Making Hospital Management Patient Centric

Dr. Shridhar Lolla

CVMark Consulting
lolla@cvmark.com

Draft 1.0: needs editing

Definition: HIMS= Hospital information management system

Based on interaction with entrepreneurs selling HIMS in south India; during 2009-10.

Keywords: HIMS, hospital information management system, health care, patient centric,
problem solving, hospital performance, patience turnaround time, performance
improvement, hospital management, right use of technology, necessary but not sufficient,
technology implementation, change management

Buyers of software systems are often at receiving end when they want to implement a
large application. They know that technology is a necessity to deal with today’s complex
environment; but they find that technology by itself is not sufficient to derive business
benefit. This document touches upon ‘ the necessity but not sufficient’ aspect of
technology, by discussing the conflicts faced in hospitals and exposes the inadequacies in
today’s way of implementing large software solution. The document proposes that
software vendor and the management of hospitals, must recognize the need to re-invent
their basic rules of business/organization before implanting a software solution.

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Introduction

Over the years, tremendous progress has been made in health care practices, which has
led to dramatic improvement in average life expectancy of people. There are medicines
that cure wider range of ailments. There are devices and equipments that not only allow
sophisticated diagnostics but also complicated surgery possible. Several of terminal
diseases now have painless cure.

While a high degree of sophistication has helped in extending human capability to fight
against diseases, the cost of health care has sky rocketed, even for an average treatment.
As we stand today, in most of the developed countries, rate of increase in per capita
medical expenditure has overshot rate of increase in per capita GDP. And it is expected
that this phenomenon will soon spill over to other countries, including India.

All stake holders, including governments, regulatory agencies, NGOs, Health Care
Providers, Pharma Companies, Medical Equipment Suppliers etc., are taking major
actions to deal with the situation. Amongst all, Health Care Providers, i.e. doctors and
management of hospitals and clinics, have a critical role to play in making quality health
care affordable, since they are engaged directly in delivering the service. Being “Patients
Centric” is, therefore, the buzzword in the health care sector .

Understanding Patient Centricity

Like other organizations, a hospital comprises a number of functions with distinct role to
play in providing quality health care to patients. However, these functions (despite being
specialized in their own way), provide health care together to benefit the patients. In a
way, Hospitals work as a System comprising different subsystems, who work together (&
dependent on each other i.e. output of one is input to other), to offer desired service to the
patient.

It being an organization, a hospital also has a goal, which is closely related to the
objectives of its founders. And, it is an entity in itself that wants to do justice with its
objective year on year, i.e. now as well as in future. In order, to meet the objective, now
as well as in future, it is fair to state that the goal of a hospital is “ TREATING MORE
PATIENTS BETTER, SOONER, BOTH NOW AND IN THE FUTURE! “[1]

At any moment, given the existing medical standard of a hospital, in order to meet its
objective, the hospital must treat and continue to treat more patients, better and sooner.

Gearing up management to being Patient Centric

That the costs are spiraling up, and for a hospital to achieve its goal, it must have in place
a system that guarantees an increase in patients turnover that is faster than increase in
the operating expenses of the hospital; without compromising on quality of service. This
is a unique or decisive contribution from the health care provider to the society.
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Thus, in order to increase the turnover of patients, it behooves on the management and
team of the hospital to ensure that the time spent by a patient in the hospital is shorter
and shorter, without compromising the quality of service.

Reality of being Patient Centric

The chances of a hospital to reduce and continue to reduce the turn around time of the
patient, depends upon its ‘capability’ to align and synchronize various functions with
which the patient interfaces.

The management of the hospital knows that patients often wait in queues to avail services
at different places(service points) during different time. Often, services , even of urgency
levels, are postponed for the reason of some resource (bed, operation theater, doctors etc.)
being over booked or not available. Surely postponing provision of service to patients on
an ongoing basis increases the average waiting time of the patients to complete health
care, that has direct and negative effect on the patient turnover of the hospital. In a more
visible way, the queues of patients registered or admitted in a day continue to remain
longer. Which means that patients keep waiting longer, before they are attended. Which
means that hospital doctors and staff are forced to work with heavy load for a period
longer than planned. Which means that a large number of stakeholders are dis-satisfied
with their working and the patient is net well satisfied. Let us understand this with a
simple example.

This example illustrates that while every body tries their best to offer quality service to
the patients (people have good intentions), since various functions are dependent on each
other (i.e. are often done in sequence and ones output is often input for others) and that
each function has its own variability; these have dramatic impact on ability of the
hospital to achieve its goal.

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What limits higher patient turnover ?

Consider a relatively simple system of a physician’s office or clinic [2]. The steps in the
process could be patients checking in, filling out forms, having vital signs taken by a
nurse, seeing the physician, seeing the nurse for a prescribed procedure such as
vaccination, and so forth. These steps could take place in a simple linear sequence or
chain of tasks as shown in Figure 1.

Fig.1. A sample interdependent activities in a clinic

Each link in this chain has the ability to perform its tasks at different average rates.

