طب انتظامی (Jan 2022)
The Impact of the Covid-19 Pandemic on the Performance and Efficiency of Selected Military Hospitals: A Cross-Sectional Study
Abstract
INTRODUCTION Acute respiratory syndrome SARS-CoV-2, the cause of the Covid-19 pandemic, started in December 2019 in the city of Wuhan, China [1]. ... [2-5]. Iran, like other countries, was not spared from the epidemic of Covid-19, and on February 19, 2020, the first cases of Covid-19 were confirmed in the city of Qom [6, 7]. ... [8, 9]. One of the challenges of the Covid-19 disease is the health consequences caused by the epidemic of the disease. The increase in the number of people suffering from the disease and the consequent increase in the demand for medical services have caused the country's healthcare sector, especially hospitals, to face serious challenges [10]. ... [11-13]. In this way, with the Coronavirus and the reduction of routine hospital activities in the emergency and elective surgery departments, the specific income of hospitals has decreased sharply, so a decrease of 355 million dollars in the specific income of hospitals is predicted on March 2022. With the continuation of the disease process in the coming months, this decrease in hospital income will continue and will greatly limit the budget of the country's health system [14]. In the meantime, military hospitals have not been exempted from this rule and have faced challenges caused by increased costs, decreased performance, and lack of efficiency. AIM(S) Since no study has analyzed the effects of the covid-19 epidemic on the operational status and efficiency of military hospitals, therefore, it is considered necessary to investigate this issue, which was analyzed in this study. RESEARCH TYPE This applied study is descriptive-analytical using performance indicators. RESEARCH SOCIETY, PLACE & TIME This study was conducted in 2019 and 2021 in four selected military hospitals affiliated with the Police of the Islamic Republic of Iran. The year 2019 was considered as the period before the epidemic of Covid-19 and 2021 was considered as the period after the epidemic of Covid-19. MATERIALS & METHODS To make the study sample more homogeneous, all these hospitals were selected from non-specialized hospitals. To preserve the ethical aspects, the names of the hospitals were avoided and the names of the hospitals were indicated by numbers. After obtaining permission from the ethics committee and presenting the letter of introduction to the investigated units, raw data was collected by referring to the statistics and medical records unit according to the forms of the new statistical system to extract the desired indicators. Standard formulas taken from the Ministry of Health and Medicine were used to calculate the indexes of bed occupancy percentage, bed turnover ratio, and the average length of hospitalization [10]. Percentage of bed occupancy=((Number of occupied beds-days)/(Number of active beds - active days))×100 Bed turnover ratio=Total number of admissions/Average number of active beds Average length of hospitalization= (Number of beds-days)/(The number of discharged and dead patients) In the following, after calculating the indicators in each hospital, the mentioned indicators were compared with the standard indicators of the Ministry of Health, Treatment, and Medical Education (Table 1) and were categorized into favorable, average, and unfavorable categories. ETHICAL PERMISSION The checklist prepared for collecting data from hospitals was provided to the officials of different units and the necessary explanations and obligations were provided about maintaining the confidentiality of the received data. STATISTICAL ANALYSIS After checking the normality of the data, the paired t-test was used in SPSS 17 software to compare performance indicators in two different years. In the following, using Excel 2019 program and the Pabon Lasso diagram, the efficiency and performance of hospitals were calculated and compared. The horizontal axis of this rectangular diagram is the bed occupancy percentage and the vertical axis is the bed efficiency (bed turnover ratio). By calculating the weighted average of the bed occupancy rate and the bed turnover ratio of the hospital, the optimal level of these two indicators was obtained for the investigated hospitals and plotted in the corresponding graph so that, with the appearance of two intersecting lines, four areas appear in the graph. Then, by using the numerical value of the two desired indicators (bed occupancy rate and bed turnover ratio) for each hospital, their location and the area corresponding to each of the four areas of the chart were determined. In addition, in this diagram, the point of the average length of stay of the patients is determined from the connection of the coordinate point of the hospital to the center of the coordinate and extending to the opposite sides [14]. Table 2 shows the characteristics of the four areas of the Pabon Lasso diagram. FINDING by TEXT The average total index of bed occupancy percentage in 2019 and 2021 was 75% and 70.5%, respectively, which compared to the standards of the Ministry of Health (Table 1), were in favorable and average conditions, respectively (Table 3). Also, in both years, the highest percentage of bed occupancy was related to hospital "1" and the lowest percentage was related to hospital "2". In general, the bed occupancy rate in all hospitals decreased greatly during the period. The average index of patient stays in 2017 and 2018 was 3.5 and 3.8 days, respectively, which showed the unfavorable condition of hospitals compared to the existing standards. The maximum average stays of patients in hospital "4" is 4.3 days in 2021. Also, the lowest average length of stay was related to hospital "1" in 2019 (Table 3). The average bed turnover index in 2019 and 2021 was 70.6 and 69.8, respectively, the highest in both years was related to hospital "1" and the lowest in both years was related to hospital "4". Also, based on the results of the paired t-test, in two years, only the variables of the death rate and the average active bed had a significant change (p-value; Table 3). In the following, the covid-19 