Enhancing patient education in aged-related macular degeneration

Master of Management in Health and Social Care

Module: Managing Finance in Health and Social care organization

Assignment Title:

  1. A) A financial proposal on the investment of a digital camera in the private ward for wound care management.
    B) Reflective commentary on the project

Part A
A financial proposal on the investment of having a digital camera in the private ward for wound care management.

Executive Summary

Health care industry is under tremendous changes; patient expectations, usage of advanced technology and medicine, cost of

the labor has increased, which cause the financial burden to the organization. The health service is Hong Kong is mainly

subsided by the government, which means the cost of the health service is collected from the public. Proper usage of this

budget must be deliberated.

A financial strategy, which is related to the organization strategies, should be considered before implements the

organizational strategies. It gives the support on the strategic planning whether the financial resources are able to achieve

the organization objective. The value for the money must be defined, so that the attributed funding has the best usage on the

service.

The following report shows the analysis on the investment on the technology equipment, which enhance the health service

quality in the private ward. This analysis includes the stakeholder’s expectation, how to choice the equipment in term of

cost and their benefit to the service. Recommendations are suggested on the proper usage of the DC with maximum benefits to

the dressing activity in the ward.

Content Page

  1. Introduction
    1.1 Project Title————————————————————-pg. 4
    1.2 Objective—————————————————————-pg. 4
    2. Background knowledge and strategic planning——————–pg. 4
    3. Stakeholder Analysis——————————————————pg. 8
    4. Organization Analysis—————————————————–pg. 9
    5. Choice of options.
    5.1 Option criteria———————————————————-pg. 11
    5.2 Benefit analysis & weighting scores——————————pg. 13
    5.3 The cost of investment———————————————–pg. 14
    6. Financial appraisal———————————————————pg. 16
    7. Recommendations
    7.1 Frequency of photo taking ——————————————pg. 17
    7.2 Auditing on the use of DC related to wound activities——-pg. 18
    8. Appendix———————————————————————pg. 20-22
    9. Reference——————————————————————–pg. 23-24
  2. Introduction
    1.1 Project title
    The effectiveness of wound management with the use of digital camera by improving documentation on the progress of the wound

and reduce the frequency of wound exposure for the medical assessment.

1.2 Objectives
~ To reduce the repeated wound exposure in private ward by performing dressing once (with photo taken) for multiple medical

examination assessment.
~ To provide an efficient access for multi-profession team on assessing the patient’s wound with the use of photo, especially

wound specialist and doctor, without unnecessary exposure.
~ To avoid the error of individual perception on the wound by providing a photo with an actual condition of the wound.
~ To improve documentation on the condition and the healing process the wound, with attaching the photo on the patient

karadex and with written description on it.

  1. Background information and strategic planning
    In the strategic plan of Hospital Authority (HA Strategic Planning 2009-2012), it stressed an emphasis on a safer and better

service quality, and maintains continuous improvement of care with the use of technology. In a private ward of the HA

hospital, patient are under the care of multiple specialties (surgical, orthopeadic, medical, oncology team,

oral-maxillo-facial team), which all have different kinds of wound, and multi-disciplinary approach is the focus of private

ward.

There are a total number of 60 private beds in the department. Those patient might has a wound due to surgical procedures, or

bedsore, or treatment procedures that required a dressing for various types of wound. There is a routine for patient in

performing dressing according to the wound nature in the ward: daily dressing for bedsore and infected wound, twice weekly

for those who has central intravenous device implanted, and 3 times of wound inspection for surgery patient during

hospitalization. Wound care is daily activity of the ward which is an important part for wound management.

The statistic data of private ward is provided from the department manager on the admission and the transfer cases in each

specialty. The data has shown that there is 333 patients occupied the private beds in August (appendix 1). Not all the

patient has a wound that needs dressing activity in the ward, since they might admit for some investigation or pharmalogical

treatment only. As there is no statistical data on the surgery procedure and patient with central line device or bedsore are

calculated, therefore, 60%, 5%, and 2% is assumed for each category respectively. The total dressing activity in the ward is

934 episodes (appendix 2). If repeated wound assessment is taken for each of these patients, then a double of the episodes in

dressing is resulted. Thus, increase the workload of nurses, and increase patient’s discomfort.

