DEPRESSURIZATION OF URBAN MEGA PUBLIC

HOSPITALPartner Agency:- Seth G.S Medical College and KEM Hospital Under the Supervision of:-Dr.T.Sundararaman Dr.R.R.Shindhe

Dean ,S.H.S.S H.O.D(Community Medicine)

Background

Source:- Asia Pacific Observatory of Health Policies and Systems

BackgroundGlobal to Local View on Primary Health Care Approach :-(Everybody’s Business, WHO’s framework for action)(Alma Ata Declaration,1978)• Primary/First Contact/Level: backed up by secondary level facilities.• Driver for health care delivery system(health conditions, levels of care and over

lifetime)Bhore Committee:-“The heads of different sections in the district hospitals dealing with medicine, surgery and so on ... it will be of advantage if they can occasionally visit the secondary unit hospitals and a certain number of primary unit hospitals and inspect and guide the professional work of officers discharging corresponding duties in these hospitals. Such contacts should help to improve the standard of professional work carried out in the hospitals of the districts generally.”(1,Page 21)

Public Health System in MumbaiMunicipal Corporation of Greater Mumbai

HEALTH POST

DISPENSARY

PERIPHERAL

HOSPITALS

TERTIARY CARE

Municipal

Maternity

Homes

Maternity

Wards

RationaleWhat literature says?

Inverse Pyramid Phenomenon• Ideally, only 5% of care and illness requires tertiary level of

care(NUHM Framework)• Over 70% of the health services including preventive,promotive

and curative clinical encounters shall occur at primary levels (NUHM Framework)

• But primary care accessed at five different levels- medical colleges, secondary care hospitals of two levels, primary care facilities and outreach services (Making the Urban Health Mission Work for the urban poor, Report of TRG NUHM ,Feb 2014,Ch.4,Pg.38-39)

RationaleWhat literature says?

RationaleConsequence !!

• Overcrowding• Long waiting time• Very cursory examination• Hasty referrals• Patient disillusionment with the health system• Discourteous communication by the doctors with patients.

What does the study aims to do?• To study the OPD and patient flow pattern at KEM Hospital.• To study the morbidity patterns reporting in the OPD of the KEM Hospital and quantify the number

of patients who could have been take care at the peripheral centres.• To study the factors influencing patient’s preference for KEM Hospital for illnesses that could be

managed at primary level outside the hospital.• To study the healthcare systems in urban settings and its linkages with the tertiary healthcare

system.• To study the measures that KEM and BMC is taking to address this situation especially with

respect to gate-keeping and referral systems, increases in number of beds and staff and the adequacy of financing.

• To develop recommendations and a policy brief in consultation with the key stakeholders in how best to de-pressurize the mega hospital and enable it to function as a quality tertiary care centre in the main.

Methodology

Methods of data collection:-• Secondary data collection from the Medical Records

Department• Primary data collection from patients(Questionnaire and

In-depth interviews) at various OPDs.• Non-Participant Observations• Time-motion Study

Progress Report and AnalysisHOSPITAL MAPPING

Progress Report and AnalysisOPD LOAD AND PATIENT DISTRIBUTION

NEW CASES

Medici

ne

Surge

ry

Opthalm

ology

Gynae

& O

bsSkin

Psych

iatry

Diabete

s

Paedia

tric

GOPD

Hyper

tensio

n0

10002000300040005000600070008000

April May June

Progress Report and AnalysisOPD LOAD AND PATIENT DISTRIBUTION

Old Cases

Medica

l

Surge

ry

Opthalm

ology

Gynae

& O

bsSkin

Psych

iatry

Diabete

s

Paedia

tric

GOPD

Hyper

tensio

n0

1000

2000

3000

4000

Chart Title

April May June

Progress Report and AnalysisOPD LOAD AND PATIENT DISTRIBUTION

MedicineSurgery

Obs & GynaePaediatric

GOPDSkin

OpthalPsychiatry

DiabetesHypertension

0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000

Chart TitleSample Size Daily Average Monthy Average

Progress Report and Analysis

• Sample Size for OPD Interviews:- 419 (30% of the average daily OPD of 10 OPDs which caters to primary care services)

• Field notes of every 5th patient or Convenience sampling of patients with narratives to tell.

• Interviews conducted:- GOPD- 94 Skin- 64Surgery - 46

Progress Report and AnalysisProcess Mapping

GOPD

Minor illness,Symptomatic treatment provided

Respective OPD Casuality Sent for investigation,follow up, then referral

Progress Report and AnalysisReferred or not?

