Impact of application of queuing theory on operational efficiency of patient registration.

Background: Hospital administrators are often challenged with overcrowding at hospitals. The study hospital receives referred patients; however, they have to wait in long queues even for getting registered. This was a cause of concern for hospital administrators. The study was undertaken to find an amicable solution to the queues at registration using Queuing Theory. Method: This observational and interventional study was carried out in a tertiary care ophthalmic hospital. In the first phase, data of service time and arrival rate was collected. The queuing model was built using the coefficient of variation (CoV) of the observed times. Server utilization for new patient registration was found to be 1.21 and was 0.63 for revisit patients. Scenario-based simulation carried out using free software for optimal utilization of both types of servers. Recommendations made to combine the registration process and to increase one server were implemented.In the second phase, after one year, patient registration data were collected and compared for the number of patients registered using SPSS 17. Results: Number of patients registered within the registration timings increased whereas the number of patients registered after the registration timings decreased significantly at 95% CI with a p-value of less than 0.001. Queues finished early and more number of patients were registered in the same time. Conclusion: Using queuing theory, the bottleneck of the systems can be identified. Scenario and software-based simulations provide solutions to the problem of queues. The study is an application of Queuing Theory with a focus on efficient resource utilization. It can be replicated in an organization with limited resources facing the challenge of queues.

Allocation scheduling leads to optimum utilization of operation theater time.

Background: Cancellation of surgeries is a regular phenomenon in any hospital, and reasons may vary from clinical to managerial ones. The aim of the study is to suggest scheduling to address the problem of time over run related cancellations. This is an observational and descriptive study conducted in a tertiary care hospital with ophthalmology facilities. The sample size is calculated with 95% confidence interval using Epi Info 6 from the total surgeries performed in the last 5 years (n = 380). Simple random sampling technique was used. Methods: Surgical time for all types of ophthalmic surgeries (n = 582) was observed. Allocation of listed cases to the available operating rooms (ORs) was carried out using the observed time using LEKIN software. Results: The time over-run of 2 h and 6 h was noted for two units, whereas idle OR time was observed in other units. An average idle time of 19% was noted on each day. Reallocation of the cases to the ORs was carried out taking all the planned cases (of both the operating units of the day) as the number of jobs and all the available ORs as parallel machines using LEKIN software. All the planned cases could be accommodated; still, an average of 17% of the total available operation theater (OT) time was found idle on each day. Conclusions: Planning of cases using procedure time and scheduling on a daily basis using allocation models with simple algorithms can provide optimal utilization of OTs and can address the time over-run and related cancellations.

Strengthening leadership capacity: an unaddressed issue in Indian healthcare system.

PURPOSE: Leadership skills are vital for efficient delivery of health reforms. India, a low- and middle-income country, is transforming its public health care significantly. The health workforce, particularly doctors, however lacks leadership skills. This study aims to highlight the leadership skills gap and raise concerns about how India might achieve its ambitious health reforms in the lack of formal, prospective leadership training for its workforce. DESIGN/METHODOLOGY/APPROACH: This study conducted nine management development programmes between 2012 and 2020 and collected data from 416 (N = 444, 94% response rate) health-care professionals using a questionnaire. Participants were asked to inform leadership challenges that they perceived critical. A total of 47 unique challenges were identified, which were distributed across five domains of American College of Healthcare Executives Competency Assessment Tool (2020). Relevant information was also obtained from review of secondary sources including journal articles from scientific and grey literature and government websites. FINDINGS: Majority of participants (85.36%) had never attended any management training and were from public sector (56.1%). Mean total experience was 18 years. Top 5 challenges were lack of motivation (54.26%), communication (52.38%), contracts management (48.31%), leadership skills (47.26%) and retention of workforce (45.56%). Maximum challenges (29) were in domain of business skills and knowledge, followed by knowledge of health-care environment (9), leadership, professionalism, and communication and relationship management (3 each). ORIGINALITY/VALUE: In absence of the leadership training, senior health professionals particularly doctors in India, suffer leadership challenges. Efforts should be made to strengthen leadership capacity in Indian health-care system to advance the country's ongoing national health reforms.

A study on economic evaluation of an outreach health-care facility in Jhajjar District of Haryana: Service delivery model for increasing access to health care.