The steps of daily local wound care include wound assessment; wound cleansing, use of appropriate dressing material. Wound

assessment is a crucial part and the initial step in wound management. Wound assessment should be performed in a systematic

and holistic approach. A precise description of a wound characteristic such as size, staging, wound bed, type of discharge,

are important in planning for wound management.

Wound cleansing indicates use of cleansing lotion to remove debris and flush away microorganisms. Aseptic technique must be

strictly followed. The last step of daily wound care is proper use of dressing material. It can be as simple as gauze or

wound pad. However, advance dressing products may be indicated for complicated wound.

Medical officer and professor assess the wound condition every day. Dressing will be done twice if they come separately.

Frequent or unnecessary wound exposure can result in:
~ Multiple wound cleansing and dressing that will increase the cost for wound management.
~ Increase nursing care time and manpower for the same procedure
~ Increase the patient pain and discomfort due the frequent change of dressing material
~ Increase the chance of infection due to frequent exposure of wounds

All these are wastage of the health cost, both tangible and intangible. With photo-taking of the wound, conditions are shown

to different health care team for advice, instead of removing the dressing again. These photos will be kept in patient record

for the nursing and medical team in the planning of the patient care. As HA stressed the core value on the team work approach

on the patient centered care (HA Annual Planning 2009), well-designed treatment after reviewing these photo can be made for

the patient.

Taking wound photography has been part of the latest trend for comprehensive wound documentation (Hess 2005). It is

convenience for all health discipline to review the wound condition and progress at any time. It enhances the communication

among health care team. Also, it ensures the ability to monitor the healing process in an accurate, consistent, and objective

manner, which minimizes patient discomfort (Krainski 1998). Therefore, the purchase of the digital camera makes clinical

works more effective and efficacy.

HA has a pilot project in sharing patient electronic record with the private sector. Patient’s private doctor can assess this

information through the computer network with patient and HA consent. These private-public-interface project aims in

improving connection with private sector, which enhances patient choice, minimize waiting time for treatment, and better

communication with private sector. Although, laboratory results, radiology results, and clinical notes are able to access on

the network in the present stage, but with the future development, this DC photo or nursing karadex might be view in the

network.

  1. Stakeholder Analysis
    In the discussed issue, there are different stakeholders: Hospital Authority panel, district hospital managers, doctors,

nurses and patient. Different opinions of the use of DC for care delivery are noted. There is support or oppose attitude that

impact on the issue (Martin 2002). Through this analysis, the stakeholder’s interests and their impact on the issue are

reflected; relevant option can be made for the success of the project or policy. Also, this analysis shows the relationship

between the stakeholder’s behaviors, intentions, interests, and influence on the decision making process (Brugha &

Varvasovszky 2000). The stakeholder analysis on the use o f DC is illustrated in Appendix 3.

According the analysis, the nursing team and the patient have a higher impact and influence on the use of DC. The nursing

team has an influence with the use of DC since this tool provides an actual evidence of the wound condition. Episode of

changing dressing for repeated assessment is decreased. This influences on the patient who decreases the episode of repeated

removal of dressing for multiple teams’ assessment, and benefits on maintaining the patient’s skin integrity. Moreover, the

decreased episodes of changing dressing relieve the nursing staff’s workload. Furthermore, the delayed attendance on the

exposed wound decreases, which prevent the potential risk of wound infection. Also, the picture shown among the nursing team

ensures the continuity of care to patient, which includes the method of disinfecting and the dressing material used.

There is also an influence on collaborating management of the patient among the nursing, the doctor’s group and other

professional team. The pictures provide evidence of wound which avoid perception’s error on the wound, and a communication

tool for the multiple teams on the patient management.

