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Journal of the Academy of Hospital Administration

Notes, News and Journal Scan

Author(s): Rajiv Kumar Jain*, Sidhartha Satpathy**

Vol. 12, No. 1 (2000-01 - 2000-06)

State of the world's children 2000

UNICEF's State of the World's Children Report of 2000 ranks India as number 49 with an under five mortality rate (u5 MR) of 105 against 108 last year. Internationally, poverty, armed conflicts and HIV/AIDS are the 3 major threats to children. Though India's efforts with the polio eradication campaign and reservation of seats in the Panchayat for women has earned praise, there is not much else to celebrate. Discrimination against women starting from in utero is widespread, deep seated and pushing women deeper into degradation, Female foeticide is reported in 27 of India's 32 states. Bihar and Rajasthan have birth rates of 60 females to 100 males. Maternal mortality is unchanged and 50% of children are underweight. Access to safe water is denied to 200 millions Indians and proper sanitation to 700 million. In Y2K 360 million Indians will be unable to read and write.

Legible Prescriptions:

Bad hand writing cost a US based cardiologist, Dr. Ramachandra Kolluru as well as pharmacist US $ 225,000 each, The doctor had prescribed Isordil (isosorbide dinitrate) 20mg 6 hourly but the pharmacist read it as plenodil (felodipine) a calcium channel blocker. The patient had a massive heart attack and died subsequently. The Texas jury attributed the death to illegible writing and hence the punitive action. Doctors with bad writing are advised to print in capitals or use computer typed prescriptions. Many-medical errors are preventable with a little care (BMJ 4 December 1999).

Home Based Neonatal Care:

Neonatal care is not available to most neonates in developing countries because hospitals are inaccessible and costly. A home based neonatal care program, including management of sepsis (septicemia, meningitis, pneumonia) developed and tested in the field in India has been found to be an effective intervention. In this program, districts in India were chosen with village health workers trained in neonatal care being involved in the intervention. Neonatal infant and perintal mortally rates in the intervention area reduced by nearly 50%, compared with the control area. Home based neonatal care cost US $ 5.3 per/neonate, and in 1997-98 such care averted one death (fetal or neonatal) per 18 neonates cared for. The authors conclude that home based neonatal care, is acceptable, feasible and can reduce neontal mortality substantially in developing countries (Lancet 1999; 354: 1955)

Unethical Drug Reviews:

If money corrupts, then big money means big corruption. The richest cash cows in medicine may well be drug companies. And what a tangled web they weave when subtly they teach us to deceive. The Los Angeles Times has recently published an analysis of the links between drug companies and authors of drug review articles in the New England Journal of Medicine, of the 36 Drug Therapy review articles published in the journal since 199. In 8 the researchers had undisclosed financial links with drug companies, whose treatments were under review. A scarlet faced NEJM is properly penitent and has decided to be more strict in future (The Lancet 30 October 1999)

Safe Injection Global Network (SIGN):

To prevent the adverse effects of unsafe injection practices, United National Organization, non-government organizations (NGOs), government, donors, and universities sharing a common interest in a sage and appropriate use of injections joined their forces in a safe infections global network (SIGN). Because of the complexity of the problem, assistance from different types of professionals will be needed (eg, public health officers, infection control practitioners, epidemiologists, anthropologists, specialists in behaviour development, researchers in administration technology, environmentalists). Because little experience is available regarding integrated program that link the community with the health system to aim at safe and appropriate use of injections, the Safe Injection Global Network plan to co-ordinate the launch of pilot projects in five countries. Results of the evaluation of these projects should be available by 2002, and will enable the Safe Injection Global Network to identify strategies that work develop a large scale initiative to ensure that safe and appropriate use of injections is a priority for all (World Health Organization Fact sheet No. 231, October 1999.)

Standards of Clinical Quality - The Scottish Regimen

The Scottish Clinical Standards board chaired by Lord Naren Patel is about to produce its first standard for clinical consultations in association with the Scottish Intercollegiate Guidelines Network (SIGN) and the Clinical Resource Audit group (CRAG). The Board has two principal functions ; (i) setting of clinical standards which can be used to measure particular services; and (ii) a process of external inspections to ensure that the standards are being met. One of the aims is to encourage clinicians to examine the standards and carry out self assessment to see how their service compares. In case the quality of services were found to be poor, necessary steps would be taken to ensure that patients do not get harmed. However, sceptics argue that it is a "toothless" organisation without any real powers, except issuing reports, which can be made public. (BMJ. 7227; 8th Jan. 2000).