BACKGROUND: An outreach (OR) health-care facility providing broad specialty outpatient services was started by All India Institute of Medical Sciences (AIIMS), New Delhi, in rural area of district Jhajjar, Haryana. OBJECTIVES: This study aimed to ascertain the resource requirement for establishing an OR health-care facility and patient satisfaction with regard to the services being provided. METHODS: A cross-sectional study was conducted in 2017 at an OR Outpatient Department (OPD) of AIIMS, New Delhi, at Jhajjar. Service delivery model adopted for health-care delivery was hub and spoke. Traditional method of costing was used for economic evaluation. Feedback pro forma of 400 patients who attended OPD services was analyzed to measure health service accessibility. RESULTS: Capital expenditure to set up the facility was calculated to be approximately INR 17,57,49,074/- ($ 2,703,832) and operational cost per year was approximately INR 8,73,86,370/- ($ 1,344,406). Approximate per-patient cost for single OPD consultation was calculated to be INR 874 ($13.45) which included medicines and investigations. High scores for all domains of accessibility of health care were observed. CONCLUSION: The study provides a preliminary evidence that OR health-care facilities can be instrumental in increasing access to health-care delivery with lesser capital outlays, however, large-scale multicentric studies are needed to arrive at any conclusion. The services have been very well accepted by the local community members being quality medical care with highly subsidized health-care services.

Outcome of Care Provided in Neonatal Surgery Intensive Care Unit of a Public Sector Tertiary Care Teaching Hospital of India.

AIMS: There is limited literature on the outcome of care in intensive care units (ICUs), especially when it comes to neonatal surgical units. Hence, this study was aimed to observe the outcome of care provided in the neonatal surgery ICU (NSICU) at an apex tertiary care teaching institute of North India. METHODS: A descriptive, observational study was carried out through retrospective medical record analysis of all the patients admitted in NSICU from January to June 2011. RESULTS: In NSICU, from January to June 2011, 85 patients were admitted. More than two-third (69.9%) patients were admitted through the emergency department. Of the total admitted patients, 69.9% were male. Mean and median age of the admitted patients were 6.31 and 2 days (range 0-153 days), respectively. The most common diagnosis was esophageal atresia with tracheoesophageal fistula (36.1%). Within a day of admission at NSICU, 88% patients underwent surgical intervention. Of the total admitted patients, 56.6% required mechanical ventilation with 3.57 days (range 0-31 days) of mean duration of mechanical ventilation. Reintubation rate (within 48 h of extubation) was observed to be 15.7%, and 27.7% (23) of the patients required vasopressor support during their NSICU stay. Patients who developed postoperative complications were 34.25%, with the most common being wound infection/discharge/dehiscence. Two patients were readmitted within 72 h of their discharge/transfer out from the NSICU. CONCLUSION: NSICU survival rate was 85.5% and net death rate was observed to be 14.5%. Sepsis was the major reason for mortality in NSICU.

Medical leadership competencies: A comparative study of physicians in public and private sector hospitals in India.

PURPOSE: Indian health care system comprising of public and private sectors needs enhancement of medical leadership capacity to face the growing challenges. Hence, this study was designed to evaluate medical leadership competencies of public and private sector doctors. FINDINGS: A survey questionnaire was developed to assess "self-assessed proficiency levels" as well as "perceived importance of competency levels," to which 532 doctors responded-290 (54.5%) from private sector and 242 (45.5%) from public sector hospitals. Statistically significant "leadership competency gap" was observed for all 30 leadership competencies in both sectors, more so in public sector. The 10 most deficient competencies were mainly in the NHS-MLCF domains of "working with others," "managing services," and "setting direction." The most low-rated competency among public sector doctors was "knowledge of HR, procurement, financial, and contract management" while "ability to influence key decision makers who determine future government policies" was most deficient among private sector physicians. Further, deficiencies related to "time and stress management" and "conducting need analysis, identifying and prioritizing requirements" were confined to public and private sector doctors, respectively. CONCLUSIONS: This study, first from India, highlights a critical need for medical leadership development programs in both sectors for enhancement of medical leadership capacity in the country.

National survey of infection control programmes in South Asian association for Regional Cooperation countries in the era of patient safety.

