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Issue 60 & 61 October 2011- March 2012

Clipboard A Quarterly Update on Management Issues from the Administrators Section of the Christian Medical Association of India Dear Members, Greetings from the Administrators Section of CMAI!


am glad to bring out another issue of Clipboard. This issue covers a number of pertinent issues. The significant one is regarding Fire Safety. Fire can be very useful but very destructive if not harnessed with due care. The AMRI fire has brought to the fore the need for best practices to avoid large scale destruction. The lead article covers the NABH guidelines in this regard. In this edition of Clipboard I am presenting two brilliant presentations made during the recently concluded Biennial Conference of CMAI at Chennai. They are listed below 1. Dr Y Thangabose : Basic skills needed for building a positive attitude 2. Mr Akilan Arun Kumar : Quality in Health Care - A need of the hour for mission hospitals An informative article on Problem Solving by Hugh Skeil is also included in this issue. The Administrators Section of CMAI has already launched a 1-year Certificate Course – Laws on Hospital Administration – under the Distance Education Programme. This would provide a wide range of knowledge and equip hospital administrators to comply with the laws of the land. We hope to introduce another course on Medical Equipment Maintenance in the near future. This course aims at giving,thorough, hands-on training to young engineers to fix and manage a wide range of bio-medical equipment. The conceptual details are being worked out. If you have any specific input to provide on this, please send in your ideas to me immediately. Please send in you comments and suggestions to: Stephen Victor Secretary, Administrators' Section




enesis 3:21 – “… for Adam and his wife the LORD God made garments of skin, and clothed them.”

In spite of me disobeying and disappointing God, He decided to keep me out of shame. Hence, He clothed me, and is still doing so. What I am, even today, goes without saying. Love of God – I need to experience it. It needs to be expressed with others, in my daily life, with all of my heart and mind. I keep questioning myself, ‘Is this happening in my day-to-day life?’ The love of God encloses me every minute, and He is faithful in loving me. Love for God – the question that needs to be addressed by me, every day is, ‘When my daily needs are met by the One who created me, then whom should I love and to whom should my allegiance be?’ I know the answer pretty well, but knowing the answer has not brought me closer / together with the Creator. Experience should be expressed in deeds rather than words and this is the reason for me to be away from the love of God and love for God (and with the garments of skin, as well). The love of God still waits for me to return. Rev A Job Jayaraj, Former Secretary, Chaplains Section, CMAI

Be careful about reading health books. You may die of a misprint. – Mark Twain

Clipboard Issue 60 & 61

Basic Skills Needed for Building a Positive Attitude 


ddressing the existent poor culture and the lack of commitment from employees in many organisations, Dr Y Thangabose opined that when employees utter excuses frequently to avoid their responsibilities, it is an indication that the organisational climate is not upto the desired level.

Excuse List  That’s not my job           

I thought someone else was doing that That’s the way it has always been done I have been far too busy It was the computer that did it I said it would happen Nobody told me I could not find it I left it at home I thought you knew about it I was on leave / holiday I thought it was finished

There are three factors that determine our attitudes and they are: 1. Environment 2. Experience 3. Education A positive attitude can be recognised when the employees:  are confident in their approach  are patient and humble  have high expectations of themselves and others  have positive outcomes  have desirable personality traits The following are the benefits of a positive attitude:


Dr Y Thangabose

 Increases productivity  Fosters teamwork  Solves problems  Improves quality  Creates a congenial atmosphere  Breeds loyalty  Increases profit  Reduces stress  Helps a person to contribute  Creates better relationship between employers and employees, customers and patients  Develops leadership and skills  God’s name will be glorified

2. Be focused: Do not hesitate to use your potential despite constraints. Goliath loomed large as a giant.

Consequences of a negative attitude

6. Show a positive approach: Do not compromise.

 Bitterness  Resentment  A purposeless life  Ill-health  High stress level for themselves and others  Defeat

Basic skills for a positive attitude King David’s attitude towards God and situations as recorded in the Bible (1 Samuel chapter 17) brought him many victories. One such victory is that he defeated the giant Goliath by applying basic skills as explained below: 1. D e c i s i o n - m a k i n g s k i l l : Sharpen your decision making skills at the right time. David chose to fight Goliath and use his potential.

