The Quarterly Bulletin of the Dept of Hospital Administration, AFMC

MISSION STATEMENT “Department of Hospital Administration strives to impart the highest quality education, training and research in the field of healthcare administration and health facility planning. The department also endeavours to be the nodal point for healthcare quality and accreditation in Armed Forces Medical Services” PLACE: PUNE

YEAR - 1 Message from Editor’s Desk ISSUE - IV It is an honour to pen down the editorial for this edition of NEETI, which is being released at a time when we have all faced and overcome the challenges of dealing with the Covid Pandemic. O C T 2 0 2 0 It is only during adversity that the true character of men is revealed. And it is during challenging times that all the Leadership Qualities of a Hospital Administrator are truly tested. The faculty and residents of our department have led the way in planning, designing and operationalizing two Covid Hospitals recently, a INSIDE THIS 1000 bedded facility at Delhi and another 500 bedded at Muzaffarpur, Bihar. The practical hands on experi- ISSUE: ence earned by the residents during these deployments will serve them well during their future endeavours.  Legal Bugle 1 The pandemic has also reiterated the importance of Situational Leadership in today’s world, forcing us all to TELEMEDICINE adapt and adopt newer modalities of Teaching-Learning which will be the new normal for the foreseeable future. Lastly it has brought into focus the importance of Evidence Based Clinical Practice like never before,  Treat Safe 2 even shining a light on difficult to discuss topics like the reliability of research findings and the role of PATIENT FALLS Pharmaceutical and Medical Equipment Manufacturers in Healthcare Delivery. To that end “Strong Medicine” has been chosen for the book review in this edition. In the Patient  Management Tool 3 Safety segment, we discuss Patient falls as a preventable occurrence in hospitals and Root Cause Analysis as ROOT CAUSE a tool for Quality Improvement. ANALYSIS Here’s hoping that you enjoy reading this edition as much as we have enjoyed putting it together.  Case Study 4 WORK STUDY -Col Surekha Kashyap (Prof & Offg HoD) RT-PCR Projects & Works 5 TELEMEDICINE ACCEPTANCE OF NECESSITY ‘The delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease  Book Review 6 and injuries, research and evaluation, and for the continuing education of health care STRONG MEDICINE providers, all in the interests of advancing the health of individuals and their Seven Elements of communities.’ (WHO) Pl find e-copy at: Tele-medicine . www.afmc.nic.in/ Restrictions on prescribing medi- Departments/HospitalAdm/ Context publications.html Neccessity in India cines Identification of RMP and

Patient  3.2 million sq km (7th largest List ‘O’- “Over the counter drugs” Editorial Board country geographically in the Medicines that deemed necessary dur- Mode of communication world) ing public health emergencies (video, audio, text or asyn-

Patron :  Varied landscape & far flung List ‘A’-safe & low potential for abuse chronous) Lt Gen Nardeep Naithani areas Consent (Implied or Ex- List ‘B’-prescribed during in-person  Deficient healthcare facility plicit) to be taken Vice Patron : consult for the same medical illness Type of consultation Maj Gen R M Gupta, VSM  75% qualified doctors-urban centres List Prohibited-Schedule X drugs, (First or Follow up within Narcotics & Psychotropic Editor-in-Chief :  68% rural population deprived 6 months for same illness) Brig A K Naik from direct access substances Patient Evaluation  Rapid technological changes Patient Management Editors : Col Surekha Kashyap “Telemedicine as a modality shall act Col Saroj Kumar Patnaik as an instrument for equitable distri- Lt Col Shashikant Sharma bution of healthcare resources in India”

Assoc. Editors : Lt Col Lavneesh Tyagi Maj Bipul Kumar Singh Maj Neelesh Patel Dr Nidhi Sharma ISRO Telemedicine programme started in 2001 & it has been connecting remote/rural/medical college hospitals and Mobile Units through the Indian satellites to major specialty hospitals in cities and towns.

Patient Falls (International Patient Safety Goals)

