PROBLEM SOLVING THROUGH SYSTEMS APPROACH -

HIS A CORE ELEMENT

Dr. Hem Chandra

Guest Lecture

Abstract :

Administrator requires information regarding hospital activities on every day, weekly, fortnightly, monthly, yearly basis. Hospital information collected on yearly basis is usually useful for long term planning. The every day information collected by the administrator is more useful in problem solving by strategic management. Once the problem is solved, we have to develop a system approach, which requires continuous monitoring & control to avoid any deviation and occurrence of same or similar problem is future. Activity status (data) received on regular basis, which can be interpreted into meaningful way, is the information. It is of paramount importance for the administrator that the desired information is received timely, accurately adequately through a proper channel and the system. Sanjay Gandhi PGIMS (SGPGIMS), Lucknow solved many day-to-day problems, which arose due to non-formation of system /procedure with the help of everyday information received from the periphery. Among the many, the common problems are non-availability of case sheet for indoor patient, excessive bed movement with in the hospital, misuse of emergency x-ray services and the dead body disposal. Now these systems are running well but are still monitored regularly every day through hospital information system, specially designed to meet certain important patient interests, which may be sensitive and require immediate attention also.

Introduction :

Problems are the part of the modern superspeciality and complex structured hospital but there are solutions also at the same time. These problems in fact creates hindrance in the day-to-day functioning of the hospitals. If observed keenly, it is easy to identify and find out the ways & means to solve these problems provided that management techniques are used to make the systems for these functioning. Identifying and analyzing the problems is the gate way towards the solution. Modern problem solving process based on work-study of the situation is the key to approach systematically toward the solution. HIS is core element as without information, no decision can be taken. The unit of the information is the data collected by work-study, which needs processing carefully, and meaningfully to result information.

Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow is a 640-bedded superspeciality hospital running with computerized and manual HIS system. The administration faced many problem and formed the systems approach with the help of HIS. This paper contains the brief of only three problems, which were solved by the work study basically conducted with following objectives.

1. Under utilization of Rogi Vishramalaya.

2. Excessive bed movement within the hospital.

3. Non-availability of case sheet for indoor patients.

1. To identify the problem (s) and confirm its magnitude by data collection on day-to-day basis.

2. To find out the possible reasons and the limiting factor responsible for the problem(s).

3. To develop, implement, monitor and evaluate the system for the success and improvement.

4. To establish the active role of hospital information system as a core element in problem solving through system approach process.

1. The problems were firstly identified, confirmed and analyzed for the magnitude by collecting the data on day-to-day basis for a fairly reasonable period.

2. The possible reasons for the problem were identified by retrospective/prospective study of the data, face-to-face interaction, floating the questionnaire etc. etc.

3. The limiting factor of each problem was identified by analyzing the data received form S. No.: 2.

4. Alternative system (s) were developed by focusing the limiting factors and the best was chosen to implement.

5. After having implemented the best alternative, the system was monitored for a fairly longer period by evaluating the data/information of post strategy implementation period on day-to-day basis with the pre strategy implementation data/information and the changes were observed.

6. The problems were solved but kept under monitoring for the future to avoid any deviation or recurrence of the problem.

Problem No.: 1

Under utilization of Rogi Vishramalaya - (total bed = 96)

The Institute has been observing very low occupancy of Rogi Vishramalaya for the last one year (approximately 49%) which was very less in comparison to space compliment and running (recurring) expenditure of the Rogi Vishramalaya. Though this facility was not created to earn revenue but basically to facilitate the OPD patients and their relatives coming from far of places. The utilization of the facility also has distinct effect on OPD crowd. The Institute earns approx. 30% of its non plan annual budget. Therefore if in case by increasing the utilization of Rogi Vishramalaya, the revenue is generated without increasing the charges of the Rogi Vishramalaya, the Institute had no problem.

Prestrategy findings - July 2000 to April 2001

1. Unawareness about the facility

2. Unwilling to use the facility

Following were the sources from where patients/relatives received the information about Rogi Vishramalaya

1. Guards

38%

2. Old patients

51%

3. Others

11%

Strategy - To focus on guards - Reallocation of guards for dissemination of information about Rogi Vishramalaya

1. Based on observations, it was planned to depute two guards at the entrance of the main registration and enquiry between 6.00 AM - 2.00 PM (OPD registration starts from 8.00 AM and closes at 12.30 PM). But patients reach much before and keep on coming even after 12.30 pm.). The guards were instructed to inform the people about the Rogi Vishramalaya facility and not to allow large brief case, suit case, bag (beyond a reasonable size) inside the hospital. They were also instructed to restrict more than two attendants with a patient and divert them to wards the Rogi Vishramalaya. These two guards deputed were from the same strength of the security keeping the expenditure stationary.

