Enhancing healthcare access for poor patients through financial waiver at point of care, the model, utilization and disease profile in an apex tertiary care public hospital in India
An estimated 29.5% population in India lives below poverty line. With meagre 1.2% of Gross Domestic Product government spending on health and necessary evil of user charges to fund healthcare in developing countries, out of pocket catastrophic expenditures restrict access at point of tertiary care due to non-affordability despite government schemes. This study explored the system established by hospital administration for waiver of user charges for poor indigent patients. 
A descriptive and ambi-spective study was done in an apex referral public hospital in India. Direct observations and interviews with key stakeholders were conducted to study exemption model. Disease profile of in-patients needing financial assistance and utilisation of surgical consumables provided free were prospectively studied for six months.
On request from treating doctors, waiver of user charges were authorized by hospital administrators through socio-economic assessment by medical social officers (both available at all times). All requests were honoured irrespective of documentary evidence of poverty. Waiver for surgical consumables was 27100 rupees (427 dollars) per patient and 837 rupees (13 dollars) per patient per day. Most prevalent were cancers (35.92 %) and kidney diseases (24.65 %). These poor patients had longer length of stay (22.3 days). Majority belonged to Bihar and Uttar Pradesh states.
The model, which can be adopted in similar settings, demonstrated increased access as all requests were honoured. Financial expenditures revealed can help in budget projections. Disease profile and types of consumables revealed can be used as basis for strengthening healthcare delivery systems of referring states.
Keywords: Length of Stay; Health Expenditure; Poverty; User fee; Waivers
Critical care is one of the essential services needed by patients who are amongst the sickest in hospital and requires the best care possible. The quality of healthcare has been a major concern for healthcare professionals and development of instruments that enable quality to be measured has been essential in the transformation of this concern into a way of working. It is important that every ICU formulates its indicators of quality as well as its standards to assess performance. Quality indicators are measurements, whose value helps to distinguish between good and bad structural processes and outcome quality. Quality indicators should be based on the best available evidence/be derived from the scientific literature. In 2008, the Indian Society of Critical Care Medicine (ISCCM) had taken the initiative, to identify quality indicators for ICUs in India. Quality indicators in ICU are Operational or Process parameters (Length of stay, compliance to protocols, ICU readmission rate etc.); Outcome parameters (Standardised mortality rate, morbidity parameters i.e. Iatrogenic pneumothorax, incidence of severe acute renal failure in non-coronary ICU, decubitus ulcer); Error and Patient Safety (Patients’ fall rate, medication error, adverse events/ error rate, needle stick injury rate, reintubation rate); Infection Control (Ventilator associated pneumonia, surgical site infection, central line associated blood stream infection, urinary catheter related infection); Human Resource (Employee satisfaction) and Customer Focus (Patient experience/ satisfaction).
Keywords: Quality of care, Quality in ICU, Quality Indicators, Cost of intensive care
Background: In India, though aging process is universal, proportion of the patient undergoing cosmetic surgical procedures are relatively less. The present article analyses the acceptability of the cosmetic surgical procedures in general population and the difference in acceptability, if any, between males and females. 
Objectives: To find out acceptability of cosmetic surgery in general population, difference in acceptability in males and females and effect of age and socioeconomic status on the acceptability of cosmetic surgery. 
Methods: The study was conducted on 120 participants (students, employees of Manipal University (MU) and their relatives) (males 57, females 63) at Manipal between Dec 2009 and March 2010. Acceptability and socioeconomic status was assessed by arbitrary rating scale. Acceptability Score >3 indicated that cosmetic surgery was acceptable to the participant. Descriptive statistics- one way ANOVA was used to analyze the result. 
Results: Total mean acceptance score of the entire respondents (3.56±0.64; 95% CI 3.44-3.67)) showed that cosmetic surgery, in general, was acceptable to them. The mean acceptability score in males (3.43±0.66; 95% CI 3.26-3.60) was less as compared to females (3.68±0.60; 95% CI 3.52-3.83) and the difference was statistically significant (p-value 0.03550 yrs) (12 respondents) were 3.50±0.53, 3.62±0.73 and 3.62±0.73 and the differences among the groups were not significant (p-value 0.620). Seventy four (male 33, female 41) participants (61.7%) were from socioeconomic class 1 (Socioeconomic score 1-3) and forty six (Male 24, female 22) participants (38.3%) were from class 2 (Socioeconomic score >3). There was no significant (p-value 0.514) difference in mean cosmetic surgery acceptance scores of participants in socioeconomic class 1 (3.59±0.63) and socioeconomic class 2 (3.51±0.66). Out of 102 of 120 (85%) respondents expressed their opinion about concerns related to cosmetic surgery: 43.14% responders were concerned about the cost, 32.35% about complications and 13.73% about both down time as well as hospital facilities.