In this example, the first resource can process 13 patients, charts, or blood samples per an
hour; the second can process 17, and so forth. The rate of attending patients (capacity of
each resource) is shown in Fig.2 below.

Fig.2. Capacity of various resource (functions) across the flow of the patient.

Using simple mathematics, the average number of patients undertaken through the above
flow is =(13+17+10+8+14+16+13)/7= 13. One may therefore think that this process can
serve 13 patients per hour.

In fact, this process or chain can serve only an average of 8, eight per hour. This is
because the task #4, Physican is the slowest one; and it can process only 8 patients per
hour. Thus, regardless of how much any other resource, before it or after it, process, the
Clinic can only serve 8 patients per hour. And in a given 4 hrs shift, not only this task #4,
but the complete flow can process no more than 4x8=32 patients.

Fig.3. The slowest step or resource decides capacity of the chain.

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Remember that the chain is only as strong as its weakest link and the rate of the slowest
resource in this example, the weakest link, decides the capacity of the chain. This is true,
regardless of how fast each of the other resources can serve individually or how much
work is stuffed into the pipeline, how complex the process or set of interconnected
processes is to complete.

Rule #1: In a dependent system the function that is the slowest, decides what is the
number of patients` (capacity: rate of flow of patients) the Clinic can serve in a day or a
week.

Bad ramification of ignoring the rule #1:

If one ignores rule#1, i.e. the pace at which the slowest task is performed, the preceding
tasks will process access of patients and there will be a long queue in front of task #4.
While it is ok to have an inflow hourly rate of 8 patients at task#4, if it is longer than that
then the task #4 (resource) will have to work longer than stipulated time, patients will
have to wait longer and the support staff will have to work longer. And this leads to a lot
of discontent among not only the staff but also patients.

Aligning Health Care Business around Patients

The direction to solution is that if the Clinic can identify the delays or disruption that
happen at resource # 4 and could resolve them, then the capacity of resource #4 goes up
and immediately, that of the clinic too.

It also tells the Clinic that if it has to improve its performance, improvement should be
centered around Resource #4 than any where else, e.g. taking part time consultants to
increase the overall capacity of Resource #4. Increasing Resource #4 by 1 hrs will
increase a 4 hr shift clinic’s capacity by 1/4=25%. That’s significant improvement and an
improvement too fast.

Of course, this improvement places Resource #4 on par with step-3. Following such
focusing mechanism, however, the Clinic can make best use of its limited resources and
increase its patient turnover on an ongoing basis, without compromising quality of care.

By now it seems logical that improving the performance of any other Resource besides
the constraint resource (#4) does nothing to improve the system as a whole.

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How to evolve the solution

From the above simple example, it becomes very clear that capacity of the hospital is
directly linked to the flow of patients. The place where patients wait for longer (flow is
slower) is the place management need to pay its attention, the most. By paying attention
at such leveraging point (constraint, slow moving), hospitals can increase their capacity,
dramatically, in short span of time and expenses.

It, therefore, now requires to understand the flow and tracking how patients move, by
having a system that gives the right perspective for business decision.

Such a System, should be able to give data pertaining to the Queue.

The BIGGER reality

Traditionally, there has not been a system that allows the management of hospital to
know where the longest Queue and for that matter, how much is the time wasted by the
patient within hospital without being medically served. In a very small clinic, it is
possible to stop the registration of new patients by visually looking at the space; but in
modern larger clinics and hospitals, it is almost impossible for the admin to have a mental
map of queue. Actually, knowing the queue is important, so that the admin can give a
more accurate appointment time to incoming patients. As illustrated above, what matters
is the queue at the slowest resource and not at other resources. It is quite possible that
admin clerk would normally look at the queue of the first resource and fix appointment
rather than the resource which is somewhere in the middle of the process.
Delays, just do not happen in outpatient treatment. A significant time is lost in
synchronizing activities required for operating patients. And in a majority of hospitals,
operation theater is the constraint, that limits number patients who could be served.
Since, often long queue exists infront of operation theater and there is, often, confusion
with the priority of the patients, beds in the hospitals tend to wait for patients and are
kept reserved. Having a system that sequences patients systematically by using a stable
scheduling technique can resolve many of the trial and errors involved in bed and
operation theater management.

Actually, some time, there is another element of hospital that becomes critical from the
point of view of quality health care and cost of service; and indirectly, lead to lack of
capacity. It makes sense from patient point of view to buy medicines at the hospitals
where he visits, instead, of making another round of visit to a different location.
However, it has been accepted that some medicines that are needed and in demand, are
often in shortage; while others that are needed rarely, are in overstock. The ones that are
out of stock, provide discomfort to patients, need re-prescription and re-visit to doctors,
cost extra money (several hospitals are entitled for subsidized medicines), disrupt normal
flow and waste time. On the other hand the medicines that are in oversupply, lie for long
time, are expired and returned. These medicines then need extra attention in accounting
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and closure; in fact, implications of unused medicines are often subject of management
discussions in hospitals, owing to their relationship with finance and budget.

