1. MHP Section January 2005 UPDATE*
07/16/96
MHP Section January 2005 UPDATE
Nazario Macalintal Jr., MD
MHP SECTION
Department of Internal Medicine
11/20/2018 *

2. MHP SECTION - CRITICAL AREAS*
07/16/96
MHP SECTION - CRITICAL AREAS
I. OPERATION COST
II. SUSTAINABILITY
III. CONSULTANT ROTATION
11/20/2018 *

3. *
07/16/96
A View on the Present Situation - Focus on OPERATION COST DAILY CENSUS relative to COST 4
11/20/2018 *

4. *
07/16/96
… P5-6M/mo
P4.2M/mo
P3.8M/mo
P3.6M/mo
11/20/2018 *

5. June-October 2004 Cost Pattern*
07/16/96
11/20/2018 *

6. Medications is half of daily costs!*
07/16/96
Medications is half of daily costs!
11/20/2018 *

7. *
07/16/96
11/20/2018 *

8. Post-Realignment of Costs*
07/16/96
Post-Realignment of Costs
11/20/2018 *

9. PX CENSUS-EXPENSES MISMATCH suggest:*
PX CENSUS-EXPENSES MISMATCH suggest:
07/16/96
The PATIENT NUMBER only partly explains the increasing cost of operation.
The every 8 day pattern of rising cost in August cannot be explained by a certain MHP Team on duty.
The SUDDEN INCREASE IN LAB COSTS AND PHARMACY in October may come from 2 factors:
New Medical Consultants decked in MHP
Re-alignment of Costs
11/20/2018 *

10. NEXT MOVE is to define the EXTENT of the problem.*
07/16/96
NEXT MOVE is to define the EXTENT of the problem.
11/20/2018 *

11. *
07/16/96
11/20/2018 *

12. Initial Actions taken / Subsequent Plans*
07/16/96
Initial Actions taken / Subsequent Plans
A. Reviewed the last 3-mo performance. DONE
B. Reviewed the DETAILS OF segments which contributes to the majority of costs
R & B and OTHERS . FOR SORTING
C. Target for an initial DOABLE reduction in costs and then aim for further reduction on costs over the next 4months or so.
D. Meet with other departments which plays a role in the delivery of care to MHP patients 6
11/20/2018 *

13. Recommendation & Anticipated Outcomes*
07/16/96
Recommendation & Anticipated Outcomes
Strategy 1: Review of LAB COSTS (which is 11% of P3M allowed expenses, or P300k)
- An initial target reduction of 5% of this LAB COSTS of P300k is = P16,500.
- P16,500 divided by 6 MHP residents = P2,750.
- FACTS:
- One ABG for MHP costs > P880.
One CXR for MHP In-Px costs > P400
- One Kendall Humidifier Fluid for MHP --> P960.
One CPK-MB for MHP In-Px costs ~ > P1,000
~ P3,000
- STRATEGY 1: Each of the 6 MHP Resident only needs to order ONE LESS of those lab tests per month to accomplish this 5% reduction in LAB COSTS
- Next move: Aim for further reduction 7
11/20/2018 *

14. Reason Behind STRATEGY 1*
07/16/96
Reason Behind STRATEGY 1
- Pre-Extubation, patients are put on T-piece weaning (which requires different humidifier bottle)
Post-Extubation, patients are invariably put in MVMasks, and requires NEW humidifier bottle even if water in existing humidifer is full or half-full;
… then shifted later to Nasal cannula, (requiring another set of humidifier and Oxygen tubing!)
- An obvious wastage! - We need to improvise!!
(FOR DISCUSSION WITH PULMO LAB)
11/20/2018 *