Falls are the second leading cause of accidental or unintentional injury deaths worldwide. Each year an estimated 6,46,000 individuals die from falls globally of which over 80% are in Types of falls low and middle income countries. Adults older than 65 yrs of age suffer the greastest number of fatal falls. 37.3 million falls that Accidental fall : are severe enough to require medical attention occur each year. (WHO) Caused by accident & can be prevented through universal Studies show falls occur at a rate of 3–5 per 1,000 bed-days precautions applied to all pa- (medalerthelp.org/blog/falls-in-the-elderly-statistics/) tients Anticipated physiological Risk factors: Most patient falls are caused by a combination of fall : factors. Few of the causes are Caused by underlying medical Risk assessment  problems or symptoms Previous fall history  Gait instability and lower limb weakness Risk assessment of a patient is a Unanticipated physiological  Urinary incontinence, frequency or the need continuous process starting right fall : for toileting from the admission of the patient Caused by an underlying medi-  Agitation, confusion or impaired judgement in the hospital till the time patient is discharged fit and cal or physiological problems  Aged patients extended if the home care that has not been diagnosed  Medications like sedation hypnotics continues. Monitoring Patient Risk Assessment ToolMonitoring can be Can be done through the done through the inci- incident reporting of falls dent reporting of falls and calculation of the fall and calculation of the rate as Falls per 1,000 occu- fall rate as Falls per pied bed days on a monthly 1,000 occupied bed basis days on a monthly basis Falls in healthcare facil- ities can be Expensive, Dangerous and Deadly

11,000 fatal falls occur each year in hospitals

Fall injuries increase hospital stays by an average 6.3 days

According to the CDC, injuries from falls are estimated to be

among the top twenty MOST Suggested Measures EXPENSIVE medical

Role of Hospitals & Universal Precautions to prevent Patient Falls conditions In 2013, total cost of healthcare  Side rails to be raised for all patients. Patient and family to be informed and fall injuries was $ 34 BIL- educated on need to raise side rails. LION  Safety First signage to be appropriately placed as applicable  Call Bells to be kept within patient’s reach By 2021, the total cost of these fall injuries could be as much as  Toilet and Nutritional needs of the patient to be met 67.7 BILLION  Transfer assistance to be provided with appropriate tagging to ensure proper $ communication of vulnerable patient Even falls that don't cause injury  Restraints to be applied whenever clinically indicated can cause fear of falling leading  Hook & Loop alarm belt to physical decline, depression  Environmental Control to be provided including and social ISOLATION i) Floors to be kept dry in ward and toilet ii) Patient to be educated not to walk holding the food trolley or STEADI -Stopping Elderly other objects containing Accidents Deaths & Injuries) iii) Grab bars to be located properly in toilets and bathroom initiative. iv) Staff to ensure assistance during patient movement or walking (CDC)

P A G E 2 “The best way to find yourself is to loose yourself in the service of others” - Mahatma Gandhi Root Cause Analysis

oot cause analysis (RCA) is a structured method R “For want of a nail the shoe was lost, for want of a shoe the used to analyze serious adverse events. Initially de- horse was lost, for want of a horse the knight was lost, for want veloped to analyze industrial accidents, now widely of a knight the battle was lost, for want of a battle the kingdom deployed as an error analysis tool in health care to was lost. So a kingdom was lost—all for want of a nail.” move quality efforts forward. As healthcare organisations become more atient safety events can cause serious harm or death. To address & complex, processes are interdependent P prevent these threats, healthcare organisations must dig deep to unearth increasing the risk of failures. the root cause(s) and develop solutions that address the problems from a These failures result in - systems perspective.  Tragedy for individuals served A multidisciplinary team analyzes the sequence of events leading to the error,  Add cost to the already overburdened with the goals of identifying how the event occurred (through identification of healthcare system active errors) and why the event occurred (through systematic identification and  Adversely affects the public’s perception analysis of latent errors)  Leads to litigations The ultimate goal of RCA is to prevent future harm by eliminating the latent  Affects healthcare professionals who are dedicated to the well-being of their patients errors that so often underlie adverse events.

Fish Bone Diagram

A WORK STUDY TO OPTIMISE THE TESTING CAPACITY OF A COVID 19 LABORATORY IN A TERTIARY CARE TEACHING HOSPITAL

Methodology: A cross-sectional descriptive work study was carried Potential increase in daily testing capacity was determined utilizing the out to determine the maximum testing capacity of the existing COVID 19 techniques of Time Study. Observed time and Standard time for all the laboratory in a tertiary care teaching hospital steps was calculated providing an allowance ranging from 10% - 20%

OBSERVED ALLOW- STANDARD Results : Processing a batch of 96 reactions takes a Steps Work Station TIME ANCE TIME standard time of 08h and 09 persons with 01 RNA (a) (b) (c) (d) = (b + c) work station and 01 RT-PCR machine. 40 min (24 12% 1 Sample screening 45 min There were Three Rate Limiting (RL) steps (step samples) (5 min) 3, 5 & 6) resulting in spare capacity of the other steps 40 min (24 12% 2 Sample processing room 45 min (Table-1) samples) (5 min)