Fitness to Practice - GPs In U.K. Lead the Way

Based on the guidance by General Medical Council, the leading GP's of United Kingdom have published criteria that will help the profession and patients to identify both "excellent" and "unacceptable" family doctors. As per the guidelines an excellent GP is one who keeps up to date and participates in clinical audit; has a satisfactory complaints procedure, possess appropriate diagnostic and treatment equipment; keeps up to date records and provides satisfactory access to patients. It is expected that although most GP's will satisfy criteria for re-validation; some will not; and hence will have to be visited and assessed. Fitness practice may be cancelled in extreme cases. (BMJ 7228, 15th Jan. 2000)

"Quality" in Qualitative Research Assessment Needed:

Qualitative methods of research have become more acceptable and commonplace in areas of health science research and health technology assessment. Interest in these methods has led to greater scrutiny of the methods, and has resulted in proliferation of "guidelines" for doing and judging qualitative work. Quality can be assesed with the same broad concepts of validly and relevance used for quantitative research, but these need to be operationalised differently. The basic strategy is to ensure rigour, have a systematic self conscious research design, data collection, interpretation and communication. (BMJ No. 7226, 1st Jan 2000).

Bench Marking Costs in Health Services:

The NHS has come up with a system of bench marking of hospital services with regard to clinical guidelines, costs, and clinical outcomes. In USA, in the early eighties, the concept of DRGs (Diagnostic Related Groups) was formulated for making cost comparistions, which have now spread internation-ally and are used in Australia, Poturgal, Italy and Ireland. The British NHS has developed Health Care Resource Groups (HRG's), which have to be costed at speciality levels in all acute care hospitals. It has been decided that, in future all hospitals must "publish and bench mark their costs on a consistent basis to inform long term agreements for 1999-2000". Poor performances will be investigated and remedial measures will be built into long term agreements valid for 3-5 years rather than customary one year. The Government through its NHS executive reginional offices, will investigate high costs and if necessary, intervene. However, there are a number of limitations of this project as total costs are not covered, current data is limited to surgeries which account for only half of total acute hospital costs and costing methods are not standardised. However the ball has been set rolling and modifications/alterations can be taken up subsequently. (J. Health Service Research Policy 4 (2) 1999, edit.)

International Health Care Expenditures - Salient Issues

Health care expenditures in forty four "least developed countries" have been analysed for the years 1990 and 1995 using four key indicators viz total national health expenditure as a percentage of GDP; Government, and private sector health expenditure as a percentage of GDP, and total health expenditure per capita. The authors have found a substantial reduction in public spending per capita; a significant shift towards private expenditures, which appears increasingly to be substituting rather than supplementing public expenditures; a fall in total and public health spending in many countries, despite a growth in national income. Two possible explanations have been forwarded, firstly, that the patterns are the direct result of the structural adjustment policies adopted, which cut public spending and promote

private health expenditure. The second explanation is that following the wave of privatisation of state industries, the governments are finding problems in adapting to their new role as tax collectors. (International Journal of Health Planning & Mgmt. (14) 1999.)

Recommendation of The National Conference

Total quality management and accreditation of hospitals

(Lucknow, 27 and 28 November 1999)

1. After due deliberations and discussions formally and informally during the two days of the National conference, Total Quality Management and Accreditation of Hospitals. It was proposed to forward these points as recommendations of this conference for future follow up action on these aspects of health care. Following recommendations were made :-

(a) It is recommended that the need to improve the quality in all areas concerned with the health sector in the public as well as private sector must be given due emphasis when considering development plan for any area. As a step towards this the attention should be focused on total quality management and accreditation of hospitals. Certain minimum standards and norms must be framed in Indian context and not copy western or USA standards for accreditation of health care facilities/institutes. To frame and ensure implementation of these standards an "accreditation body" is recommended to be formed at national level.

(b) In our country, like any other developing country, the private sector is playing a major role in health care sector as 70% health care is in the hands of private practioners individually and collectively, hence it is recommended that the "accreditation body "to be evolved at national level should be an "autonomous body" with proportionate representation from government, private sector and non-governmental organisations. The Government should not be made to issue licences in the name of accreditation of hospital should be made members of this autonomous body and a core group should be formed to work out modalities.

(c) A task force of ten members namely : SK Biswas, P.C. Chaubey, VK Singh, Cedric BFinch, AK Talwar, R.K. Jain, Praneet Kumar, Kishore Muthy, Kameshwar Prasad and SC Arora have been appointed unanimously by all delegates of the conference to work out the modalities for accreditation of hospitals. The recommendations of the task force would be taken up in next workshop for consideration and implementation.

2. The follow up action of Regional Chapter of Hospital Administration, Lucknow to hold a workshop in November 2000 on accreditation, by invitation to Health Secretaries, DGHS of Centre & State governments, AIIMS, NIHFW, AFMC, WHO, MCI,BIS, VHAI, FICCI and all other institutes, organisations and individuals who have interest in the subject has been accepted to Executive Committee of Academy of Hospital Administration to formulate approach paper on following aspects:

  1. To frame guidelines for forming an autonomous accreditation body at the national level.
  2. To prepare an approach paper on "National Accreditation Policy" for health care facilities/Institutes and submit it to Government of India for consideration and necessary imple-mentation thereafter.
  3. To work out the modalities for developing norms and standards for accreditation of hospitals
  4. To prepare and forward recommendations for accreditation of health care facilities/institutes in a time bound schedule

3. Regional Chapter AHA Lucknow, commits itself to continue its efforts in this direction.

* 480, Sector 37, Faridabad -121003, Haryana - India .

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