15. Recommendation & Anticipated Outcomes*
07/16/96
Recommendation & Anticipated Outcomes
Strategy 2: Review of R & B (which is 65% of expenses, or P1.95M)
- An initial target reduction of 10% of this R & B of P1.5M is = P195,000.
P195,000 divided by 3 MHP residents groups = P65,000 per resident group….duty is q3days = 10 duties per month --->
Therefore P65k/10 = P6,500 per duty is the targeted savings per each duty group per day
QUESTION : WHAT ARE THE R AND B DETAILS?
WHERE ELSE CAN WE PULL THESE SAVINGS, ASIDE FROM THOSE ALREADY INDENTIFIED? 7
11/20/2018 *

16. OTHER Immediate Control / Stop-Gap Measure 1*
07/16/96
OTHER Immediate Control / Stop-Gap Measure 1
SENIOR MHP MRODs MUST HELP REGULATE Costs , both at ER and WARDS
11/20/2018 *

17. Immediate Control / Stop-Gap Measure 2*
07/16/96
Immediate Control / Stop-Gap Measure 2
NEED TO COORDINATE EFFORTS WITH DEPARTMENTS involved in handling MHP patients!
- Have made initial discussions to FW and MW Head Nurses (Sept 11,2004) on a sample issue:
That ALL to-follow orders of parenteral medications (Aminophylline, H2-antagonists and PPIs) on all MHP patients who are already eating /receiving meds by mouth/NGT have to be shifted to oral - and MRODs attention must be called. MEMO Prepared.
11/20/2018 *

18. Immediate Control / Stop-Gap Measure 2a*
Immediate Control / Stop-Gap Measure 2a
07/16/96
NEED TO COORDINATE EFFORTS WITH DEPARTMENTS involved in handling MHP patients!
- Have made initial discussions with Ed Batitis of Pulmo Lab (Sept 11,2004) on a sample issue:
> That it may help to create policies on the step-down process of oxygenating patients without sacrificing adequacy and quality of care.
>
Will Join PULMO LAB meeting next month. NOV
11/20/2018 *

19. Immediate Control / Stop-Gap Measure 2b*
07/16/96
Immediate Control / Stop-Gap Measure 2b
NEED TO COORDINATE EFFORTS WITH DEPARTMENTS involved in handling MHP patients!
- Have made initial discussions with Dr. Bobby Alojipan of MHP Department (Sept 10,2004)
> Had a Fellowship gathering for ER MDs, OSMAK ER MDs, and MHP IM MDs week1 October
FINDINGS: NOT MUCH PROBLEM RELATED TO IM AND OSMAK. (more of MMC ER and OSMAK ER issues)
11/20/2018 *

20. CRITICAL AREA II. CONSULTANTS’ ROTATION*
07/16/96
CRITICAL AREA II. CONSULTANTS’ ROTATION
11/20/2018 *

21. MUST TIE UP PLANS OF ACTIONS COLLECTIVELY WITH*
07/16/96
MUST TIE UP PLANS OF ACTIONS COLLECTIVELY WITH
HOSPITAL EXPECTATIONS
IM DEPT REQUIREMENTS
PCP EXPECTATIONS
RESIDENTS REQUIRED TRAINING EXPOSURE
JCI AND ISO REQUIREMENTS - NOT AN ISSUE.
THEY CAN BE DECKED AS LONG AS THEY ARE MEMBERS OF THE MEDICAL STAFF ASSOCIATION / MILA UY SEPT
11/20/2018 *

22. Recall MHP SECTION Goals…*
07/16/96
Recall MHP SECTION Goals…
To utilize the MHP service in complying with the General Requirements of Section 3.5 No. 10, to wit “assist in any Medical Staff-approved teaching activities for medical students, interns, residents, fellows, nurses, Medical Staff members, and others as required by the Department of which they are a member”.
11/20/2018 *

23. Oct-Dec 2004 Schedule of Decking for MHP Admissions*
07/16/96
Oct-Dec Schedule of Decking for MHP Admissions
Memo released for this last quarter
INITIAL Observations:
Objections from Consultants was NIL
PROJECTION:Only a handful from the WHOLE IM STAFF will refuse being decked for MHP 3-5x a year…
11/20/2018 *

