NEETI Edition October 2020

PLACE: PUNE 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” YEAR-1 Message from Editor’s Desk ISSUE-IV OCT 2020 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. INSIDE THIS 1 It is only during adversity that the true character of men is revealed. And it is during challenging times that ISSUE: 2 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  Legal Bugle 1000 bedded facility at Delhi and another 500 bedded at Muzaffarpur, Bihar. The practical hands on experi- ence earned by the residents during these deployments will serve them well during their future endeavours. TELEMEDICINE The pandemic has also reiterated the importance of Situational Leadership in today’s world, forcing us all to adapt and adopt newer modalities of Teaching-Learning which will be the new normal for the foreseeable  Treat Safe future. Lastly it has brought into focus the importance of Evidence Based Clinical Practice like never before, 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.  Management Tool 3 To that end “Strong Medicine” has been chosen for the book review in this edition. In the Patient 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 TELEMEDICINE Projects & Works 5 ACCEPTANCE OF ‘The delivery of health care services, where distance is a critical factor, by all health care professionals using information NECESSITY  Book Review 6 and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease STRONG MEDICINE and injuries, research and evaluation, and for the continuing education of health care Pl find e-copy at: providers, all in the interests of advancing the health of individuals and their Seven Elements of www.afmc.nic.in/ communities.’ (WHO) Tele-medicine Departments/HospitalAdm/ publications.html . Editorial Board Neccessity in India Restrictions on prescribing medi- Context cines Identification of RMP and Patron :  3.2 million sq km (7th largest Patient List ‘O’- “Over the counter drugs” Lt Gen Nardeep Naithani country geographically in the Medicines that deemed necessary dur- Mode of communication world) ing public health emergencies (video, audio, text or asyn- Vice Patron : chronous)  Varied landscape & far flung List ‘A’-safe & low potential for abuse Maj Gen R M Gupta, VSM Consent (Implied or Ex- areas List ‘B’-prescribed during in-person plicit) to be taken Editor-in-Chief : consult for the same medical illness Type of consultation  Deficient healthcare facility (First or Follow up within Brig A K Naik  75% qualified doctors-urban List Prohibited-Schedule X drugs, 6 months for same illness) Narcotics & Psychotropic Patient Evaluation Editors : centres substances Col Surekha Kashyap  68% rural population deprived Col Saroj Kumar Patnaik Lt Col Shashikant Sharma from direct access Assoc. Editors :  Rapid technological changes Patient Management Lt Col Lavneesh Tyagi “Telemedicine as a modality shall act Maj Bipul Kumar Singh as an instrument for equitable distri- Maj Neelesh Patel Dr Nidhi Sharma bution of healthcare resources in India” 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. Types of falls Each year an estimated 6,46,000 individuals die from falls globally of which over 80% are in low and middle income countries. Accidental fall : Adults older than 65 yrs of age suffer the greastest number of fatal falls. 37.3 million falls that Caused by accident & can be are severe enough to require medical attention occur each year. (WHO) prevented through universal Studies show falls occur at a rate of 3–5 per 1,000 bed-days precautions applied to all (medalerthelp.org/blog/falls-in-the-elderly-statistics/) patients Anticipated physiological Risk factors: fall : Most patient falls are caused by a combination of Risk assessment Caused by underlying medical factors. Few of the causes are problems or symptoms Risk assessment of a patient is a  Previous fall history continuous process starting right Unanticipated physiological from the admission of the pa- fall :  Gait instability and lower limb weakness tient in the hospital till the time patient is discharged fit and Caused by an underlying medi-  Urinary incontinence, frequency or the need extended if the home care cal or physiological problems for toileting that has not been diagnosed  Agitation, confusion or impaired judgement  Aged patients  Medications like sedation hypnotics continues. Monitoring Patient Risk Assessment ToolMonitoring can be Can be done through the incident reporting of falls done through the inci- and calculation of the fall dent reporting of falls rate as Falls per 1,000 occu- and calculation of the pied bed days on a monthly fall rate as Falls per basis 1,000 occupied bed days on a monthly basis Falls in healthcare facili- ties 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  Side rails to be raised for all patients. Patient and family to be informed and In 2013, total cost of healthcare educated on need to raise side rails. fall injuries was $ 34 BILLION  Safety First signage to be appropriately placed as applicable By 2021, the total cost of these  Call Bells to be kept within patient’s reach  Toilet and Nutritional needs of the patient to be met fall injuries could be as much as $  Transfer assistance to be provided with appropriate tagging to ensure proper 67.7 BILLION 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 wheels iii) Grab bars to be located properly in toilets and bathroom Accidents Deaths & Injuries) iv) Staff to ensure assistance during patient movement or walking initiative. (CDC) PAGE 2 “The best way to find yourself is to loose yourself in the service of others” - Mahatma Gandhi