epidemic was investigated on the performance of covered hospitals using the Pabon Lasso model. The results of the performance of hospitals in 2019 showed that among the hospitals studied, hospitals No. 1 and No. 3 were located in Region 4 (Northeastern Region of Tehran) (Figure 1). The hospitals located in this area had the best performance in terms of bed occupancy and bed turnover, and the level of efficiency was very high. In the same year, Hospital No. 2 and Hospital No. 4 were located in Region 2 (southwest region), and the results indicated low bed turnover and low bed occupancy. But in 2020 and after the Covid-19 disease, the results showed that all the hospitals covered by police, especially hospitals 1 and 3, were more affected and the performance of these hospitals has severely deteriorated (these hospitals in Region 3 (Northwest region in Tehran). As a result of the disease epidemic, the bed occupancy rate in these two hospitals decreased drastically and the performance of these hospitals was more affected by the ill effects of the disease epidemic (Figure 1). MAIN COMPARISION to the SIMILAR STUDIES In this study, the index of bed occupancy percentage in the hospitals of this study in 2019 was higher than the desired level and the national average (70%), and these results are consistent with the study of Sadeghi Far et al. [15]. Also, in the study of Kavousi et al., in terms of bed occupancy index, 4 centers were in favorable condition, 2 centers were in average condition and 8 centers were in unfavorable condition [16]. Arzamani et al. have also shown in their study that the level of these indicators in the hospitals of North Khorasan province in Iran is higher than the national standard and they are in a favorable condition [17], which were not different from the performance indicators obtained in the present study. In some foreign studies, the bed occupancy rate was much higher than the results of the present study; for example, according to Zhu's study in Singapore, the average bed occupancy rate is reported to be nearly 90% [18]. Also, in a study conducted in a specialized hospital in Egypt, the results show that in the period under review (2004-2013), the bed occupancy rate increased from 54.3 to 86.3 [19]. Although in Uy's study conducted in hospitals in the capital of Cambodia, this coefficient was 58%, which was much lower than the results of the present study and was consistent with the results of the present study after the Covid-19 epidemic [20]. This difference could be due to lower public health care expenditures, ineffective management or hospitalization, and treatment of diseases with long stays. In the present study, the index of bed turnover and the distance of bed turnover were also in good condition compared to the standard before the Covid epidemic, but after the epidemic, these indicators were in a bad condition. In Joneidi et al.'s study, the index of bed turnover distance and average patient stay is in an unfavorable situation, and other indicators are in a favorable situation or even some of them are at a level beyond the optimal level [21]. Although in some domestic and foreign studies, these indicators are far from the standard levels and are in an unfavorable situation [22, 23]. This difference can somehow be caused by the lack of demand and too many beds remaining empty, or there may be a defect in the procedure for accepting patients. Hence, solving these issues can improve the index of bed turnover in these hospitals. The results of the present study showed that the studied hospitals are not in favorable conditions in terms of the average indicators of patients' stay compared to the country's standard indicators. The results of this study were consistent with the results of Barfar et al. [24]. Kalhor et al. also showed in their study that in general hospitals, the average length of stay of patients was 4.3, 4.8, and 4.5 days, respectively, and they were not in a favorable condition [25]. Also, in a study conducted in public hospitals in Jordan by Ajlouni et al, long-term hospital stay is considered a serious challenge [26]. Although, unlike the present study, in other studies that included different hospitals in Iran, the results showed the average favorable condition of the patient's stay; accordingly, in the study by Arzamani et al. and the study by Sadeghifar et al., hospitals were in a favorable condition in terms of the average index of patient stay [15, 17]. In a study conducted by Pabon Lasso in Colombian hospitals, the average stay of patients in hospitals with less than 100 beds and more than 200 beds was 5.2 and 7.2 days, respectively [27]. According to the World Bank report, the average length of stay in Australia has been 14 days, Canada 12 days, Egypt 8 days, France 11 days, Germany 14 days, Italy 11 days, Japan 46 days, Sweden 8 days, England 10 days, and America 8 days [28]. Also, the examination of the performance indicators of hospitals in the two countries of India and Egypt showed that in the investigated periods, the average stay of patients was 6.3 and 7.75 days; however due to the lack of definition of standard level for each index, judging the performance of hospitals was associated with problems [19, 29]. Although in a study conducted by Iswanto in Indonesia, the average stay of patients was 2-3 days and was obtained at a satisfactory level [30], which difference could be due to the difference in the type of population covered by hospitals, the status of providing hospital services and the type and time of the study and finally the amount of public costs of care in the wards and hospitalization of patients with long stays. Regarding the comparison of the performance of hospitals based on the three indexes of bed occupancy percentage, bed turnover rate, and average patient stay according to the location of the studied centers in the four areas of the Pabon Lasso diagram in 2019 and 2021, hospitals 2 and 4 were located in the same areas in both years and there was no difference in their performance, but hospitals 1 and 3 were located in the efficient area before the epidemic, but after the epidemic, these hospitals were placed in the inefficient area