3. Gain experience in smaller things: Use your potential in smaller things and the Lord will give you bigger tasks. David had smaller troubles while tending sheep and he was able to tackle them. 4. Use familiar proven practices: Use God-given abilities in you. David used ordinary objects and known practices. 5. Have a contingency plan: Be prepared for any eventuality. David took five stones.

7. Have confidence, courage and faith in God: David relied on God for success. The name of Jesus will be glorified. Your attitude and skills will bring glory to Jesus. God’s name was exalted through David. Be available to our Lord Jesus. Are we available to our Lord Jesus at all times to do His will?

Conclusion The road to success is not straight – there is a curve called failure, a loop called confusion, speed bumps called friends, red lights called enemies, caution lights called employees but if you have a SPARE called determination, an ENGINE called perseverance, an INSURANCE called Faith, a DRIVER called Jesus, you will make it to a place called SUCCESS.

Clipboard Issue 60 & 61

Fire Safety Norms – NABH Guidelines 


he nation was shocked by the devastating AMRI Hospital fire that killed close to 100 people. Primary investigation says that a lit cigarette was the main cause of the fire. Police said the fire spread from a dump in the basement that caught fire from a burning cigarette. The investigators have pointed a finger at the irresponsibility of some workers of the hospital for this. They also suspect that there was a mound of cotton beside the bio-medical store in the basement After conducting a probe, Fire Department officials and authorities of the intelligence wing of the state police confirmed that the fire in AMRI Hospital originated from the inflammatory articles and cotton kept in the upper basement of the hospital. To add to their woes, the fire-fighting systems were insufficient as well as faulty. In addition, ill-trained hospital staff were more interested in saving their own lives! In the aftermath of this incident, there were appeals for steps to prevent the recurrence of such disasters. All were shocked at the failure of the systems and procedures in such a prestigious hospital. Fire department officials have said that hospital authorities

Ms Neetu Singh

were unable to even tell them where the emergency exits and stairs were. The hospital has also been accused of violating safety norms and using the basement as a godown. Instead of mulling over past failures, it would be pertinent to look at our own institutions to find out the lacunae and rectify them. One of the reliable documents that could be referred to in this context is the NABH Guidelines. Fire safety norms as specified by NABH are elaborated below for reference and application. FMS 5: The organisation has plans for fire and non-fire emergencies within the facilities FMS a): The organisation has plans and provisions for early d e t e c t i o n , containment a n d abatement of fire and non-fire emergences The Health Care Organisation (HCO) has a Fire Non-fire Emergency Committee (FNEC) to

review the HCO’s preparedness. The HCO has conducted an exercise of hazard identification and risk analysis (HIRA) and accordingly taken all necessary steps to eliminate or reduce such hazards and associated risks. The HCO has:  a fire plan covering fire arising out of burning of inflammatory items, explosion, electric short circuiting, acts of negligence or due to incompetence of the staff on duty  deployed adequate and qualified personnel for this  acquired adequate firefighting equipment for this, and records for which are kept up-to-date  adequate training plans  schedules for conduct of mock fire drills  mock drill records  exit plans well displayed If these instructions are followed in letter and in spirit, many a calamity will be avoided. If you need any more details regarding these norms, please send your queries either to Ms Neetu Singh ( or Mr Stephen Victor (

Quality in Health Care – The need of the hour for mission hospitals 


ase 1: After delivery, the paediatrician finds that the baby has asphyxia and orders supplementary oxygen till the baby is transferred to an NICU of another hospital. After attaching the masks, when the valves are opened, the nurse finds that the

Mr Akilan Arun Kumar

cylinder is empty. When the ambulance arrives, ironically, it is found that the cylinder in the ambulance is also empty. The baby is transferred to the NICU without supplementary oxygen for 30 minutes. And you know the outcome.