BACKGROUND: The implementation of hospital infection prevention and control (IPC) in south Asia is not well described. We aimed to assess IPC programmes in hospitals in this region and explore opportunities for improvement. METHODS: Attendees from hospitals in the South Asian Association for Regional Cooperation (SAARC) region who were at one of four National Initiative for Patient Safety workshops organised by All India Institute of Medical Sciences (New Delhi) from 2009 to 2012 were invited to complete a semi-structured questionnaire. The survey addressed six main components of IPC programmes. RESULTS: We received responses from 306 participants from 82 hospitals. Five key opportunities for improvement emerged: (1) lack of healthcare epidemiologists, (2) relative infrequency of antibiotic guidelines (53%) and prescribing audits (33%) (3) lack of awareness of needle stick injury rates (84%) (4) only 47% of hospitals were prepared for surge capacity for patients with infectious diseases, and (5) limited coordination of hospital infection control personnel with other support services (55%-66%). CONCLUSION: These results outline IPC challenges in the SAARC region and may be useful to guide future quality improvement initiatives.

A comparative cost analysis of polytrauma and neurosurgery Intensive Care Units at an apex trauma care facility in India.

CONTEXT: Although Intensive Care Units (ICUs) only account for 10% of the hospital beds, they consume nearly 22% of the hospital resources. Few definitive costing studies have been conducted in Indian settings that would help determine appropriate resource allocation. AIM: The aim of this study was to evaluate and compare the cost of intensive care delivery between multispecialty and neurosurgery ICUs at an apex trauma care facility in India. MATERIALS AND METHODS: The study was conducted in a polytrauma and neurosurgery ICU at a 203-bedded Level IV trauma care facility in New Delhi, India, from May 1, 2012 to June 30, 2012. The study was cross-sectional, retrospective, and record-based. Traditional costing was used to arrive at the cost for both direct and indirect cost estimates. The cost centers included in the study were building cost, equipment cost, human resources, materials and supplies, clinical and nonclinical support services, engineering maintenance cost, and biomedical waste management. STATISTICAL ANALYSIS: Statistical analysis was performed by Fisher's two tailed t-test. RESULTS: Total cost/bed/day for the multispecialty ICU was Rs. 14,976.9/- and for the neurosurgery ICU, it was Rs. 14,306.7/-, workforce constituting nearly half of the expenditure in both ICUs. The cost center wise and overall difference in the cost among the ICUs were statistically significant. CONCLUSIONS: Quantification of expenditure in running an ICU in a trauma center would assist health-care decision makers in better allocation of resources. Although multispecialty ICUs are more cost-effective, other factors will also play a role in defining the kind of ICU that needs to be designed.

Healthcare associated infections in Paediatric Intensive Care Unit of a tertiary care hospital in India: Hospital stay & extra costs.

BACKGROUND & OBJECTIVES: Healthcare associated infections (HAIs) increase the length of stay in the hospital and consequently costs as reported from studies done in developed countries. The current study was undertaken to evaluate the impact of HAIs on length of stay and costs of health care in children admitted to Paediatric Intensive Care Unit (PICU) of a tertiary care hospital in north India. METHODS: This prospective study was done in the seven bedded PICU of a large multi-specialty tertiary care hospital in New Delhi, India. A total of 20 children with HAI (cases) and 35 children without HAI (controls), admitted to the PICU during the study period (January 2012 to June 2012), were matched for gender, age, and average severity of illness score. Each patient's length of stay was obtained prospectively. Costs of healthcare were estimated according to traditional and time driven activity based costing methods approach. RESULTS: The median extra length of PICU stay for children with HAI (cases), compared with children with no HAI (controls), was seven days (IQR 3-16). The mean total costs of patients with and without HAI were ' 2,04,787 (US$ 3,413) and ' 56,587 (US$ 943), respectively and the mean difference in the total cost between cases and controls was ' 1,48,200 (95% CI 55,716 to 2,40,685, p<0.01). INTERPRETATION & CONCLUSIONS: This study highlights the effect of HAI on costs for PICU patients, especially costs due to prolongation of hospital stay, and suggests the need to develop effective strategies for prevention of HAI to reduce costs of health care.

Need for a hands-on approach to hand-offs: A study of nursing handovers in an Indian Neurosciences Center.