The stakeholder’s analysis in a project shows the expectation and fear of having a project, which allows all the stakeholder

to express opinion , and allay those fear in the planning stage. With the planning, in term of satisfy hope and minimize

fear, a commitment of the project among the team can be made (Martin 2002). As HA has a strategic plan of improving patient

service with the use of advanced technology (HA Strategic Planning, 2009-2012), the use of DC in the ward should have benefit

on a consistent and collaborate care delivery, and shows a benefit on the patient.

  1. Organization analysis
    The private ward has to evaluate the department’s current position so as to maintain the competitive advantages. With the use

of SWOT analysis, the internal strength and weakness of the organization is illustrated, and the external opportunity and

treats are too. Through maximizing the internal strength and external opportunity factors, and minimizing the internal

weakness and external threats factor, the mission of the organization can be achieved (Heizer & Render 2006). The SWOT

analysis on the dicussed topic is shown in the below diagram.

Diagram 1: SWOT analysis on present status of private ward

Strength
~Multiple specialties for wound management, e.g. in-charge physician, microbiologist, stoma nurse.
~Each team will assess the wound for wound progress.
~Photos are better evidence of wound condition, instead of written description.
~Photos can be used as a teaching tool in the university or experience sharing session, so as to improve quality of service.
~Team approach in patient-centered care delivery in private ward Weakness
~Frequent changing of dressing after various team assessments.
~Skin integrity of patient becomes worse due to multiple time of removing the adhesive tape.
~Due to shortage of nursing staff, wound dressing cannot perform right after assessment.
~Different people have different perception on wound condition.
~Chances of mix up or loss of the photo
Opportunity
~Patient eager to have better treatment.
~HA policy
– Enhance quality and safer care to patient
– use of new technology
– enhance public-private parternership by sharing the digital photo.
~latest trend of wound documentation Threat
~Comparison with private sector on the service and facilities provided

The results of SWOT are:
~ The department is a multidisciplinary approach of care delivery.
~ The photo can be used as a teaching tool for all the staff as experience sharing.
~ The manpower shortage is the main weakness of the ward, cause a delay in performing dressing frequent changing the dressing

which might increase the chance of wound infection.
~ The frequent removal of adhesive tape decreases the skin integrity of the surrounding skin.
~ The HA policy to improve service quality with the use of advanced technology.
Therefore the use of DC can benefit to the ward by decreasing the workload in the ward, and improving service quality and

maintaining patient skin integrity, and enhancing a better communication among the professional team.

  1. Choice of option
    5.1 Option criteria
    The DC is a resource of the department, which must show benefits on the health service. This analysis states the

characteristic of having what type of DC. Those characteristic has different weighting to detect the appropriateness of the

camera. From the group discussion among the nursing team, the users of the DC, 5 characteristics are involved in the

selection of the DC: easiness to use, size of DC, function, picture resolution, and economic. The option analysis is shown

below:

Diagram 2: Option Analysis

Benefit Criteria Priority Weight Measure
Easy to use 2 30 Every staff can operate
Simple icon for taking photos
Easy to upload the files to computer
Actual size 5 5 Light in weight NOT heavy
Around in size (90mm X 60mm X 20mm), should be smaller than a pocket
Function 3 20 Thorough user’s manual
Guarantee card
Files can upload to computer without extra accessories
Resolution of picture 1 35 Clear pictures are shown
Larger screen on the camera
Around 10.0 mega pixel
Economic 4 10 Use rechargeable batteries to protect the environment
Maintenance from the manufacturer
total 100

According to the analysis, picture resolution is the most concerned aspect; whereas the actual size of the camera is the

least one. The percentage is shown for the criteria weighting in the calculation later.

5.2 Benefits Analysis and weighting scores
There are many types of DC in the commercial market, which have different functions, resolution, and prices. The Department

manager has fixed the investment of DC below $3000. The options that chosen are below the budget suggested. However, there is

still having many choices for this issue. The nursing team has decided 3 models from different brands for the choice of

investment. The 3 choices are illustrated in the below table.

These 3 choices are weighted according to the benefit analysis that stated previously. The calculation has illustrated in

diagram below.