Case 2: In the first post-operative day, the physician orders 0.04 mg morphine sulphate, to be delivered intramuscularly for pain. Instead of using a 5ml vial, which is the customary practice, the nurse uses a 10 ml vial. Instead of 0.04 ml, she administers 0.4 ml, 10 times the in-


Clipboard Issue 60 & 61 tended dosage. Shortly after being administered morphine sulphate, the infant encounters respiratory arrest. Who is to be blamed for these lapses? Is it the nurse or the doctors? No! Systems. And it is the Administrator’s responsibility to establish systems. The above disasters could have been avoided if there were a good quality management system in place. Three cardinal components of quality in health care are presented in this article as follows: 1. Statutory Compliance 2. Infection Control 3. Patient Safety Statutory Compliance Statutory norms such as the Clinical Establishment Act, 2010, PNDT Act, Biomedical Management and Handling Rules, 1998, Drugs and Cosmetics acts, Narcotics and Psychotropic Substances Act, Registration of Births and Deaths Act, Transplantation of Human Organs act, 1994, and Radiation Safety are not only mandatory but vital for our existence. The noncompliance to these Acts is mainly due to a lack of understanding about them. We have another typical excuse – that we have been busy with an unabated demand by an ever-growing number of patients. Thus, no system was established to review and monitor the compliance to these Acts.


Infection Control The importance of infection control and hygiene practices was established through three historic episodes, wherein merely instituting hand washing, donning gloves before procedures and such asepsis brought down morbidity and mortality rates significantly. These three historic eras were from 1865-70 followed by formal planned prevention programmes between 1950-70 and currently through mandatory Infection Control Regulations. According to the current scientific data, 75% HAI are accounted for by four categories, namely, Urinary Tract Infections, Surgical Site Infections, Blood Stream Infections and Pneumonias. All four are primarily related to procedures and use of devices and are mostly preventable (75% to 100%). Suggestions to improve would be to establish a multi-disciplinary Infection Control Committee which meets frequently. Hospitals should have a well-developed Hospital Infection Control Manual. The management should ensure implementation of a well-designed surveillance programme, ensure rational use of antibiotics by way of an Antibiotic Policy and appoint a designated Infection Control Nurse (ICN) to coordinate all these activities within the institution. Every hospital should develop an antibiotic policy and strictly implement and monitor: • Surgical Site Infection rate • Urinary Tract Infection rate • Respiratory Infection rate • I n t r a - V a s c u l a r D e v i c e Infections These rates should be monitored and communicated to all staff and appropriate corrective actions taken, which are, but not limited to, hand washing / hand scrub, monthly surveillance of operating rooms, ICUs,barrier nursing (when applicable), universal precautions,

employee health checkup and hazardous waste management.

Safety in Facility (Hospital Environment) The third important factor, most overlooked in mission organisations, is safety – generally misunderstood as only patient safety. A holistic view of safety covers not only patient safety but also safe hospital infrastructure, no system failures such as medication errors, employing regular assessments for safety preparedness etc. Infrastructural safety would include provision of sufficient ventilation, lighting, safety arrangements for fire prevention and fire fighting, non-slippery floors, handrails for the aged, management of hazardous materials (HAZMAT) and regular mock drills. Medication error is not an unfamiliar term for hospitals, and the clinician accounts for a major number of mortality and morbidity episodes in the hospital. Medication error alone accounts for 44,000 deaths in the US. In order to curb such incidents, the following must be kept in mind: • • •

Use CAPITAL letters in drug prescriptions Be aware of sound-alike and look-alike drugs Double check  Dosage  Route  Time

Surgical safety • 13.4% of all sentinel events is due to wrong surgeries (wrong site, wrong patient, etc.) • WHO supports “safe surgeries” • Perform a “Time out” procedure during a surgery to ensure  Correct patient  Correct surgery  Correct part being operated

Clipboard Issue 60 & 61 Why the Need for Quality in our Hospitals? Sufficient references abound to prove that health care institutions have a moral, ethical and spiritual responsibility towards society, and the patient visiting our institution has a “right” to return healed and safe. The way to ensure that such practices endure in our institutions lies in one word i.e. quality, which ensures that the HCO moves in the right direction through set guidelines and standards to be followed and ensures improvement through firm commitment.