24. Oct-Dec 2004 Schedule of Decking for MHP Admissions*
07/16/96
Oct-Dec Schedule of Decking for MHP Admissions
COSTS skyrocketed !!!
Only 7% of remaining for the OCT budget allotted as of Oct 19th
11/20/2018 *

25. OCTOBER COST UPSURGE! New Consultant every day - Defensive medicine?*
07/16/96
OCTOBER COST UPSURGE!
New Consultant every day - Defensive medicine?
Baseline abg in pneumonia patient / ER Consultant included in Dept of Medicine roster
Private patients being worked up as MHP admission
Immediate referral to Subspecialists by Consultant on deck
Loss of control on diagnostics orders -
“Why Refer when suggestions would be not carried out anyway?”
11/20/2018 *

26. *
07/16/96
ISSUE 1
ARE THERE EXISTING GUIDELINES with regards to the admission policies for MHP px?
The adherence to department policies takes priority over patients’ preference or attending physicians’ preferences. ADMISSION IS BY DECKING SCHEDULE.
Considered EXCEPTIONS: Onco-Hema patients with planned chemotherapy, AND renal patients considered for transplant need to be admitted under their previous consultants
11/20/2018 *

27. *
07/16/96
ISSUE 2: What is the role of MHP Service to the patient previously admitted as pay seeking confinement under the same doctor BUT UNDER MHP with orders from the non-MHP Consultant?
11/20/2018 *

28. *
07/16/96
ISSUE 3:Private but Yellow-card bearing px’s being admitted for work-ups?
11/20/2018 *

29. ISSUE 4:Consultants not receiving communication letter on decking*
07/16/96
ISSUE 4:Consultants not receiving communication letter on decking
11/20/2018 *

30. ISSUE 5: ER Consultants under the Dept of Medicine - for decking??*
07/16/96
ISSUE 5: ER Consultants under the Dept of Medicine - for decking??
11/20/2018 *

31. *
07/16/96
11/20/2018 *

32. Original assumption that is no longer valid*
07/16/96
Original assumption that is no longer valid
“PREVIOUS DECKING STRATEGY WORKED”
Px GETS REFFERED TO MD NEXT-ON-DECK AND SO ON.
NEXT ON LINE COMPLAINED.. And REFUSED, AND DID THE SAME….
11/20/2018 *

33. Option 1 - ROTATE ALL INTERNISTS in the MHP Decking*
Option 1 -
07/16/96
ROTATE ALL INTERNISTS in the MHP Decking
Problem 1:DO THEY HAVE OPTION TO REFUSE?
HOSPITAL DIRECTIVE ON ALL CONSULTANTS -
General Requirements of Section 3.5 No. 10, ...“assist in any Medical Staff-approved teaching activities for medical students, interns, residents, fellows, nurses,, Medical Staff members, and others as required by the Department of which they are a member”.
Implemented : October 1st, 2004 per ADL Memo Sept 28, 2004
11/20/2018 *

34. Option 2 - DECKING PROBLEM Solution : GET A BACK UP*
07/16/96
Option 2 -
DECKING PROBLEM Solution : GET A BACK UP
MAKE THE SECTION BOSS THE BACK UP -
The one on deck will think twice before calling his/her back up.
Should back up be called, the Section Boss just decides whom to refer and ORDERS the transfer of service or referral, not necessarily to the one next on deck.
THE ONE CALLED WILL BE HESISTANT TO REFUSE BEC IT’S HIS/HER SECTION BOSS WHO CALLED
11/20/2018 *

35. *
OTHER ISSUES
07/16/96
NEED TO DECK ALL SPECIALTY REFERRALS TO THOSE ON CALL FOR THE SAID SPECIALTY BY PRACTICE
CANNOT DECK ADMISSIONS BY SPEC OF CASES SINCE
~1/3 OF CASES IS CARDIO.
~ 1/3 IS PULMONARY
Cannot use On-Call for Private Patients - almost ALL CARDIOLOGISTS! (Why?)
BY PRACTICE, REFERRAL TO SPEC IS BY THE DATE THE NEED FOR REFERRAL IS REQUIRED , NOT ON THE DATE CASE WAS ADMITTED
11/20/2018 *