Diagram 3: Calculation on the benefit weighting scores

Ref Benefit
criteria Benefit
weighting Option A
Option B Option C Option D
weight
Xscore Weight
Xscore Weight
Xscore Weight
Xscore
1 Easy to use 30 0 0 6 180 7 210 5 150
2 Actual size 5 0 0 8 40 5 25 6 30
3 Function 20 0 0 7 140 5 100 5 100
4 Resolution 35 0 0 7 245 5 165 6 210
5 Economic 10 0 0 6 60 9 90 5 50
TOTAL 100 0 665 590 540

Option A: No option is chosen
Option B: Cannon IXUS 110IS
Option C: Casio EXILIM EX-Z19
Option D: Nikon Coolpix S60

The calculated weighting score states the Canon IXUS model has the highest score. This means this model of DC is the best fit

for the department to use. However, the analysis of the investment should be included in other costs.

5.3 The cost of investment
As Bean & Hussey (1996) states that identification of service cost is a important issue, since it shows the best value on the

money spent on the service in terms of quantity and quality. The DC is new equipment in ward for providing a better quality

of care. The cost of the investment should also include the maintenance cost, stationary and material used for the investment

(Martin 1996).

The total cost of the investment has made up of a fixed and a variable cost. The fixed cost does not changed throughout the

process, whereas, a variable cost changes and affect the total cost (Blocker et al 2007).
The table below shows the sum of these costs:

Diagram 4: Summation of the total cost on the use of DC

OPTION B OPTION C OPTION D
Direct Cost( Capital cost)
DC hk$2280 hk$990 hk$2490
computer software hk$1000 hk$1000 hk$1000
Total 3280 1990 3490

Overhead cost( Running Cost)
maintenance fee(for 2 year) hk$0 hk$0 hk$0
(from 3rd year till 5th year) hk$300 hk$200 hk$300
600 400 600

Variable Cost (Running Cost) estimated cost per year
paper for printing 100( $1per page)
Electricity for recharging batteries hk$100
color toner for printing hk$300
Total 500 per year

~ Fixed cost includes the price of the camera and computer software which is a non-changeable cost in the investment.
~ Variable cost for the investment includes paper, color toner for the printer, which is varies according to the number of

the photos.
~ Overhead cost consists of the maintenance fee for the DC, although the manufacturer has 2 years free maintenance service to

the DC, but starting from the third year, the fee is varies for different model.
~ The capital cost is the one time purchase of the DC and the software, which is obtained by the ward.
Computer and printer are not considered as a cost since it already existed in the ward. Human training is not listed since

most of the people know how to use camera.

  1. Financial appraisal
    With the calculation on the cost and benefit weighting, the option for the organization which has the most effective is

listed. From the diagram below, the total cost of each option is calculated, which consists the fixed and variable cost of

having each model for 5 years.
Diagram 5: Cost-benefit analysis

Year 1 Year 2 Year 3 Year 4 Year 5 Mean Score/year
Option A 0 0 0 0 0 0
Option B 3780 500 1100 1100 1100 1516
Option C 2490 500 900 900 900 1138
Option D 3990 500 1100 1100 1100 1558

Option C (Casio EXILIM) has the lowest benefit/cost analysis which means it has the best value for the benefits. Therefore,

the DC from Casio brand should be chosen for the issue.

However, there is a need to control the variable cost in the issue, since these variable costs are related to the frequency

of using the DC for dressing documentation. The number time of photo-taking, paper for printing out, and toner, these all

contain the cost on the issue.

  1. Recommendation
    As Bean & Hussey (1996) states cost control is an essential process, which is the control on spending money within the

financial allocation on the project; and the control of the output and expenditure on the project, corrective measures should

be done in order to maintain the financial sustainability of the department. The following recommendations are the control on

the cost in using the DC for wound assessment.

7.1 The frequency of photo taking
Since the healing process of different kinds of wound varies according to its nature, therefore, the frequency of photo

taking needs to be standardized. As photography contains running cost, like the toner or the paper used, to monitor the use

of DC should be done to control the expenses of the department. As Bean & Hussey (1996) states cost control is an essential

process, which is the control on spending money within the financial allocation on the project; and the control of the output

and expenditure on the project, corrective measures should be done in order to maintain the financial sustainability of the

department. The recommended frequency on photo-taking is twice weekly for daily bedsore and infected wound dressing; once for

all surgical wound and with central line device. Since healing process needs time (Hess 2005), this time interval can provide

the picture on the progress of the wound condition.