Benefits to Hospital  Continuous improvement in patient care processes and outcomes  Increased efficiency  Strengthen the public’s confidence  Enhanced brand image

 Tool to attract corporate clients  Your guard in litigations Benefits to the patients  Safety is ensured  Service by qualified staff  Patient rights protected  Satisfaction guaranteed  Less errors Benefits to the Staff  Provides continuous learning opportunity  Safe and good working environment  Ownership of service processes  Professional development of staff  Provides leadership for quality improvement

How to Go About Attaining Quality After discussing a plethora of information, the question remains as to where to start and how to go

about it. Many of us are already aware of the PDCA cycle i.e. Plan, Do, Check and Act. All the activities within the hospital should be studied in order to gauge the existing performance and whether it will deliver the intended results and if not, the gaps should be registered and further reengineered to suit the requirements of the health care institution. Hence to summarise: • • • •

Examine what you are doing Find what you should be doing Document the gaps Identify areas for improvement In conclusion, it may be said that the current deficiencies in our mission hospital network can be overcome and rectified through a concerted effort for which we have the potential and in which we have amply proved ourselves through long years of successful existence with dedicated service to our ailing brethren in society.

Problem Solving 

Hugh Skeil on finding a solution rather than on the problem itself.

Tips, Techniques and Tools for Problem Solving

Stage 2: Specify desired outcomes

Stage 1: Understand and define the problem

The outcomes set can be challenging, but also SMART: Specific, Measureable, Acceptable to all stakeholders, Realistic and Time Bound

1. History of the problem – where does it come from, when / how was it first noticed, what effects has it had on the organisation already? 2. Root cause analysis using the Ishikawa (Fishbone) diagram – this is an example of directed brainstorming. Start by writing the problem you are facing in the box marked “Effect”. Against each main “bone” write as many possible causes of the effect you want to understand. For example if the Effect is poor staff morale, the causes might include poor working conditions (Infrastructure), bad relationships amongst staff

(Personnel), badly designed administrative systems (Methods), poor quality medical supplies (Materials) etc. 3. Re-state the problem – try rewriting your problem in a number of different ways. It is good to express it positively as a “how to” statement. E.g. if your problem is a shortage of funds, you could express is as “how to increase income”. This puts the emphasis

One helpful exercise is to write out the potential effects of doing nothing. E.g. if we fail to address the shortage of surgeons in the hospital we will a) lose money; b) put extra pressure on other staff; c) have no time for training & development; d) theatres will be underutilised; etc. etc. This helps you understand what the problem is and assess how important it is to take effective action. It puts a fire under people to get them moving forward.


Clipboard Issue 60 & 61 Stage 3: Gather information This is not gathering information about the costs etc. of proposed solutions. It is about creating a clear understanding of the background to the problem and looking ahead to the future so that we aren’t just fixing an historical problem but trying to future-proof our solution. We need information about our own organisation (Internal Factors) and about the world around us (the External Environment). 1. List internal resources, capabilities, strengths and weaknesses. Resources include finance, assets, human capital, brand name / reputation, locational advantages. Capabilities are things you are good at doing – particularly efficient systems, team working, learning and research skills etc. Strengths are areas where you think you are better than other hospitals around you. Weaknesses are vulnerabilities and areas where you recognise a need to improve. 2. Carry out environmental scanning. The team looks at what is going on in the local, national and business contexts and tries to work out the impact of this on their problem. One useful framework is STEEP Analysis. Brainstorm for relevant issues and changes occurring in each of the following areas: Social, Technological, Economic, Environmental and Political Stage 4: Identify Limiting Factors and Constraints The limiting factor is the one (or possibly more than one) factor which will limit how much you can do. Usually it will be finance, but it might also be personnel, or available land etc. The key to finding the best solution is to aim to optimise the return from this limiting factor (biggest bang for your buck).


However, there will always be other constraints that you need to list out and remain aware of. Constraints are ethical, legal or other factors that mark out the boundaries of what you can do. For example:  government restrictions on the maximum ratio of floor space to land area  environmental concerns that might make it difficult to develop in the way you want to  ethical issues or things which might conflict with your organ­ isational values or upset some of your stakeholders Stage 5: Generate alternative options Of all the stages, I would say that this is one of the most important and yet most neglected. The temptation is to jump on the first workable idea that comes up. Good decision makers refuse to look at one idea only (it ceases to be a decision) and insist on evaluating a number of options. Searching for alternatives only sometimes comes up with a brand new solution that no one had thought of before, but it always helps understand the problem and the component variables better, avoid some pitfalls and refine the final solution chosen.