and area 2. In the first area of the diagram, there are centers with lower than average occupancy and bed turnover percentages, the number of beds is highly dependent on demand, and the hospital shows poor performance, in this study, hospitals 2 and 4 were located in this area after the epidemic. In Mohammadi et al.'s study and Hafidz's study, 36% and 37% of hospitals are located in this area, respectively [31, 32]. Also, in the study of Barfer et al., three hospitals are located in the first region [24]. Yousefzadeh et al. have also shown that 5, 4, 3, and 2 hospitals were located in this area from 2012 to 2015, respectively, and these results are consistent with the present study [33]. Also, by examining the foreign studies conducted by Nabukeera et al. and the study by Nwagbara Rasiah, the results show that 50 and 37 percent of hospitals are located in Region 1, respectively [23, 34]. Although in some studies, no hospitals were included in this area [25] which could be due to differences in the system and management style of the hospitals. The second area of the graph is dedicated to those centers that have a high bed turnover due to their specific type of activity (such as short-term hospitalization centers or maternity hospitals). In this study, after the epidemic, hospitals 1 and 3 were placed in Region 2, so it can be said that they did not have an acceptable efficiency in managing affairs, and it is recommended that the management of the center plan to improve the performance indicators and move the center to the region 3. Zahiri and Keliddar have shown in their study that 7 of the 26 hospitals studied were located in Region 2 [35]. Also, in the study of Mehr al-Hasani et al., 9 hospitals were located in this area [36]. In a study conducted by Iswanto in a medical center in Jakarta, Indonesia, during the investigated period, this medical center was located in the Region 2 of Pabon Lasso diagrams [30]. This hospital had a high bed turnover due to being a single specialty and an outpatient treatment center; for this reason, the performance results were similar to the present study. In the third area of the diagram, some hospitals have good efficiency; this means that these hospitals have reached the appropriate efficiency with the minimum number of beds used and have a favorable efficiency in the administration of affairs. The present study showed that in 2019 and before the epidemic, only hospitals 1 and 3 were located in Region 3. Bahadori et al and also Asbu et al., have shown in their study that 39 and 27 percent of hospitals, respectively, are located in Region 3 [22, 37]. Also, Sajadi et al. have shown that 45% of the hospitals they studied are located in Region 3 [7]. In a study conducted among the hospitals of Cairo in Egypt, the results show that during the period review (2006-2008), 46, 60, and 53 percent of the hospitals were located in this area [26]. In the study of Nabukeera et al., the study of Nwagbara and Rasiah, and the study of Hafidz et al., respectively, 20, 35.6 and 37 percent of hospitals were located in this area [23, 32, 34]. SUGGESTIONS It is suggested that future studies improve the performance indicators of hospitals by using modern quality approaches, especially six sigma which is based on increasing quality and reducing costs at the same time, to formulate clear and specific treatment methods and procedures to prevent possible infections that cause an increase in the average length of stay and the decrease in bed turnover. Also, for future research, it is suggested that this study be conducted in more periods and more hospitals. LIMITATIONS In the current study, the lack of access to some financial indicators such as the cost of personal protective equipment and performance indicators such as deaths caused by Covid-19 in police hospitals, and also the lack of access to information on a larger number of hospitals covered by the police, were among the limitations of this research. It is suggested that in the future, by solving such cases, the foundation of new studies be done. CONCLUSIONS The results of the present study are very useful for managers and policymakers of the health department of military hospitals who are looking for ways to improve performance and optimal use of resources in the field of treatment. By comparing the performance indicators with the standards and examining the performance of military hospitals using the Pabon Lasso model, in addition to knowing the amount of deviation from the standards, those inefficient hospitals with inappropriate performance were also identified. Therefore, the managers and employees of the police health department must take corrective measures about the hospitals that are in Region 1 (inefficient hospitals) and also the indicators that are far from the standard levels, to find the root of the weakness and improve the performance. Also, by examining and evaluating the managerial and economic performance of efficient hospitals (hospitals located in Region 3) or other internal and external hospitals with optimal performance, the factors affecting success and desirability can be identified and by modeling these factors (adjusting different conditions hospital) to make progress as fast as possible in various therapeutic, economic and management indicators in police hospitals. Clinical & Practical Tips in Police Medicine Considering the adverse effects of the covid-19 epidemic on the performance and efficiency of selected police hospitals, crisis management, and proper planning at the level of the health department can have a significant effect in reducing the adverse effects of the covid-19 epidemic. Acknowledgments The authors thank the deputy of the health department of the police of the Islamic Republic of Iran and also all hospital personnel for their cooperation in conducting this research. Conflict of Interest The authors state that there is no conflict of interest in the present study. Funding Sources The present study is a part of the research project numbered "91000368" which was carried out with the financial support of the Police Command of the Islamic Republic of Iran.
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