productivity of hospital beds.
Pabon Lasso (PL) Model of Hospital Performance Measure

39. It has to be stressed that an assessment based on only one of the
ratios of hospital bed capacity utilization, may be flawed and
misleading. For example, bed occupancy rate may be relatively high,
in presence of unnecessarily high ALS, emanating from such factors
as poor nursing care, improper schedule of diagnostic and
therapeutic interventions and development of Hospital Acquired
Infection.
Thus although, BOR may indicate that there is a good level of capacity
utilization, the result may be due to under performance or
inefficiency of the hospital.

40. Pabon Lasso (PL) Model is to overcome this conflicting conditions and
to rightly identify the technical efficiency of hospitals.
This graphical model was devised by Pabon Lasso (Spain) in 1986 to
determine the relative performance of hospitals. When three (ALS,
BOR, BTR) indicators are put together into PL plot, it allows the
hospital to analyze its ‘Technical Efficiency’.
In Pabon Lasso Graph, BOR is placed in X-axis and BTR is placed in Y-
axis. It creates four quadrants (Zones) of performance-efficiency of
hospitals

42. The Pabon Lasso's (PL) model

43. Zone-1
Inference:
- First zone have lower BOR and BTR compared to their mean.
- Number of hospital beds is more than what is demanded.
- Patients seemingly demanding hospitalization are either diverted
to other centers or rejected.
- Further increase of beds are not required.
- Physicians are mostly reluctant and de-motivated.
- Hospitals are inefficient due to poor management.

44. Zone-2
-The second zone is characterized by lower BOR and higher BTR than
the average.
-They have numerous unused beds as well as excessive and hasty
hospitalizations.
-Most of these beds might be used for patients with no need to
hospitalization or for their possible examination.
-Obstetrics hospitals and short-term inpatient centers usually fall in
this zone.

45. Zone-3
-Hospitals in the third zone are both of high occupancy and
turnover;
-Pointing to an efficient resource utilization.
-In fact, a high BTR and BOR indicate that hospitals have reached an
appropriate level of efficiency, with relatively few vacant beds at any
time.

46. Zone-4
-Ultimately, a lower turnover and a higher occupancy than average
rate are featured by the quadrant IV.
-More chronic diseases with unnecessary long-term hospitalizations
and inefficient service delivery may cause this situation.
-Psychiatric, dermatological, geriatric hospitals and nursing homes
are normally placed in this area.
Quadrant III is ideal and I is the most inefficient.