Where can we get alternative solutions from?  Memory search – ready-made, existing or previously used solutions  Active search – look outside your own experiencefor things others have tried  Design – dreaming up new approaches, participative and creative techniques e.g.: Brainstorming: A group  meeting with a facilitator to lead and a scribe to note down all the ideas that come no matter how crazy they are

 L a t e r a l t h i n k i n g : T o encourage people to think “outside the box” or jump out of the rut that forces us along well-worn channels  Diagramming techniques: Explained below The Tree Diagram helps you to explore all possible approaches to solving a problem. You start with the stump, which is the problem; for example, the hospital is losing money. Then you identify the overarching ways you can address this. For example you can increase profit in only two ways, by increasing income or by reducing spending. These are your first branches. Then you look at the Income branch, and list all possible sources of income:

patient fees, investment income, grants, donations etc. Go through each of these in turn to give more detail. Gradually some possible ideas will emerge that you might have overlooked before. The key is to be comprehensive in trying to cover all possible sub-branches, particularly at the early stages. Stage 6: Filter the alternatives to make a shortlist Hopefully, from Stage 5 you will have a large number of ideas. Some may be impractical for various reasons and some may be unacceptable to stakeholders or out of line with the overall values and aims of the organisation. Here are some screening tests that can be applied:

Clipboard Issue 60 & 61  Consistency – a viable option must present goals and policies that are consistent with mission and with each other  Suitability – does it match needs, resources and capabilities identified in the analysis stage  Feasibility – how well will it work in practice, what difficulties would be faced, how will competition react  Acceptability – financial risk/ return, effect on stakeholder relationships, collateral impact on the organisation Stage 7: Detailed Evaluation This can be time-consuming and costly, which is why you want to carry out stage 6 (filtering) first and only do it on a limited number of options. However there should always be more than one alternative evaluated, preferably at least three. You also need to perform a similar “benchmark” analysis of the “do nothing” option: what will happen if you take no action. You will use the same tests used in stage 6 but in more detail / more rigorously. Tools to be used include: 1. Quantitative – a. Forecasts of patient numbers, occupancy rates, and prescriptions filled etc. b. Financial forecasts and budgets c. Financial analysis (for example Discounted Cash Flow or Pay back Period) d. Comparison of return on scarce resources e. Decision Trees (not to be confused with Tree Diagrams shown before) A decision tree is a way of exploring possible outcomes, given that we cannot be 100% sure of what will happen when we implement our new project. The tree diagram on the left looks at the choice of doing a new lab test in-house or

outsourcing it to a commercial lab. It analyses the outcome at various levels of activity: 1,000, 2,000 or 3,000 tests performed. Because of the fixed costs involved, it is quite risky doing the test in-house. Risk means the spread between the worst and best outcomes. However if you are confident that there will be over 2,000 tests you will make more money doing it in-house.

2. Qualitative analysis of intangible factors: a. Cost benefit analysis b. Impact Assessment on service q uality, staff, community relationships, environment etc. c. Impact on overall mission objectives 3. Risk Analysis: We tend to do this, but this is at our peril. Risk is a measure of the variability of outcome – high risk means it is more difficult to predict the outcome (see Decision Tree ). Risk analysis involves taking time to identify all the things that could possibly go wrong and trying to assess the threat that these pose as if this is what is bound to happen. In real life all forecasts are prone to be highly unreliable – either because they are based on inaccurate models of the real world, or because of unknown and unpredictable variables that throw everything off course. It is far better to present your numbers as a range of possible outcomes, perhaps as best – most-likely – worst-case scenarios.