7.2 Auditing on the use of DC related to the wound dressing activities
As Bean & Hussey (1996) states the cost control can be assisted by comparing the estimated cost and the actual unit cost in a

regular time based; therefore, a regular audit should be performed to monitor the effect on the use of DC in related to the

times of dressing in the ward.

This is an calculation on the dressing set used in the ward in a monthly bases with the use of DC. As David (1997) mentioned

that this comparison on the expected performance with the actual performance, provide information on whether the cost is

overspend or under spend; then a corrective measure can be made so as to maintain the maximum benefit on the system.

In order to calculate the variance on the use of DC on the dressing activity, the number of sterile set used is counted every

month in the ward, as the optimal number is maintained at 934 which is the number estimated for the dressing activity per

month in the ward (appendix 2). If the variance is too much then the investigation on the reason is needed, which is focused

on whether there is lack of support, or skill, or motivation on the use of DC. Then a corrective action in this issue may be

changing the ward practice or close monitoring on the staff on the use of DC.

(2604 words)

  1. Appendix 1
    The statistic data of private ward occupancy per speciality in August 2009
    Specialty Adm T/I Disch. T/O Death Occupied Bed Days
    GYN 65 3 63 4 0 224
    MED 69 8 69 5 1 274
    NEU 2 0 2 0 0 23
    O&T 17 0 20 0 0 113
    OMD 3 1 4 0 0 9
    OPH 2 1 2 2 0 5
    R&O 7 1 7 0 0 45
    SRG 131 23 135 16 3 590
    Total 296 37 302 27 4 1283
    Grand Total 333 333

Adm : Admission case MED: Medical unit
T/I : Transfer-in case NEU: Neuro-surgery
Disch : Discharge case OPH: Ophthalmology
T/O : Tranfer-out case R&O: Radiotherapy & Oncology
SRG : Surgery unit unit
GYN: Gynecology unit OMD: Oro-maxillo-facial unit
O&T: Orthopedic & Trauma unit

Appendix 2
Assumption of dressing activity in private wards (August)

% of patient per month No of Patient per month Estimated dressing activity per month
Surgical wound 60% 199.8 599.4 = 199.8 x 3 times
Central line device 5% 16.7 133.6 = 16.7 x 2 times per week x 4 weeks
Bedsore 2% 6.7 201 = 6.7 x 30 days
Total: 934 times of dressing activity per month

Appendix 3

9) References

Bean J & Hussey L (1996) Costing and Pricing ~Public Sector Services. HB Publications.

Bean J & Hussey L (2000) Strategic Financial Planning for Public Services. HB Publications.

BLocher E, Stout DE, Cokins G, Chen KH (2007) Cost Management~ A Strategic Emphasis (4th edition). McGraw-Hill.

Brugha R & Varvasovszky Z (2000) Stakeholder analysis: a review. Health Policy and Planning. 15 (3), pg.239-246.

David D (1997) The Art of Managing Finance (3rd edition). McGraw_Hill Publishing Company.

Heizer J & Render R (2006) Operations Management (8th edition). Pearson International Edition.

Hess CT (2005). Wound Care (5th edition.).Philadelphia: Lippincott William & Wilkins.

Hospital Authority (2009) Annual Planning 2009. www.ha.org.hk (accessed on 25th July, 2009).

Hospital Authority (2009) Strategic plan 2009-2013. www.ha.org.hk (accessed on 25th July, 2009).

Krainski M (1998) Photography in Nursing. American Journal of Nursing. 98(9), 16.

Martin V (2002) Managing project In Health and Social Care. Routledge.

Part B) Reflective commentary

Before having this module, the term—finance has little knowledge to me as the other nurses who work in a public hospital,

since the money is getting from the government. Most of the nurses in Hong Kong are mainly working in the public hospital.