Root Cause Analysis Root cause analysis (RCA) is a structured method “For want of a nail the shoe was lost, for want of a shoe the horse was lost, for want of a horse the knight was lost, for want used to analyze serious adverse events. Initially de- of a knight the battle was lost, for want of a battle the kingdom veloped to analyze industrial accidents, now widely was lost. So a kingdom was lost—all for want of a nail.” deployed as an error analysis tool in health care to move quality efforts forward. Patient safety events can cause serious harm or death. To address & As healthcare organisations become more complex, processes are interdependent 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  Leads to litigations analysis of latent errors) Affects healthcare professionals who are The ultimate goal of RCA is to prevent future harm by eliminating the latent  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 techniques of Time Study. Observed time and Standard time for all the out to determine the maximum testing capacity of the existing COVID 19 steps was calculated providing an allowance ranging from 10% - 20% laboratory in a tertiary care teaching hospital Results : Processing a batch of 96 reactions takes a Steps Work Station OBSERVED ALLOW- STANDARD (a) TIME ANCE TIME standard time of 08h and 09 persons with 01 RNA (b) work station and 01 RT-PCR machine. 1 Sample screening (c) (d) = (b + c) 40 min (24 45 min There were Three Rate Limiting (RL) steps (step 2 Sample processing room samples) 12% 3, 5 & 6) resulting in spare capacity of the other steps (5 min) 45 min 3 RNA extraction & addition of 40 min (24 (Table-1) RNA to Master mix (RL) samples) 12% 2 hr (5 min) Utilizing the spare capacity of the other steps by 1 hr 40 min augmenting the equipment, manpower and automation (24 samples) 20% in the rate limiting steps, and moving to a 24hr working (20 min) model, daily testing capacity was enhanced from 288 to 576 tests per day 4 Clean room (for Master mix prepara- 1 hr (46+2 20% 1 hr 12 min tion) (Parallel Process to Step3 above) samples) (12 min) Conclusion: With a manpower of 14 (PER 5 RT- PCR (RL) 2 hr (46+2 10% 2 hr 12 min SHIFT), 02 manual RNA extraction stations and 02 RT samples) (12 min) 2 hr 18 min PCR machines, the lab was able to process 576 samples Data verification SRFs with report in a single day . 2 hr (46+2 15% 8 hr 6 of RT-PCR and report generation samples) (18 min) Scaled up testing capacity also required deployment of & final review by Departmental additional workforce, procurement of corresponding 7 hr 1 hr 12 consumables for testing and scale-up of sample Head (RL) min collection and transportation facilities Time taken for processing 01 batch of samples (excluding time for parallel process) 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 PAGE 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. AON Demand for and planning of After careful consideration of the new works proposal as explained in the SOC & the new work Board proceedings AON Decision taken to carry out the proposed work services Formal orders issued by the CFA accepting the necessity of the proposed work Preparation of Approximate Estimates (AEs) CFA orders preparation of Approximate Estimates & CFA also ascertains that funds Administrative Approval availability at the appropriate time for carrying out the works before passing such orders Appropriation of Funds Technical Sanction Tender Action 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 experimental drug. Under the mentorship of a supportive boss, Sam Hawthorne, Celia struggles to improve standards of Arthur Hailey is a highly acclaimed training and research and bring more transparency in the British / Canadian novelist who wrote marketing of newer pharmaceutical products. several best sellers like Hotel, Airport, The Moneychangers, Wheels, The Final There are interesting side plots in the story. A brilliant scientist Diagnosis and Strong Medicine. Each of his and researcher from Britain, Dr. Martin Peat, is persuaded to novels has a different industrial or commercial setting, and switch over from a government job to head a new, fully includes, in addition to dramatic human conflict, carefully equipped lab built by Fielding Roth to help him discover a researched information about the way that system functions promising new drug for treatment of Alzheimer's Disease. A and affects society. senior doctor, Dr. Noah Townsend, has a drug habit fueled by free samples; and the silence of his colleagues ultimately results About the book in professional negligence. He also gives his pregnant daughter an experimental drug for morning sickness, causing a still born Strong Medicine, published in 1984, has its storyline based on baby, and family ties are broken. the workings of the Pharmaceutical Industry. The main character is Celia Jordan, a medical representative who rises Celia had resigned over safety concerns about this drug, and is through the ranks of a major pharmaceutical company, Fielding Roth, to head its International Sales Division in a career re-instated at a higher post after the truth is known. The book spanning three decades. She gets married to an idealistic doctor, 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]