36. CRITICAL AREA 2: CONSULTANT DECKING - PLANS OF ACTION*
07/16/96
CRITICAL AREA 2: CONSULTANT DECKING - PLANS OF ACTION
Create Stop-Gap measure for the next quarter DONE
Secured Consultants’ Updated Directory - talked to Mila Uy
Announced the new Decking System before year end
But some not aware of their scheduled decking
Summary of Results - if things go as proposed
Total decking / consultant : only 3-5 / YEAR for each of the 180 consultants
MMC General Requirement for consultants to train residents /fellows is ADDRESSED
11/20/2018 *

37. CRITICAL AREA 2: CONSULTANT DECKING - PLANS OF ACTION*
07/16/96
CRITICAL AREA 2: CONSULTANT DECKING - PLANS OF ACTION
Need to address and improve cost-effectiveness concern by newly decked MHP consultants
11/20/2018 *

38. *
07/16/96
Problems as of Nov 06 04
Superada Case
11/20/2018 *

39. Conslutant decked on that day - not move *
07/16/96
Forced admission by ER constulatnts- previously OB, sent home with cathter, came back after 1 month ‘septic’, admitted direct to IM MHP
Dr estrella - IM addressed the sepsis, ttied to step up kidney function, creat 5 reduced to 0.8 sev leuco 44k down to 13k , saved
Issues:
px in urosepsis, prev ob open-close case, uro masintained Fcath, -why IM? Should have been OB, Uro.
ER entries are from OB and Uro before referring to us.
OB consultant Antonio. OB ROD Ocampo?
“do not carry out above suggestion” by ER ROD. Admit to IM since OB and Uro does not want to admit.
Fr NURse Station: “ER consutlant making rounds to ward and pinpointing beds that can be used fro admission
True or not? 2nd hand info? Find out. C/o Dr estrella nov 6 04
Conslutant decked on that day - not move
PATIENTS FROM OPD are not admitted by ER if there is not assurance from IM that they will be admitted / Dr Estrella
Can you get their ER guidelines on admission policies?
11/20/2018 *

40. *
07/16/96
Nov sexecom
need tp discuss the admission of MHP patients by being seen first by IM Reisdnets
11/20/2018 *

41. MUST RECONCILE ITS DIRECTION COLLECTIVELY WITH*
07/16/96
MUST RECONCILE ITS DIRECTION COLLECTIVELY WITH
HOSPITAL and IM DEPARTMENT’s MISSION AND VISION
PCP EXPECTATIONS
RESIDENTS REQUIRED TRAINING EXPOSURE
11/20/2018 *

42. MHP Section MISSION Statement*
07/16/96
MHP Section MISSION Statement
To become an effective arm of the MMC in its commitment to provide adequate medical care to the indigent constituents of the community 2
11/20/2018 *

43. *
07/16/96
MHP Section Goal 1
To actively participate in the MMC MHP Service by providing adequate medical care within the prescribed working budgetary allocation provided by the institution, with the view in mind of achieving the vision-mission statements of the institution and the department.
11/20/2018 *

44. *
07/16/96
MHP Section Goal 2
To maintain the delivery of quality services and ensure the competent medical residency program via continuous cooperation from all Medical Consultants of all subspecialties
11/20/2018 *

45. *
MHP Section Goal 3
07/16/96
To utilize the MHP in helping Consultants comply with the General Requirements of Section 3.5 No. 10, to wit “assist in any Medical Staff-approved teaching activities for medical students, interns, residents, fellows, nurses, Medical Staff members, and others as required by the Department of which they are a member”.
11/20/2018 *

46. *
07/16/96
MHP Section Goal 4
To help MMC reduce the cost of healthcare delivery while maintaining an effective, practical management of medical cases 3
11/20/2018 *