CONTEXT: Standardized nursing handovers have been known to improve outcome, reduce error, and enhance communication. Few, if any, studies on nursing handovers have been conducted in the India. AIM: The aim was to study nursing handover practices in a Neurosciences Center in India. SUBJECTS AND METHODS: This study was conducted in a 200 bedded public sector Neurosciences Center in New Delhi, to assess nursing handover practices across five wards, all shifts, weekdays, and weekends using a pretested checklist. Ten elements were observed under the categories of time, duration, process, nurse interaction, and patient communication. STATISTICAL ANALYSIS: Analysis of variance, Z-test, and Spearman's correlation coefficient. RESULTS: Totally, 525 nursing handovers revealed varying compliance levels among (63%) time, place (76%), process (82%), staff interaction (53%), and patient communication (44%) related elements. Poorer compliance was seen in morning shifts and weekends; the difference being statistically significant. Bedside handovers were more frequent during weekends and night shifts and were positively correlated with increased staff interaction and patient communication and negatively related to handover duration. Though nurses showed better adherence to process related elements, background patient information, and assessment was explained less frequently. Differences between wards were insignificant except in categories of nurse interaction and patient communication which was better in the neurosurgery than neurology wards. CONCLUSION: Study revealed a need for a system change and standardization of handovers. Greater administrative commitment, use of technology, training, and leadership development will aid in continuity of care, promote patient safety, and ensure better outcomes.

Does a single specialty intensive care unit make better business sense than a multi-specialty intensive care unit? A costing study in a trauma center in India.

CONTEXT: Though intensive care units (ICUs) only account for 10% of hospital beds, they consume nearly 22% of hospital resources. Few definitive costing studies have been conducted in Indian settings that would help determine appropriate resource allocation. AIM: To evaluate and compare the cost of intensive care delivery between multi-specialty and neurosurgery ICU in an apex trauma care facility in India. MATERIALS AND METHODS: The study was conducted in a polytrauma and neurosurgery ICU at a 203 bedded level IV trauma care facility in New Delhi, India from May, 2012 to June 2012. The study was cross-sectional, retrospective, and record-based. Traditional costing was used to arrive at the cost for both direct and indirect cost estimates. The cost centers included in study were building cost, equipment cost, human resources, materials and supplies, clinical and nonclinical support services, engineering maintenance cost, and biomedical waste management. STATISTICAL ANALYSIS: Fisher's two-tailed t-test. RESULTS: Total cost/bed/day for the multi-specialty ICU was Rs. 14,976.9/- and for the neurosurgery ICU was Rs. 14,306.7/-, manpower constituting nearly half of the expenditure in both ICUs. The cost center wise and overall difference in the cost among the ICUs were statistically significant. CONCLUSIONS: Quantification of expenditure in running an ICU in a trauma center would assist healthcare decision makers in better allocation of resources. Although multi-specialty ICUs are more expensive, other factors will also play a role in defining the kind of ICU that need to be designed.

Cost Analysis of Operation Theatre Services at an Apex Tertiary Care Trauma Centre of India.

Operating room services are one of the major cost and revenue-generating centres of a hospital. The cost associated with the provisioning of operating department services depends on the resources consumed and the unit costs of those resources. The objective of this study was to calculate the cost of operation theatre services at Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi. The study was carried out at the operation theatre department of Jai Prakash Narayan Apex Trauma Centre (JPNATC), AIIMS from April 2010 to March 2011 after obtaining approval from concerned authorities. This study was observational and descriptive in nature. Traditional (average or gross) costing methodology was used to arrive at the cost for the provisioning of operation theatre (OT) services. Cost was calculated under two heads; as capital and operating cost. Annualised cost of capital assets was calculated according to the methodology prescribed by the World Health Organization and operating costs were taken on actual basis; thereafter, per day cost of OT services was obtained. The average number of surgeries performed in the trauma centre per day is 13. The annual cost of providing operating room services at JPNATC, New Delhi was calculated to be 197,298,704 Indian rupees (INR) (US$ 3,653,679), while the per hour cost was calculated to be INR 22,626.92 (US$ 419). Majority of the expenditures were for human resource (33.63 %) followed by OT capital cost (31.90 %), consumables (29.97 %), engineering maintenance cost (2.55 %), support services operating cost (1.22 %) and support services capital cost (0.73 %). Of the total cost towards the provisioning of OT services, 32.63 % was capital cost while 67.37 % is operating cost. The results of this costing study will help in the future planning of resource allocation within the financial constraints (US$ 1 = INR 54).