2. Posters / Hoardings at many places were increased so as to develop more awareness.

3. The drivers of local vehicle carrying patient/relatives from main gate to the hospital and back were also instructed to run the service through Rogi vishramalaya and inform the passenger about the facility. It was made mandatory for the vehicle to have a hault at RV for some moment.

Post strategy finding - May 2001 - September 2001 (Total bed - 96)

Month

Occupancy (%)

Revenue Generated (Rs)

May 2001

89

19620

June 2001

65

15590

July 2001

73

17510

August 2001

60

14330

September 2001

60

14330

We can conclude that the problem solving exercise undertaken by hospital administration was very successful as it pinpointing come out with the deficiencies in the management and running of Rogi Vishramalaya. It brought out the major factor for under utilization/revenue less viz non-information to patients/attendants about the existence of Rogi Vishramalaya and moreover it suggested steps how to propagate increase in utilization. When the steps were implemented fruitful results were delivered resulting in: -

	Increase in % of occupancy at Rogi Vishramalaya
	Thereby increase in revenue generation from Rogi Vishramalayas.
	And moreover decrease in unnecessary attendants crowd in the hospital, which were duly guided to the Rogi Vishramalaya by the guards posted at strategic places.

Achievement :

- Pre strategy occupancy = 33%

- Post strategy occupancy = 70%

Non-availability of case sheet for indoor patient.

The institute (hospital) has been observing that during the past 6 months that case sheets for a number of patients admitted in the wards were not available on the 1st day of admission, also there were certain cases were the case sheets were not available even after 3-4 days of admission. The senior residents/consultants/nurses often complained about the non-availability of the case sheets, as it would cause delay in starting the treatment. Efforts were made and OPD was analyzed for generation of case sheets. It was found that case sheets of the patients admitted through OPD were sent to their respective ward within 2 hours. However, the problem continued to persist even then. In view to decode the problem and analyze the situation, the hospital administration decided to go for a work-study with the following aim and objectives.

Admission routes : following were the routes through which admission were made

1. OPD appointed cases

2. OPD un-appointed cases

3. Directly in the ward

4. ERS

Analysis of the magnitude :- Prospective study between 3-7 and 10-14 June 2003 was carried out to find out the total admission and the missing case sheet

Distribution of type of admission & missing case sheets - 3-7 and 10-14 June 2002

Limiting factor - Admission directly in the ward is the main limiting factor and responsible for the missing of the case sheet (68.9%).

The strategy evolved to minimize the missing case sheets was based on the fact that

1. Any admission in the hospital should be in the knowledge of medical record section, so that the case sheet can be made available.

2. Secondly if the missing files are the result of some wrong practices followed by doctors should be stopped.

Every situation was analyzed for its feasibility to avoid any confusion and minimize the missing case sheet. Situational analysis revealed the followings.

1. Maximum number of missing case sheet belongs to the category no. 4 i.e. admission done directly in the ward (68.7%). It was found that about 70.4% case sheets are not available for  those went directly in the ward for admission. As per the system the patient should not directly report in the ward for the admission. Therefore the main emphasis was laid down on this category.

2. Admission through category 3 is unavoidable as matter belongs to gravity of illness.

3. Admission through category 1 i.e. OPD appointed case is the correct procedure.

4. Admission through category 2 i.e. OPD unappointed is also not correct but sometimes

it has to be accepted. Moreover % missing file was the minimum. Therefore effort to improve the condition was ignored inview to take corrective action against the category no. 4 first.

CORRECTIVE MEASURES : Steps

1. At present, all activities including the admission, of the hospital are run by computerized Hospital Information System (HIS). This is an easy path for the doctor to call the patients directly in the ward and admit them through ward computer. The first step decided was to withdraw the admission facility in the ward computer. The solution was very easy but the present module of HIS does not have the provision to withdraw the facility from the ward computer. Therefore this could not be implemented.

2. Based on present HIS system, the doctor can directly admit the patient and administration has no role to monitor it. It was thought that the administration must monitor all the admissions and therefore all admissions must be routed through the administration.

3. Based on finding, much emphasis was laid down to stop the admission the category No. 4 admission i.e. those directly reporting the ward for admission, as this constitutes the chunk of missing case sheet. Once this will be controlled, other will be dealt gradually.

4. A centralized admission cell was formed and all admissions were routed through this centre. An admission card (FLIMSY) is issued to every patient.

5. Ward sister I/Cs and staff nurses were directed not to offer any bed to any patient unless patient produces the admission card.

6. This system helped the administration to stop the direct admission in the ward. The administration ensured that every admission should be accompanied with the case sheet.

7. One person from the medical record was dedicated to find out the total number of admission for the day (all types) and make sure that case sheet of all patients is reached in the ward.