The resources in the public hospital are supplied from the Hospital Authority, which is funded from the government. The

limited knowledge of nurses on the cost and its benefit results in wastage of resource, for example, excessive use of sterile

item or medical equipment, overstockage of resources, items stored beyond the expiry date. These items are the service cost

of the organization. This item might cost a lot of money in purchasing. There is a loss of money when discarding this.

There is a relationship between organization vision and financial planning. As Bean & Hussey (2000) states that the realistic

strategies on financial planning of an organization affects the performance of the service delivery in the future. The

objective in providing best quality and patient-centered care in a teamwork approach in the department, give rise in the idea

of rethinking of the nursing process—use of DC. Then, a financial planning gives the information –purchasing which type of

DC, and how to achieve in terms of budgeting. These two considerations are interrelated in the planning stage.

Through reading the course materials, I understand why the equipment needs to wait so long to get it. Like, the DC as an

example, the brainstorm on my mind is just the convenience of having it in the nurses’ work. However, the stakeholder

analysis shows the impact and influence on different parties on having the new resources. Considerations are thought of in

implementing this project on all the parties, so as to gain consensus on the use of DC. The SWOT analysis shows what can

improve and minimize the weakness on the organization or department so to enhance the market value of the organization. Also,

this analysis gives the idea on how to plan a change that is correlated to the organization’s vision. The benefits and costs

analysis helps to figure out the best value on purchasing a new equipment or product. Before having this module, the cheapest

is considered mostly for purchasing because to save money and limited department budget. However, through working on this

proposal, the coefficient on the benefits and costs is considered on planning stage; and evaluated the best benefits to the

service.

Learning concerns about changing a behavior (Robbins & Judge 2008). After studying this module, there is a positive

reinforcement on operant conditioning to my personal life, which I start to think of the benefit analysis while I go to

shopping. The overstockage of food and clothes decreases in my house; aborts the idea on changing the latest model of the

mobile phone. More space is there in my closet and refrigerator.

With more understanding on the financial planning, I start to think of the cost of every item or procedure while delivering

the care to patient, and minimize the wastage of resources. With this knowledge, I start to think of the decrease the wastage

of resources; for example, an assessment of wound material before I start the dressing or open an extra gauze pack, or return

the unused intravenous or oral drug back to the pharmacy, or maintain a minimum stockage of consumable items in the ward to

avoid expiry of item. These act minimize wastage of item, thus decrease the expenses of the ward. Under the limited budget

from the organization, every dollar that spends should have its value to the service.

Staff in the department should be aware of the proper use of the resources. The attitude on the financial consideration on

using the resource is started among the nursing team. As a supervisor in the ward, a clear picture on cost and benefit gives

the insight how to plan the daily work and how to guide the junior staff on their work and attitudes towards better service

delivery. Through modeling (Greenberg 2005), their attitude is being shaped. The junior staff are now decreased the wastage

of resources. An assessment of material before the dressing, return the unused intravenous or oral drug back to the pharmacy,

maintain a minimum stockage of consumable items in the ward to avoid expiry of item, are now happened in the team. These act

minimize wastage of item, thus decrease the expenses of the ward. The sharing of the financial knowledge, which relate to the

productivity or cost control, does gain benefits on team cooperation, mutual understanding and consensus (Herkimer 1986)

There is a recent ward policy discussion on the changing date of infusion set for the patient. Previously, each antibiotic

has its individual infusion set for transfusion. The latest information is that the antibiotic can be used with one infusion

set only. With the knowledge shared on the cost and benefit, together with the drug safety consideration, now a consensus is

happened among the team that one infusion set is used for antibiotic infusion, with flushing of tubing in between drugs.
(846 words)

Reference

Bean J & Hussey L (2000) Strategic Financial Planning for Public Services. HB Publications.

Greenberg J (2005) Managing Behaviors in Organizations (4th edition). Pearson Prentice Hall.

Herkimer AG (1986) Undertanding Hospital Financial Management (2nd edition). An Aspen Publication.

Robbins SP & Judge TA (2008) Essentials of Organizational Behaviors (9th edition).Pearson Prentice Hall.

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