Hospital economics a primer on resource allocation to improve productivity sustainability

Hospital Economics A Primer on Resource Allocation to Improve Productivity & Sustainability Hospital Economics A Primer on Resource Allocation to Improve Productivity & Sustainability A Heri Iswanto A PRODUC TIVIT Y PRESS BOOK First published 2018 by Routledge Park Square, Milton Park, Abingdon, Oxon OX14 4RN and by Routledge 711 Third Avenue, New York, NY 10017 Routledge is an imprint of the Taylor & Francis Group, an informa business © 2018 by A Heri Iswanto The right of A Heri Iswanto to be identified as author of this work has been asserted by him in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988 All rights reserved No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data Names: Iswanto, A Heri, 1977- author Title: Hospital economics : a primer on resource allocation to improve productivity & sustainability / A Heri Iswanto Description: Boca Raton : Taylor & Francis, 2018 | "A CRC title, part of the Taylor & Francis imprint, a member of the Taylor & Francis Group, the academic division of T&F Informa plc." | Includes bibliographical references and index Identifiers: LCCN 2017051162| ISBN 9780815388777 (hardback : alk paper) | ISBN 9781351172523 (ebook) Subjects: LCSH: Hospitals Business management | Hospitals Administration Classification: LCC RA971.3 I89 2018 | DDC 362.11068 dc23 LC record available at https://lccn.loc.gov/2017051162 ISBN: 978-0-815-38877-7 (hbk) ISBN: 978-1-351-17252-3 (ebk) Typeset in ITC Garamond Std Light by Nova Techset Private Limited, Bengaluru & Chennai, India To my loving wife, Shika, and our children, Naya and Farrel Contents Acknowledgments xi Author .xiii The Importance of Hospital Economics Introduction Hospital Cost Savings Ratio of Hospital Beds Hospital Economics Issues References Hospital Resource Allocation .11 Introduction 11 Production Function 12 Cost Function 16 References 19 Hospital Productivity 21 Introduction 21 Hospital Productivity Factors 25 References 29 Hospital Competition and Quality 31 Introduction 31 Competition versus Quality 31 Nonfinancial Factors 33 References 38 vii viii  ◾ Contents Cost Components in Medical Procedures .39 Introduction 39 Cost Elements 40 Analysis of Covariance .43 References 47 Economic Burden of Disease 49 Introduction 49 Perspectives on Study of the Economic Burden .49 The Economic Burden of Disease 51 Sociological Role .52 Stigma 53 The Proportion of Direct and Indirect Costs 56 References 56 Economical Aspects of Hospital-Acquired Infections 57 Introduction 57 Implementation of Work Standardization 58 Economic Analysis of Hospital-Acquired Infections .59 Hospital Costs Spent 60 The Importance of Hospital-Acquired Infections 61 Incremental Cost-Effectiveness Ratio .63 References 64 Hospital Resource Management 67 Introduction 67 Technical Efficiency 68 Economic Efficiency 69 Scale Efficiency 71 The Relation among Efficiencies 73 References 75 Economy Scale of Hospitals 77 Introduction 77 Economy of Scale .78 Economy of Scope 80 Application 81 References 85 Contents  ◾  ix 10 Hospital Human Resources Development .87 Introduction 87 References 93 11 Methods of Improving the Quality of the Hospital 95 Introduction 95 Total Quality Management, Six Sigma, and Lean 95 Plan, Do, Check, Act 99 The Seven Quality Control Tools 100 References 101 12 Lean Implementation in Hospitals 103 Introduction 103 Waste .103 Lean Implementation 104 Lean Principles 106 References 110 13 Utilization of Hospital Resources .113 Introduction 113 Consumer Rates 115 Insurance 117 References 119 14 Hospital Revenue Components 121 Introduction 121 Payment-Based System 123 Hospital Revenue 123 References .129 15 Diagnosis-Related Groups 131 Introduction 131 Diagnosis-Related Groups in Indonesia 132 Indonesia Case Base Groups 136 References .138 Index 141 134  ◾  Hospital Economics Health No 1161/Menkes/SK/X/2007 on Decision of Hospital Rates Based on Indonesia Diagnosis Related Group (INADRG) Previously, this system was tried at 15 hospitals as a calculation system of service costs through the Decree of Indonesia Minister of Health No 