RNA extraction & addition of 1 hr 40 min 20% Utilizing the spare capacity of the other steps by 3 2 hr augmenting the equipment, manpower and automation RNA to Master mix (RL) (24 samples) (20 min) in the rate limiting steps, and moving to a 24hr working Clean room (for Master mix prepara- 1 hr (46+2 20% model, daily testing capacity was enhanced from 288 to 4 1 hr 12 min 576 tests per day tion) (Parallel Process to Step3 above) samples) (12 min)

2 hr (46+2 10% 2 hr 12 min 5 RT- PCR (RL) samples) (12 min) Conclusion: With a manpower of 14 (PER Data verification SRFs with report SHIFT), 02 manual RNA extraction stations and 02 RT of RT-PCR and report generation 2 hr (46+2 15% 2 hr 18 min PCR machines, the lab was able to process 576 samples 6 & final review by Departmental samples) (18 min) in a single day . Head (RL) Scaled up testing capacity also required deployment of Time taken for processing 01 batch of 1 hr 12 samples (excluding time for parallel additional workforce, procurement of corresponding 7 hr 8 hr process) min consumables for testing and scale-up of sample collection and transportation facilities Table -1 : SUMMARY OF TIME TAKEN AT EACH WORK STATION (For 01 cycle at each work station)

“He has the most who is most content with the least” - Buddha P A G E 3 New Major Capital Work: Acceptance of Necessity

STEPS IN PROCESSING OF AON at the lower level is based on rough estimates, however, at Ministry level AON must NEW CAPITAL WORKS be taken based on a detailed Approximate Estimates.  Demand for and planning of After careful consideration of the new works proposal as explained in the SOC & the new work AON Board proceedings AON Decision taken to carry out the proposed work services  Preparation of Approximate Estimates (AEs)  Administrative Approval Formal orders issued by the CFA accepting the necessity of the proposed work  Appropriation of Funds  Technical Sanction CFA orders preparation of Approximate Estimates & CFA also ascertains that funds  Tender Action availability at the appropriate time for carrying out the works before passing such orders  Contract Action

Consultancy Services

 Proposal of any outside consultancy agency for carrying out any part of the proposed work at planning/execution stage should be indicated by the engineers & accepted by CFA while according Administrative Approval

Go-Ahead Sanction

 Specific cases where, in the opinion of Chief Engineer, proper technical or cost appreciation of works project or its timely implementation requires certain preliminary activities ( like site survey, soil investigation, enabling works, preparation of basic design or estimates etc) a ‘Go Ahead’ sanction of amount not exceeding 5% of the rough cost estimate will be taken for such activities from an Officer of the level GOC-in-C or equivalent or above with concurrence of IFA.  Such proposals should be submitted to Ministry of Defence/Defence (Finance) in case of works proposals for which administrative approval would have to be accorded by Government/Cabinet. A Copy of CFA sanction will also be sent to CDA concerned

New works Proposals requiring administrative approval of a CFA of level Service Headquarter / Government, proposals may be submitted to the CFA along with Board Proceedings and Approximate Estimates for obtaining AON & Administrative Ap- proval at the same time.

Strong Medicine

About the author

Arthur Hailey is a highly acclaimed experimental drug. Under the mentorship of a supportive boss, British / Canadian novelist who wrote Sam Hawthorne, Celia struggles to improve standards of several best sellers like , , training and research and bring more transparency in the , Wheels, The Final marketing of newer pharmaceutical products. Diagnosis and Strong Medicine. Each of his novels has a different industrial or commercial setting, and There are interesting side plots in the story. A brilliant scientist includes, in addition to dramatic human conflict, carefully and researcher from Britain, Dr. Martin Peat, is persuaded to researched information about the way that system functions switch over from a government job to head a new, fully and affects society. equipped lab built by Fielding Roth to help him discover a promising new drug for treatment of Alzheimer's Disease. A About the book senior doctor, Dr. Noah Townsend, has a drug habit fueled by free samples; and the silence of his colleagues ultimately results Strong Medicine, published in 1984, has its storyline based on in professional negligence. He also gives his pregnant daughter the workings of the Pharmaceutical Industry. The main an experimental drug for morning sickness, causing a still born character is Celia Jordan, a medical representative who rises baby, and family ties are broken. through the ranks of a major pharmaceutical company, Fielding Roth, to head its International Sales Division in a career Celia had resigned over safety concerns about this drug, and is spanning three decades. She gets married to an idealistic doctor, re-instated at a higher post after the truth is known. The book Andrew Jordon, whom she meets while helping him save the life ends on a positive note, with the protagonist flying off to meet

of a patient by expediting the FDA approval for an her new challenges.

Readers interested in contributing articles may contact us at: Dept of Hospital Administration, Armed Forces Medical College, Wanowrie, Pune 411040; Tele: 6046 (Mil) ; Email id: [email protected]