8. Strict monitoring was observed on admission procedure. Sister in the wards did not accept any patient with out FLIMSY.

9. Finally the objectives were achieved by meeting following two conditions

   a) Stop admission through directly in the ward by introducing the FILMSY.

   b) Nurse will not provide bed to any patient without FILMSY.

Post strategy findings - Prospective study for total admission and missing case sheet was done between 21 March - 30 March 2024

Distribution of type of admission & missing case sheets :

Total Admission, admission category, missing case sheet profile of the post strategy months on June, July, Aug 2003

S.No.    

Jun

July

Aug

Total

1

Adm. through OPD (A)

1175

1405

1257

3837

2

Adm. through OPD  (UA)

03

NIL

NIL

03

3

Adm. through ERS

356

384

478

1218

4

Direct Adm. to Ward

NIL

NIL

NIL

NIL

5

Missing file

43

26

115

184

Problem No.: 3

Problems :

ADVERSE EFFECTS :

1. Damage to door and corners of the elevator

2. Damage to bed

3. Large size of bed causes inconvenience to other patient/relatives

4. Increase in down time of elevator & the bed

5. Increase in expenditure on maintenance of elevator & bed

The administration wanted to have the first hand information as to why there is excessive bed movement with in the hospital. Some justified reasons such as serious patient with prolong illness can not be shifted, certain procedure such as ERCP where after the procedure the patient should not be moved etc. were taken into the account but still the administration was not satisfied. Doctors, nurses were ordered/requested to restrict the movement of beds within the hospital and use this facility only for needy patient but no improvement in the bed movement (decrease) was observed. After having interrogated more health care providers, it was observed that simply using the bed for any type of patient is the easiest task for Health Care Providers (HCP) therefore they would continue it. The SGPGI has a centralized internal transportation system (ICTS). The centralized station receives the demand from all patient care areas including OT, ICU, Investigation/procedure. Ultimately the hospital administration has to evolve the strategy for improving the situation. Based on above, a study was carried out with following objectives.

Prospective study to confirm the problem and its magnitude was carried out between Nov. 2002 to 04 Jan 2024

Pre strategy period - Nov 2002 to 04 Jan 2003

1. Month wise distribution of total bed movement

Month

Total internal Transportation movement

(TITM)

Bed movement

% of bed movement

November 2002

7624

650

8.5

December 2002

7631

750

9.8

Jan 1-4, 2003

1019

103

10.1

2. Internal transportation (Average)

Mode

Numbers

Percentage

By wheel chair/ Trolley

14771

91.8

By bed

1503

9.2

Total

16274

100

Limiting factor - It was easy to order the internal transportation center and send the bed

STRATEGY EVOLVED:

Alternatives :

a. Request to restrict the bed movement

- No effect

b. Office order to restrict the bed movement

- No effect

c.  Introducing Bed Movement Requisition Form (BMRF)

- Effective

BED MOVEMENT REQUISITION FORM (BMRF)

1. Name of the Patient

: ---------------------------------------------

2. CR. NO.

: ---------------------------------------------

3. Ward and bed no.

: ---------------------------------------------

4. Diagnosis

: ---------------------------------------------

5. Reason for bed movement request

: ---------------------------------------------

6. Why not the patient can be moved by the stretcher/trolley. Please justify the reasons

. -----------------------------------

Date: ----------------

Signature of S.R./Sister I/c

Name :

Post strategy finding -

Post strategy period - 05 Jan to March 2003

After the implementation of BMRF, the prospective study was carried out again to find out the effect.

1. Month wise distribution of total bed movement

Month

(TITM)

Bed movement

% of bed movement

Onward 05 Jan 2024

6947

213

3.0

Feb 2003

7913

183

2.3

March 2003

8112

324

4.0

2. Internal transportation (Average)

Mode

Numbers

Percentage

By wheel chair/ Trolley

22252

96.9

By bed

720

3.1

Total

22972

100

Post strategy period - April 2003 to Oct 2003

It was thought to withdraw the BMRF after 03 months of the implementation and observe the improvement even in absence of BMRF. Again a prospective study was carried out.

1. After withdrawal of bed movement requisition form (BMRF) - Month wise distribution of total bed movement

Month

(TITM)

Bed movement

% of bed movement

April 2003

7750

206

2.7

May 2003

8730

204

2.3

June 2003

7486 

250 

3.3

July 2003

8317

272

3.2

Aug 2003

8423

278

3.3

Sept 2003

8793

317

3.6

Oct 2003

8669

311

3.6

2. Internal transportation (Average)

Mode

Numbers

Percentage

By wheel chair/ Trolley

56330

96.8

By bed

1838

3.2

Total

58168

100