1663/Menkes/SK/XII/2005 on Implementation Experiment of Case-Mix Diagnosis Related Group (DRG) System The rationale for DRG implementation in Indonesia is that it provides tariff and transparent standardization, more objective tariff calculation on the basis of the actual cost, hospital payments that are based on the actual work load, and the ability to increase hospital service quality and efficiency There are 1077 disease groups, with 23 categories of main diagnoses This number is considered large for a developing country Generally, developing countries have DRGs consisting of 500–800 groups In Kyrgyzstan and Mongolia, the number of groups is lower Meanwhile, in Thailand, there are 2700 case groups The high number of cases encompassed in the DRGs indicates that the available health system service is quite advanced, so it is able to provide various services (Mathauer and Wittenbecher, 2013) INA-DRG was derived from IR-DRG by adding several new groups based on characteristics of Indonesia INA-DRG consists of 789 inpatient DRGs and 288 outpatient DRGs The main supporting data to determine INA-DRG codes were obtained from ICD-10 and ICD-9 CM ICD-10 is the tenth revision of the classification system of international disease consisting of 21 diagnostic categories ICD-9 CM is the ninth revision of the classification system of international disease with clinically necessity modifications consisting of 16 diagnostic categories The government buys INA-DRG licenses for Rp billion, and this license ended on September 30, 2010 The main diagnostic categories of INA-DRG include: Disease and nervous system disorders Disease and eye disorders Diagnosis-Related Groups  ◾  135 Disease and ear, nasal, oral, and larynx disorders Disease and respiratory system disorders Disease and circulatory system disorders Disease and digestive system disorders Disease and hepatobiliary and pancreatic system disorders Disease and musculoskeletal and Conn tissue system disorders Disease and skin, subcutaneous tissue, and breast disorders 10 Disease and endocrine, nutritional, and metabolic disorders 11 Disease and urinary tract disorders 12 Disease and male reproduction system disorders 13 Disease and female reproduction system disorders 14 Giving birth 15 Newborn babies and other neonates 16 Disease and blood, blood-forming organ, and immunological disorders 17 Disease and myeloproliferative and neoplasm disorders, which are differentiated badly 18 Infection and parasitic disease, systemic location, or not found 19 Disease and mental disorders 20 Organic mental disorders due to the use and induction of alcohol/drugs 21 Injury, poison, and medicinal poison effects 22 Factors affecting health status and other contacts to health service 23 Medical outpatient visits INA-DRG was initially implemented in the CHI program in 2008 A study conducted by Diah Indriani et al at RSUP Dr Sardjito indicates that there is still a tariff discrepancy between health service real costs and INA-DRG tariffs This discrepancy is due to inefficient medicine service and the use of laboratory resources (Indriani et al., 2013) Meanwhile, an INA-DRG study at RS Panti Waluyo Surakarta indicated a greater cost problem in reality compared to INA-DRG tariffs by 52.2% for comotio cerebri cases and 61.9% for nonhemorrhagic 136  ◾  Hospital Economics stroke cases, which became the study case (Pitaloka, 2011) Generally, for surgical cases, the INA-DRG cost is lower than the FFS cost, but for nonsurgical cases, the INA-DRG cost is often higher than the FFS cost, which is more traditional Indonesia Case Base Groups After the INA-DRG license ended, the government developed the Indonesia Case Base Group (INA-CBG) system INA-CBG was accepted by the Ministry of Health on January 9, 2013, after the development was carried out at the United Nations University–International Institute for Global Health (UNUIIGH) case-mix system, which was funded by AusAID The basic part of the funding is the main diagnosis The main diagnosis is the final diagnosis selected by a doctor on the patient’s last bed day with the most criteria related to using resources, or what causes the longest bed day The