Conclusions: In general cosmetic surgery is acceptable to general population. The acceptability of cosmetic surgery was significantly less in males than females. There was no significant difference in acceptability of cosmetic surgery in different age group and in different socio-economic class. Responders were concerned about cost, complications, down time and hospital facilities in descending order of importance.
Materials management is generally cost and efficiency driven, however, quality assurance is its critical aspect. This study explores system of inspection of hospital supplies. It captures an important quality indicator, the percentage of items rejected before goods receipt note generation on inspection, in the store of a tertiary care public hospital in India.
A prospective study was conducted in the store in 2017. Direct observations were conducted. Details of items rejected and reasons were captured by the researchers while carrying out the inspections as part of the stores inspection committee.
There was a well established system of inspection of hospital supplies with all requisite tools. An inspection committee strategically composed of qualified hospital administrator with insight for both quality & supply chain management, nurse administrator with eye of a user and store manager. Percentage of items rejected was initially higher at 3.8% but subsequently lower (up to 0.76%) thereby suggesting that it leads to quality improvement besides setting benchmark for similar hospitals. The reasons for rejections were invalid test reports, supply from manufacturers not approved, items non complaint to approved specifications or different model, short expiry items, “X-hospital supply-not for sale” not stamped, etc.
Stringent and objective evaluations against predefined criteria are a means to achieve quality assurance of drugs and consumables in hospitals. Notable is strategic inclusion of nurses as users and qualified hospital administrators in the stores inspection committee. The findings are a benchmark quality indicator for other similar hospitals.
Key words: Quality Improvement; Materials Management, Hospital; Hospital Administration; Equipment and Supplies, Hospital. 
Purpose: Patients availing insurance with commercial insurance providers constitute just 3.6 percent. These insured patients become prime targets of private hospitals. Thus, satisfaction of these patients is of prime importance. Yet, many hospitals struggle to manage the one key process, which could spoil the overall favourable experience that patients have during their stay in the hospital, i.e., the discharge process. In this study, time tracking for the discharge process of insured patients is done, using the shadowing technique, with the objective of finding out the major causes of delay, and to recommend solutions for reducing them.
Methodology: This study is cross sectional and is carried out for the period of three months, i.e., from March 2018 to May 2018. A sample size of 174 patients is taken, using the systematic random sampling technique; unadjusted linear regression is used so as to find out major sub processes affecting the overall discharge process time. For finding out vital categories of queries sent by the external TPA department, Pareto analysis is used.
Findings: The two main sub processes explaining the maximum variance in the overall discharge process are the time taken for discharge summary to reach the in-house TPA department, and its approval by the external TPA after submission of the discharge summary, with adjusted R2  .554 and .219 respectively. Additionally, from the Pareto analysis, it was found that out of total 128 categories of queries, 5 categories accounted for 64 percent of total queries.
Practical Implications: Hospitals need to focus on the time taken for the discharge summary to reach the in-house TPA department. In fact, they can opt for technological solutions, such as the “electronic discharge system”, which can facilitate the stages of typing, review, revision and submission to the in house TPA department. Similarly, hospitals should collect the data of the queries raised by the external TPA and analyse them with Pareto technique so as to find out the major categories accounting for the maximum number of queries. In this way, they can develop a tool such as a checklist, which, when implemented in its intended form and spirit, will result in significant saving of time and efforts.
Keywords: TPA, Health Insurance, TAT, Query, IRDA
Background: Intensive Care Unit (ICU) is an area where intensive nursing and medical care are provided round the clock in a hospital. Intensive care beds account for at least 12% of the hospital beds and 20-40% of all hospital operating costs. Cost calculation is necessary to enhance conceptual uniformity and to optimize resource consumption. Based on the National Sample Survey in 2014, 63 million individuals or 12 million households fell below poverty line due to health expenditures (6.2% of all households). Even more disconcerting is the fact that more than 40% of those admitted to an ICU had to borrow money or sell assets. Cost analytic studies are needed for better knowledge of the costs and economics involved in intensive care of a developing country like India. Aim: To analyse the profitability margin of ventilator usage in a hospital. Six Intensive Care units were considered for the study purpose, which housed 46 ventilators. The Variable Costs, Fixed Costs and the Revenue were collected during a 3-month duration. Results: There was a 70% contribution margin from each ventilator towards the fixed costs. The Cost-Volume-Profit from total ventilators was Rs. 23,51,363/- (Rs. 51,116/- per ventilator) during the study period. 