71

23

GOPD

Not Referred Referred

39%

61%

GOPD

Referral NoteWithout Referral Note

Progress Report and AnalysisReferred from?

53%

24%

18%6%

GOPD

Private PractitionerPrivate HospitalsPublic HospitalInterdepartmentalHealth Post

Progress Report and AnalysisPathways of Referrals and Consultations

• Referrals made after considerable time and investigation(more than 3 visits/month):-60% of the total number of patients referred

• High cost of care in private hospital a reason for visiting KEM:-20.1%

• Did not know about any government hospital nearby: 26.9%

• KEM’s reputation for better care:-59.25%

Progress Report and AnalysisPathways of Referrals and Consultations

1) Referred by a Private

Practitioner/Private Hospital

Referral Note

No Referral Note(Ora

lly Referred

)

2)Seen in a government hospital dissatisfied didn’t go to private,

came directly to KEM

3)Consulted private provider, dissatisfied

didn’t go to other government facility

came to KEM

4)Patient's Attendant 5)Came directly to KEM

Based on specific

reputation

Based on general

reputation

6)Diagnosis made but visits KEM for follow

up and drugs 7)OTHERS

Progress Report and AnalysisPathways of Referrals and Consultations

12%7%

23%

11%

33%

5%10%

GOPD Pathways of re-ferrals and consulta-

tions1234567

1) Referred by a Private Practitioner/Private Hospital

2) Seen in a government hospital dissatisfied didn’t go to private, came directly to KEM

3) Consulted private provider, dissatisfied didn’t go to other government facility came to KEM

4) Patient's Attendant5) Came directly to KEM6) Diagnosis made but visits

KEM for follow up and drug

7) OTHERS

Progress Report and AnalysisShould these cases be managed at Peripheral centres?

71%

13%7%

8%1%

GOPD

Should have been managed at primary careOne consultation to rule out complex-ityDiagnosis established,follow up at peripherySceondaryTertiary care

Progress Report and Analysis• “I have been coming here since childhood, I was born here”• “I delivered both my children here at KEM, so I consult doctors here

only.”• “We don’t go to any other hospitals, we directly come to KEM for all

illnesses”• “We get all the specialists for various illnesses here at KEM, hence we

don’t go anywhere else”• “The BMC health posts are only to give medicine for cough and fever,

those medicines are of no use.”

Possible RecommendationsDisruptive Innovation Incremental InnovationRecommendations Risks and

AssumptionsRecommendations Risks and

AssumptionsStop OPDs(As being considered at Safdarjung Hospital, Delhi)

Sudden refusal of services without ensuring peripheral centres to be well equipped.

Functional and geographically well distributed peripheral centres.

Patients with chronic illness referred back to peripheries for investigations, follow up and drugs

Lab facilities available as per norms at peripheral centres.Drug availability

Refusal of services without a referral card

• Care seeker has voluntarily by passed peripheral services inspite of availability of services at periphery

Direct access to the patients with colour coded referral card

Limiting the number of patients registered in daily OPD

No corruption in issuing the referral card

Increased waiting time ,span of treatment and multiple visits.

Possible Recommendations

Zoning Units

Zones based on the basis of roads leading to

district hospitalDISTRICTHOSPITAL

Internal deputation of specialists

Direct Access by patients by passing the queue.

References• Lawn, J. E., Rohde, J., Rifkin, S., Were, M., Paul, V. K., & Chopra, M.

(2008). Alma-Ata 30 years on: revolutionary, relevant, and time to revitalise.The Lancet, 372(9642), 917-927.

• Van Lerberghe, W. (2008). The world health report 2008: primary health care: now more than ever. World Health Organization.

• Bajpai, V. (2014). The challenges confronting public hospitals in India, their origins, and possible solutions. Advances in Public Health, 2014.

• World Health Organization. (2007). Everybody's business--strengthening health systems to improve health outcomes: WHO's framework for action.

References

• Dilip, T. R., & Duggal, R. (2004). Unmet need for public health-care services in Mumbai, India. Asia-Pacific Population Journal, 19(2), 27-40.

• Yadav, K., Nikhil, S. V., & Pandav, C. S. (2011). Urbanization and health challenges: need to fast track launch of the national urban health mission.Indian Journal of Community Medicine, 36(1), 3.

• “Making the Urban Health Mission work for the Urban Poor” Report of the Technical Resource Group, National Urban Health Mission, Feb 2014

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