definition of the main diagnosis is considered fair because it is from an economic perspective, so it does not disadvantage the hospital If there is more than one diagnosis, then the diagnosis considered eminent is the one that uses the most resources compared to the one that threatens the patient the most The secondary diagnosis involves complications and comorbid conditions Complications are conditions that appear during the treatment period and are considered to add to length or stay for at least one bed day Comorbid conditions are conditions that were present at admission and are considered to add to length of stay for at least three-quarter bed day On the other hand, INA-CBG is also more from the patients’ perspective compared to INA-DRG INA-DRG is considered to prioritize procedures rather than diagnosis Meanwhile, INA-CBG places more of an emphasis on the diagnostic approach than on procedures Furthermore, INA-CBG is applied more widely than CHI Because this is the JKN era, INA-CBG is implemented as the Diagnosis-Related Groups  ◾  137 claim payment quantity by BPJS Kesehatan to the reference health facility for an advanced level of service package, which is based on disease and procedural diagnosis grouping This is stated in Decree of Minister of Health No 59 of 2014 on Standard for Health Service Tariff in the Implementation of Health Assurance Program The number of available diagnosis groups is similar to the previous, that is, 789 inpatient groups and 288 outpatient groups In INA-CBG, patients’ conditions are divided into three conditions: severe, subsevere, and chronic A severe condition is defined as 1–42 days of length of stay, a subsevere condition is 43–103 days of length of stay, and a chronic condition is 104–180 days of length of stay Tariffs for each condition are as follows: ◾◾ Severe phase tariff = Tariff of direct grouping result from INA-CBG tariff data ◾◾ Subsevere phase tariff = Severe phase tariff + top-up payment of subsevere phase ◾◾ Top-up payment of subsevere phase = 0.375 × RIW × UC  × LOSsa ◾◾ Resource intensity weight (RIW) is calculated with the formula: RIW = ADL score/60 ◾◾ The activities of daily living (ADL) score indicates the inability of patients to perform daily activities and is calculated with the WHO–Disability Assessment Schedule (WHO-DAS) set, which is performed on patients included in subsevere and chronic cases (Regulation of Minister of Health No 27 of 2014 on Technical Instruction of Indonesian Case Base Group [INA-CBG] System) ◾◾ Unit cost (UC), which is by Rp 879,103 ◾◾ Length of stay (LOS), which is patient length of stay in one treatment period For subsevere cases, the formula for LOS is LOSsa = LOS – (LOS – 103) – 42, with the criteria of LOS – 103 > 0 If LOS – 103 ≤ 0, then it is considered = 0 This means LOS for the subsevere phase is none other than the difference of days between the 138  ◾  Hospital Economics severe and subsevere phase lengths of stay, but it cannot exceed 103 days ◾◾ Meanwhile, the tariff for the chronic phase is severe phase tariff + subsevere phase top-up payment + chronic phase top-up payment Chronic phase top-up p ­ ayment  = 0.25 × RIW × UC × LOS For chronic-phase LOS calculation, LOSk = LOS – 103 with the criteria of LOS – 103 > 0 If LOS – 103 ≤ 0, then it is considered = 0 because it means the chronic phase has not occurred (it has not reached 104 days) References Indriani, D., H Kusnanto, A G Mukti, and K Kuntoro 2013 Dampak Biaya Laboratorium Terhadap Kesenjangan Tarif INA-CBGs dan Biaya Riil Diagnosis Leukemia Kesmas: Jurnal Kesehatan Masyarakat Nasional 7(10), 440–446 Kriegel, J., F Jehle, H Moser, and L Tuttle-Weidinger 2016 Patient logistics management of patient flows in hospitals: A comparison of Bavarian and Austrian hospitals International Journal of Healthcare Management 9(4), 257–268 Mathauer, I and F Wittenbecher 2013 Hospital payment systems based on diagnosis-related groups: Experiences in lowand middle-income countries Bulletin of the World Health Organization 91(10), 746–756A Niinimäki, T., P Jalovaara, and E Linnakko 1991 Is DRG useful in orthopedics? Acta Orthopaedica Scandinavica 62(241 suppl), 