Stage 8: Decide – select the best option Bringing together all the evaluations in Stage 7, it is now a matter of selecting the one that is the best, based on the comparative costs and benefits.  Facts and figures: Analysis / comparison of the results of your evaluation of the shortlisted options  Experimentation: Testing or simulation if possible  E x p e r i e n c e : E s p e c i a l l y collective experience, including Consultation – both in and outside the organisation Where there is a lot of quantitative analysis one clear winner should emerge. Where there is a lot of qualitative assessment then a group will need to sit to weigh this up and choose the best option. Experimentation or testing is often possible with limited investment. For example when planning a new ward, why not lay it out in the car park and see whether there will be enough room etc. Stage 9: Implement, monitor and control This will only be effective if good outcome measures have been designed and clear objectives set. Controlling means regularly checking on actual results against the plan and taking whatever action is necessary to get the project back on target.

Summary DO clarify and agree on your objectives and expected outcomes. DON’T take short cuts: these make you feel good – decisive and effective – but they will usually cost you far more in the long run than going through the steps in order. Make sure that you look at many different options not just those that appeal to you on the surface. Even looking at ideas that prove to be unworkable is not time wasted: you will have learned more about your problem.


Clipboard Issue 60 & 61



What is meant by “informed consent�? Consent is consensus of mind between two persons and in this context, between the doctor and the patient. Legally, both, the doctor, who is to provide treatment to a patient, and the patient have a similar understanding about the treatment / test proposed. Informed consent is permission obtained from a patient to perform a specific test or procedure. It means the patient gives the consent in writing (signs the written consent form) after being informed in detail about the proposed treatment / procedure. Informed consent is required before performing most invasive procedures and before admitting a patient to a research study. Informed consent is voluntary. A valid consent form shall have the following features: a. D e t a i l s o f t h e p r o p o s e d operation/ treatment / diagnostic procedures b. The possibility of performing another operation, if the first operation ends in failure; this decision will be taken by doctors while they are in the operation theatre itself c. The approximate cost of the operation / treatment d. The risks resulting out of failure of the operation and the type of disability arising out of the failure, with examples e. Proper witnesses (two in number) with signature, name and address so that they can be identified later, perhaps even after a lapse of 5 years f. Signature of the patient; if he / she is less than 18 years of age, then signature of his / her parent / guardian/ relative The consent form can be produced in court as a support for the medical practitioner / hospital.




A CMAI publication focussing on issues related to hospital administration

A patient filed a complaint against a hospital before the District Consumer Disputes Redressal Forum. He was awarded a compensation of Rs 1 lakh. This amount should be paid by whom – the doctor or the hospital?

Christian Medical Association of India



The hospital has to pay according to the vicarious liability doctrine in law. Supposing a hospital engages consultants to perform operations or treat patients. If a patient files a complaint against a consultant on some grounds and if a court awards compensation to the patient, should the amount be paid by the hospital or by the consultant?


A consultant performs an operation on a patient and is paid fees by the hospital for it. The consultant is not an employee of the hospital. On the contrary, the patient has a contractual relationship only with the hospital and not with the consultant. Moreover, the consultant performs an operation only on behalf of the hospital. Hence, only the hospital has to pay the compensation to the patient and not the consultant.


But in rare cases, the consultant too could be asked to pay, as in a case in Chennai, where the State Consumer Disputes Redressal Commission divided the compensation amount to be paid to a patient into two and directed that one half of the amount be recovered from the doctor himself (from his salary) and the other half from the hospital, because there was gross negligence on the part of the doctor. Excerpts from: Laws on Hospital Administration, Mr D Samuel Abraham

Published by The General Secretary CMAI, Plot no. 2, A-3 Local Shopping Centre, Janakpuri New Delhi 110 058 Tel: (011) 2559 9991/2/3 E-mail: Website: CMAI Bangalore Office HVS Court, 3rd Floor 21 Cunningham Road Bangalore 560 052 Tel: (080) 2220 5464, 2220 5837 E-mail: Editorial Committee Dr Vijay Aruldas Dr Jeyakumar Daniel Mr Innocent Xess Sr Vijaya Mr Samuel NJ David Mr Edward David Dr CAK Yesudian Ms Jaya Philips Editor Mr Stephen Victor Editorial Coordinator Ms Jaya Philips Design & Production Susamma Mathew Printer: Bosco Society for Printing & Graphic Training

Clipboard October 2011- March 2012