Keywords: Contribution Margin, Ventilators, Variable Costs, Fixed Cost, Cost-Volume-Profit
Background : Cash has been king in mode of payment in Indian hospitals and one of the reasons for this is to cover unforeseen medical treatment. However, now-a-days the government prefers the cashless transaction for conduction of public health programs. Though Sanjay Gandhi PGIMS (SGPGIMS) Lucknow, a tertiary care hospital has also been providing digital payment facilities since 2011, but utilisation was minimal. Usage of digital payment mode though increased significantly just after demonetization but its sustenance after remonetisation has been topic of discussion. Materials and method : Study  conducted  from March 2017 to March 2018 for revenue generation and card swipes was compared with previous studies conducted on utilization of card for payment. Public perception on digital mode of payment was also observed. Results : Following demonetization, digital payment  / number of card swipe saw sharp spike of 27%/365% increase from base line in Nov-Dec 2016. As remonetisation picked up pace, digital payments fell down to the level of  18% /342%  increase in comparison of above value between March –December, 2017. But usage of card payment was again  geared up to the level of  32%/427% increase from base line from January to March 2018. 80% of public preferred for digital mode of payment  but all of them did not use. 
Conclusion : A notable finding of huge increase in % of card swipes in comparison to increase in % of revenue generation is a positive sign favouring the acceptance of digital mode of payment. Gradually public is adopting digital mode of payment in hospital.
Managing nursing services in a hospital is the most challenging task to any Hospital Administrator. Attrition among nurses are alarmingly high owing to disproportionate workload, workplace stress, expanding scope of nursing services to include documentation, inventory, Quality Compliances etc. Hospitals are working under tight financial considerations because of reducing Average Revenue per patient and one of the common cost containment strategy followed is reducing the manpower. A study was conducted at an ICU of a large tertiary care hospital to determine optimum staffing level using WISN method. It was an observational study conducted between January 2015 and May 2015 at a multidisciplinary ICU and Calculation was made as per WISN method.
Results: ICU had an average occupancy level of 71 through the year and based on WISN method, 41 nursing staff posted at ICU was found to be optimum including the need to manage emergency. If the occupancy increases beyond 85%, there is a need to post 4 additional staff to manage the workload.
Key Words: WISN, Nursing Workload, Staff Optimisation, Nursing Efficiency
Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST) is an Institute of National Importance under Govt of India (Act 52 of 1980) which has a referral hospital offering tertiary care advanced treatment for cardiac and neurological disease. The Department of Cardiac surgery which has both adult and paediatric divisions offers treatment for various types of cardiac diseases including congenital and acquired valvular diseases requiring homograft cardiac valves for corrective surgery.
A joint collaborative programme between SCTIMST and Govt. Medical College, Thiruvananthapuram was therefore initiated for the purpose of harvesting, processing and subsequent implantation of homograft valves into the patients requiring them.  The paper outlines the process of obtaining consent, the eligibility and exclusion criteria and factors responsible for lack of consent in cases which are fit for harvest.  Valves were harvested from persons who had died of Road Traffic Accident (21.4%) and hanging (10.14%) mainly during the period 2006 – 2012.  The rate of consent for the harvest of organs was found to be 50.72 %.  Harvest could not be materialized in 20 % of cases due to logistic reasons.  Absence of immediate relatives (as per THOAct) in the mortuary premises and unwillingness on the part of relatives to consent were the major causes for the low rate of harvest.
Objective: To determine the knowledge and attitude of nurses regarding medication administration and barriers in reporting medication errors in a tertiary care hospital in India
Methods: In an exploratory cross-sectional survey, a pre-tested and validated questionnaire on knowledge and attitude regarding medication administration and barriers in reporting medication errors in a tertiary care hospital in India  was self administered to 296 conveniently selected nursing personnel working in indoor facilities of medical and surgical disciplines of a tertiary health care facility. The data was collected and analysed from June 2013 to Aug 2013.
Results: Out of 296 nursing personnel enrolled, majority were females (83.4%)   in the age group of 25-29 years (42.6%) with the professional qualification of General Nursing and Midwifery (64.2%). Sixty eight percentage of the participants were working in general wards.   
 The mean knowledge score of nurses regarding medication administration was 9.76±2.4, which indicates average level of knowledge. Incidence of medication error as reported by the subjects through the self- administered questionnaire is 53.7%, whereas 92.45% among them reported this error to the competent authority and the rest did not report the error. The major reasons for committing medication error as identified by the nurses were work overload (44.65%) and illegible handwriting of the prescriber in the instruction book (22.64%).     
Multiple comparisons using Bonferroni test revealed that staff in the age group of 25-29 has significantly higher level of knowledge as compared to those who are in the age group of 30-34 (p=0.002) and 35 and above(p=0.000). The nurses working in the ICUs have the highest mean score of knowledge (10.57) as compared to nurses working in other areas like ward, OPD, Emergency and OT. The nurses working in the ICU have a significantly higher level of knowledge (p=0.006) as compared to nurses working in OPD. Nurses with GNM have a significantly lower level of knowledge as compared to nurses with BSc Nursing (p=0.000) and Post Basic BSc Nursing(p=0.001).
Conclusion: The study revealed that nurses have average level of knowledge regarding medication administration which need to be updated regularly. The major factor identified by nurses leading to medication error was increased workload. Most of the time errors in the system lead to errors in the medication errors. 
Key words:  Knowledge, Attitude, Nursing Personnel, Medication Error 
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