40–41 Permenkes No 27 Tahun 2014 Tentang Petunjuk Teknis Sistem Indonesian Case Base Group (INA-CBGs) http://www.kpmakugm.org/id/assets/public/PMK 27-2014 Juknis Sistem INA CBGs pdf Pitaloka, S 2011 Pelaksanaan Indonesia Diagnosis-Related Group (INA-DRG) Di Rumah Sakit Panti Waluyo Surakarta http://etd repository.ugm.ac.id/index.php?mod=penelitian_detail&sub=Pe nelitianDetail&act=view&typ=html&buku_id=​52038 Diagnosis-Related Groups  ◾  139 Rodríguez-Rieiro, C., P Carrasco-Garrido, V Hernández-Barrera, A. López de Andrés, I Jimenez-Trujillo, A Gil de Miguel, and R. Jiménez-García 2012 Pandemic influenza hospitalization in Spain 2009: Incidence, in-hospital mortality, comorbidities and costs Human Vaccines & Immunotherapeutics 8(4), 443–447 Rokx, C et al 2009 Health Financing in Indonesia: A Reform Road Map Washington, DC: World Bank Publications Index A Academic conferences, 90 Admission status, 47 Affinity diagram, 100 Altruism, 33 Analysis of covariance (ANCOVA), 43–47 Antibiotic-resistant bacteria (ARB), 62 Arrow diagram, 100 NHI facility, 123 Association of physicians, Association of Swedish Quality, 100 Attendance index, 15 Average length of stay (ALOS), 28, 82 B Badan Penanggulangan Bencana Daerah (BPBD), Badan Penyelenggara Jaminan Sosial (BPJS), 4, coordination of benefits (CoB), 127 DRGs, 12 gatekeepers, 34–35 INA-CBG rates, 124, 126, 128 Lean system, 108 medical funding, 124–128 Bed occupancy rate, 12 BPJS Kesehatan, 124, 126–128 key improvements, 128 Businesses, C Capital investment, 77 planned costs, 91 Capitation system, 34 Caring complexity, 58 Central line–associated bloodstream (CLAB) infections, 59 Character assassination, 53–54 Charts, 100 Check sheet, 100 Check with Study, 99 CHI (Community Health Insurance), 122 Childbirth assurance, 122 Chronic diseases, 50–51 Cipto Mangunkusumo Hospital, 104 Civilian groups, 2–3 Class C hospitals, 34–35 Clinics, 34–35 141 142  ◾ Index The Community Association (TCA), 4 Community health centers, 4, 12, 34–35 Community organizations, Company assurance, 121 Competition nonfinancial factors, 33–38 quality versus, 31–33 scale efficiency, 71 Competitive area, 36 Comprehensive clinical admission severity group (CC-ASG), 60 Conjoint analysis, 100 Constant return to scale (CRS), 71 Consumer rates, 115–117 Continuous/unplanned costs, 91 Contribution margin (CM), 114–115 Control chart, 100 Cook and Weisberg test, 82 Corporate social responsibility (CSR), 90 Correctional facilities, Cost caging, 35–36 Cost function, 16–18; see also specific costs application, 81–85 economy of scale, 16, 81–85 Cost savings, 5–6 Covering skin diseases, 54 Cream skim behavior, 35 Customer service, 90 D Daily case and elective stay ratio, 28 Data envelopment analysis (DEA), 15–16 Diagnosis costs, 40 Diagnosis-related group (DRG) index, 58 Diagnosis-related groups (DRGs), 12 importance, 131 in Indonesia, 132–136 initial version, 132 patient classification system, 132 types, 133 Direct advantages private cost, 92 social cost, 92 Direct costs components of training, 88 of diseases, 51 health behavior, 54–55 hospital-acquired infections (HAIs), 60 indirect cost versus, 56 Disease occurrence, 49 Diseconomy of scale, 77 Disutility phenomena, 69 DRG in Indonesia (INA-DRG), 132, 134–136 Drugstores, 34–35 E Economic burden of disease categories, 51–52 incident-based approach, 50–51 prevalence-based approach, 49–50 proportion of direct and indirect costs, 56 sociological role, 52–53 studies on, 49–51 types of stigma, 53–55 Economic efficiency, 69–71 mathematical calculation, 69–70 Economic issues, 7–8 Economy of scale (EOS) cost versus, 78–80 definition, 80 dilemmas, 77–78 Index  ◾  143 equation, 84 plural product model, 78 Economy of scope cost and product mix, 80–81 equation, 81 Elasticity of demand, 114 Emergency institutions, Emergency medical services, Emergency room costs, 40–41 Employers, Enterococcus faecium, 63 European Quality Award, 100 Experimental design, 100 External advantages, social costs, 93 Extraordinary case, 122 F 5S method, 108 Failure modes and effects analysis (FMEA), 100 Firefighters, First ordo condition, 14 Flowcharts, 100 Fox paradox, 70 Free for service (FFS)-based services, 127, 132 Free of charge, 122 Full-time equivalents (FTEs), 15 G Poor family/OT, 123 Gatekeepers, 34–35 Genchi Genbutsu or go-to-Gemba, 107 Generation resource issues, Governments, 3; see also Health insurance heads of state, local, Group activities, 90 H Health behavior stigmas, 54–55 types, 52–53 Health insurance, 117–119 copayment mechanisms, 118–119 coverage limit, 119 types of issues, 118–119 Health Service Guarantee, 122 Herfindahl–Hirschman index (HHI), 37 Histogram, 100 HIV/AIDS, 53, 55 Home care, Hospital manager, 73 Hospital-acquired infections (HAIs) definition, 57 economic analysis, 59–61 examples, 58 forms of antibiotic exposure, 62–63 hospital environmental factors, 58–59 importance, 61–63 incremental cost-effectiveness ratio (ICER), 63–64 net operating margin (NOM), 60 occurrence in the United States, 59 work standardization, 58–59 Hospitals; see also Diagnosisrelated groups; Economic burden of disease; Hospitalacquired infections; specific resources competition and quality, 31–38 costs of medical procedures, 39–47 economics, 1–8 economy of scale, 77–81 human resources development, 87–92 144  ◾ Index Hospitals (Continued) inefficiency characteristics, 67 productivity, 21–28 quality improvement methods, 95–101 resource allocation, 11–18 resource management, 67–75 revenue components, 121–128 role in community service, working area, 15 Households, Housekeeping, 12 Huber–White method, 82 Human resources (HR) development development activities, 89–90 economic perspectives, 87–93 by education, 90–91 private advantages, 92 social advantages, 93 training, 88–91 United States comparison with Indonesia, 87 I IHA (Indonesian Hospital Association), 128 Improvement cycle methodology, see Plan, Do, Check, Act Incremental cost-effectiveness ratio (ICER), 63–64 Indirect advantages private cost, 92 social cost, 92 Indirect costs components of training, 88 direct costs versus, 56 of diseases, 51–52 health behavior, 53–55 hospital-acquired infections (HAIs), 60 prevalence-based approach, 49–50 sociological role of sufferers, 52 Indonesia; see also Indonesia Case Base Group diagnosis-related groups (DRGs), 132–136 Indonesia Case Base Group (INA-CBG) diagnostic categories, 134–135 health facilities, 136–137 tariff, 137–138 Indonesian Doctors Association (IDI), Indonesian National Board for Disaster Management, Indonesian Red Cross (PMI), Indriani, Diah, 135 Information management, 55 Input variables, 18 Insurance agents, 117 Integrated service posts, Internal training, 90 Interrelationship diagram, 100 Ishikawa diagram, 100 ISO 9000, 100 Isolation of individuals, 55 J CHI/LHI, 122 INA-DRG program, 135 SHI, 123 Just in time (JIT), 106–107 K Kaizen, 104, 109–110 Kanban (sign card), 107 LHI facility, 123 L Laboratory costs, 41 Law enforcement agencies, Index  ◾  145 Lean, 95–100 benefits on hospitals, 109 definition, 96 implementation, 103–106 objectives, 103 principles of quality, 106–110 systematic approach, 97 Leprosy, 55 LHI (Local Government Health Insurance), 122 Life expectancy, 45–46 Linezolid versus vancomycin, cost effects, 62–64 Long-run average cost (LRAC), 16–17 Long-term care, 50 M Malcolm Beldrige National Quality Award, 100 Marginal cost (MCi), 32–34, 82 marginal product (MP), 15 Market, 37 Matrix data analysis, 100 Matrix diagram, 100 MCU (Medical Check-Up), 122 Medical and surgical supplies costs, 43 Medical errors, 57 Medical procedures analysis of covariance, 43–47 cost elements, 40–43 Medical staff, 12–13, 15, 18; see also Nondoctor staff Mental health coaching institutions, 1–2 Model for Improvement, 99 N Natural selection pressure, 62 Neglect behavior, 54–55 The Neighborhood Association (TNA), Net operating margin (NOM), 60 NHI (National Health Insurance), 121 Nondoctor staff, 15 Nongovernmental organizations (NGOs), Nonteaching hospitals, 26 Nonwage workers (NWWs), 127 Nonlabor costs, 42 Nonprofit organizations, Nonworkers (NWs), 127 Nosocomial infections, 57 Nurses, allocation, 12 Nursing school, 12 O Operating room costs, 42 Opportunistic advantages private cost, 93 social cost, 93 Opportunity costs, education, 91, 92 Outside training, 89 Ownership, 26 P