Remembering that medicines could cost as much a 30% of patients bill, it behooves on
the management of the hospitals to avoid the paradox of ‘out of stock’ and ‘over stock’
medicines and materials, by having an inventory management system that not only help it
in avoiding wastage of human effort but also in increasing accuracy of its operations
while providing hassle free service to patients.

If you know it, then you can fix it

(The other way of saying it is, if you know it poorly, you fix it poorly.)

The way, a majority of hospitals and clinics is being managed and operated, has been the
way, they have been managed for decades. And some of the conflicts and realities that
are described above have been taken as the nature of the industry, and management has
got accustomed to it.

There were reasons why things were being done this way decades back. But since then, a
lot of changes have taken place around us and it is good to re-look into the way things are
being done and make possible improvements that have been waiting for long time. While
the examples considered above illustrate the need to have right information, hospitals are
embedded within them a huge amount of data that carry a large amount of value, only if
they are accessible and process able.

Today technology (information technology) has made possible doing things, in split
seconds. It has provided facility to store data in huge volumes and retrieve them at
lightening speed. It has made possible communication and contacts with people and
devices timeless, spaceless and seamless.

The workflow of hospitals deals with a lot of information in various forms. Sorting,
retrieving and presenting the information in a way that could be used for quick decision
making is paramount to the improvement in operation of hospitals and, therefore,
improving productivity. Not to forget that each point increase in productivity results in
significant improvement in it capacity to treat more patients. Thus taking it closer to the
goal, of providing quality health care to an increasing number of patients at lower cost.

As a result, the market is crowded with a variety of HIMS(Hospital Information

Management System) that are a sort of specialized ERP package and application for
hospitals. They allow the management of the hospitals to organize and operate its
functions seamlessly in a cost effective way. It helps critical functions in planning,
organizing, executing, analyzing and improving their work. Brochures of these system
detail a large number of features that claim to provide transparency, visualization and
organization of information and ability to take a variety of reports.

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What to know ?

While a majority of HIMS help generating huge mountains of data, once implemented
they are also blamed for information overload. Without exception, it has been found that
HIMS are implemented upon existing processes and leave the clients into painful
transition, that last years. What does it mean?

Technology is a necessity to manage the complex workflow. However, as discussed

above the workflow within hospitals across functions itself has been running for decades
the same way. That is, patients wait for longtime to get attended, even critically ill
patients do not find beds in time, operation theater run at low utilization, and doctors and
staff work overtime, exhausted and unsatisfied. Most of the HIMS are implemented on
the top of this existing workflow and therefore the business results remain the same.
Since implementation of an HIMS is a big project involving money, energy and time, the
current way of implementing HIMS face significant hurdles in its roll out and actual
adoption by the hospital staff. Several hospitals languish in the roll out phase, since the
staff sees HIMS as an additional work of data entry over what they have been doing. This
is because the staff does not see any major value addition in their work. There are several
hospitals who got fed up with the implementation delays and have written off several
thousand dollars, just because the staff does not find it worth i.e. did not see solving their
problems.

A true and successful implementation of HIMS requires, a dedication on the part of the
vendor to make significant contribution in health care sector. It must understand the
objective of health care section and align its offerings accordingly. It must spend time
and closely work with leading medical practitioner, staff and management, in
understanding and resolving the management conflicts of managing more with less. Its
close interaction will help it, in understanding the underlying needs of an information
system for Hospitals, which not only automates workflow but also helps the management
in addressing the core business requirements. It needs to show direct benefits to the
hospital management and staff. For example, after implementation of HIMS, how many
more patients could be operated, what will be the improvement in bed utilization, how
many patients can be treated in outpatient departments, how low the stock out of drugs be
in pharmacy, what will be the reduction in the turn around time of patients visiting clinics
etc. The bottom line, how does the HIMS guarantee TREATING MORE PATIENTS BETTER,
SOONER, BOTH NOW AND IN THE FUTURE! By targeting such clear benefits to the
organization, the HIMS supplier will be able to seek the right buy-in, that will go a long
way in successfully rolling out the system across the organization. By using such a
system, hospitals will be able to have historical information and records of its patients
and treatment, that will help them in immediately making a patient centric effort as soon
as the patient turns up at the hospital. On day today basis, the relational database backed
system will help its staff in monitoring flow of patients across the organization and
scheduling its functions optimally. Without these considerations, all HIMS are same,
trying to force technology on an existing business rules that will only force additional
work on hospital staff and discomfort to patients.
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References:
1. We all Fall Down: Goldratt's Theory of Constraints for Healthcare Systems, by
Julie Wright and Russ King, North River Press (January 31, 2006)
2. Applying the Theory of Constraints in Health Care: Part 1-The Philosophy,
Breen, Anne M. MD; Burton-Houle, Tracey MS; Aron, David C. MD, MS,
Quality Management in Health Care: Spring 2002 - Volume 10 - Issue 3 - p 40-46

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Disclaimer:
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Bangalore, INDIA

Clet:08-10

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