Pareto chart, 100 Patient age and health status, 44–45 characteristics, production function, 27–28 satisfaction, 12 sex and life expectancy, 45–47 PC (Poverty Certificate), 122 Pelni Hospital, 104 Penyakit Infeksi Prof Dr Sulianti Saroso Jakarta Hospital, 123 Pharmaceutical costs, 42 Physical deformity stigma, 53 Plan, Do, Check, Act (PDCA), 99, 110 146  ◾ Index Plural product model, 78 Poka-yoke, 100 Poor family/OT, 122 Prejudice, 54 Primary costs, education, 90–91 Private payments, 121 Process decision program chart, 100 production function affecting factors, 25–28 formula, 13–14, 21 hospital characteristics, 26–27 output types, 21–23 patient characteristics, 27–28 resource allocation, 12–16 service quality, 27 Production waste, 104 Profit margin, 32–34, 38 Prospective payment, 123, 128 Pull systems, 108 Q QS 9000, 100 Quality; see also Lean; Six Sigma; Total Quality Management circle, 100 competition versus, 31–33 elephant and three blind men, example, 95–96 improvement methods, 95–101 patient information, 33–34 Quality function deployment (QFD), 100 R Radiology costs, 42 Ratio of beds ideal size, 77 resource allocation and, 11 2009–2013, Rehabilitation, Rejection, 55 Religious institutions, Resistance, 55 Resource allocation cost function, 16–18 issues, production function, 12–16, 28 regulation, 11 scale dilemma, 78 scope dilemma, 78 Resource management economic efficiency, 69–71 issues, relation among efficiencies, 73–75 scale efficiency, 71–73 technical efficiency, 68–69 Resource use efficiency, 28 Resource utilization consumer rates, 115–117 equation, 114–117 insurance, 117–119 overview, 113–115 Respiratory support costs, 43 Retrospective payment, 123 Revenue components 14 ways, 121–122 other sources, 123–128 payment-based system, 123 Room costs, 43 RS Panti Waluyo Surakarta, 135 S Scale diseconomy, 71 Scale efficiency, 71–73 equation, 71–72 Scatter diagram, 100 Schools, Scope dilemma, 78 Scouts, Search and Rescue (SAR), Secondary costs, education, 91 Self-concept, 53 Index  ◾  147 Service costs, 32 Service quality, 27 Seven management tools, 100 Seven quality control tools, 100–101 Severity of illness, 47 Shame or neglect, 53 SHI (Social Health Insurance), 121 Short-run returns to the variable factor (SRVF), 78–80 Sick role, characteristics, 52 Six Sigma, 95–99, 103 business process, 97 definition, 96 Size, 26 Skimp behavior, 35 Skipping behavior, 54 Social costs, 91 Specialization, 37–38 Standardized work, 108–109 Staphylococcus aureus (S aureus), 62, 64 Statistical process control (SPC), 100 Student aid costs, 92 Study visits, 90 Subsidy, 122 Sumber Waras Hospital, 104 Swedish Quality Award, 100 Systematic diagram, 100 T Taguchi method, 100 Taichi Ohno, 104 Teaching hospitals, 26 Technical efficiency, 68–69 mathematical calculation, 69 Theory of moral hazard, 117 Therapy costs, 43 Timeliness or waste of time, 104 Total Quality Management (TQM), 95–100, 103 definition, 96 objective, 97–99 Toyota Production System (TPS), 104 Training features, 89 in certain divisions, 90 participants, 89 Treatment, inpatient activities, 78, 80–82 outpatient visits, 78–79, 81–83 U U.S Commission on Chronic Illness, 50 V Value stream mapping (VSM) method, 108 Vancomycin, 62–65 Variable return to scale (VRS), 71–73 Visual management, 108 W Wait time, 36 Waste, turnover of goods, 103–104 types, in hospitals, 105–106 Weighted case mix, 12 WHO–Disability Assessment Schedule (WHO-DAS), 137 Work standardization, 58–59 Workforce ratio, 26 Workplace training, 89 World War II, 96 Y Younger patients, 56 Youth organizations, Z Zyvox, 62–64 .. .Hospital Economics A Primer on Resource Allocation to Improve Productivity & Sustainability Hospital Economics A Primer on Resource Allocation to Improve Productivity & Sustainability A Heri... is available from the British Library Library of Congress Cataloging-in-Publication Data Names: Iswanto, A Heri, 1977- author Title: Hospital economics : a primer on resource allocation to improve. .. Indonesian National Board for Disaster Management, Badan Penanggulangan Bencana Daerah (BPBD) (Regional Disaster Management Agency), scouts, and so on, have proficiency in the health sector and