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Fiscal Management

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This is a case study of a hospital operating from its clinics. The major issue is that the hospital is recording losses from the recent past. The approach taken in this case study is more or less of auditing, more specifically, a procedural audit of the operations of the hospital. This is a thorough, analytical and critical review of the internal control systems of the organization as a whole. The utmost and prerequisite objective the study is to closely examine the internal control systems of the hospital and establish its strengths and weaknesses. In fiscal management, once the internal control systems are okay, the other things fall in place. This methodology is operations based and it aims at improving the procedures in the hospital as far as the delivery of services is concerned. Improvement of the internal control systems has an overall effect of improving service delivery.

1 .ANALYSIS OF THE DATA

The data given is specific and it addresses the ground scenario of the hospital. To create a clearer picture of the internal control systems, it is important to analyze the numerical data as follows:

Number of clinics: 3

Average clinic visits: 67%

Patient satisfaction: 82%

ONSITE CLINICS

Patient beds: 3

Bed occupancy: 70 - 80%

Skill mix change: 2 years ago

Resulting visits per day due to the skill mix: 117 - 97

Patient appointment waiting time: 63 days

Appointment times: Monday- Friday

RN Turn over: 20% annually

Percentage of available patients seen: 90%

Patients requiring MD assessment and intervention: 25 - 30%

OFFSITE CLINIC

Time of establishment: 5 years earlier

Clinic visit bookings: 90%

Average visits per day: 37

Patient satisfaction: 94%

Assessments bookings times: Monday - Friday

Patients who see physicians: 50%

Patients who see CRNP: 50%

2. APPARENT OPERATIONAL AND FINANCIAL ISSUES

 A close study of the operations of the hospital reveals many weaknesses that need correction very urgently, before the whole organization tumbles down. They pertain to the internal control systems of the organizations. Below is a list of issues that have come out from the previously mentioned study.

  • It is clear from the information available, that on average, the current clinic visits are only 67% of the available capacity based on exam rooms and physician/CRNP coverage. This is a great problem since the capacity of the clinics is greatly underutilized
  • According to the patient satisfaction surveys  that have been carried out as regards the service delivery at the clinics, it comes out clearly that close to 20% of the patients go home unsatisfied
  • The number of beds in the clinic (10) is rather too small. It is unthinkable that a clinic offering a wide spectrum of services should have such few beds. The short stay procedures are doing the clinics more harm than good
  • A very great challenge in the system of the clinics is the understaffing. This limits the clinics on the number of patients that they can serve in one day, thus exposing themselves to tough competition from other clinics that are better staffed
  • The MD schedules are very unfavorable to the clinics if sometimes they can even cause the clinics not to utilize their full capacities. The MD schedules ought to be flexible enough, to allow for unforeseen demand for the services by the patients
  • Idle time: There should not be times where the Aides are “sitting around doing nothing”. Since some of the patients still need attention, the idle time of the Aides is a great waste to the clinics.
  • The skill mix of the onsite clinics quite inappropriate: A new skill mix should not have adverse results to the service delivery of the hospitals. Apparently, the new skill mix has resulted to a drop of the visits per day from 117 to 97. This is a difference of around 17% which pretty much significant
  •  Having that the patients served in one day are only 97, it is then unreasonable that a patient should wait for an average of 63 days to secure an appointment. Take a scenario of a very sick patient; he will obviously not wait for all those days, but he will opt to secure faster appointments with better clinics
  • In the offsite clinic, it appears the sole reason that makes the 10% of the capacity go unutilized is understaffing
  • The 20% annual turnover among the RNs is rather too high, having that the clinics are already understaffed
  • The staff structure in the offsite clinic is unfavorable. There lacks proper segregation of duties since much of what should be done by the aides is done by the RNs
  • It seems that although the clinics are understaffed, someone could still decide to take an unplanned sudden leave. This is very detrimental to the operations of the clinics.

3. SHORT TERM RECOMMENDATIONS

 Having that the Hospital is already in a slippery financial position, only some short-term solutions may work for now. Long-term solutions will come to play when the clinics will be in a good financial position to implement them. Some of the workable short-term recommendations would include the following:

  • To counter the understaffing problem, it would be advisable to outsource staff. This will help in that no patient will go home unattended. It will also prevent some patients from resorting to looking for other competitor clinics
  • Proper surveys should be carried out to determine which specific areas need improvement so as to offer services that are tailored to satisfy the patient
  • The aides who “sit around doing nothing”, should be engaged in more productive activities like talking to the patients as they wait to be attended by the RNs
  • The MD schedules should be made more flexible to make sure that no patient goes home unattended simply because of the faulty and rigid schedules
  • No one should go on an unplanned leave. This can cause unnecessary staff overstretch

4. LONG TERM RECOMMENDATIONS

These recommendations are very important since they help in ensuring that the going concern of the clinics is not threatened. They may take a little longer to implement since they may involve restructuring the operational systems of the clinics. Again, they may involve some capital expenditure. In this case, some of them may include:

  • The setting up of more patient examination rooms for patients and increasing the number of CRNPs/Physicians: This will help raise the capacity utilization of the clinics from 67%
  • Set up more beds for the onsite clinics. Normally, many patients may need close attention and 10 beds cannot be enough. This reduces the risk of the clinics finding themselves in situations such that there are many patients who need beds but all the ten beds are occupied
  • The clinics need to employ more staff. This will prevent the problem of not serving some patients simply because the available staff are too busy
  • The clinics need an overall professional human resource manager. The manager will come up with an appropriate skill mix that will not have negative effects. We notice from the case study that the new skill mix has led to a drop in the patient visits per day by 17% which a big percentage being on the negative side
  • The clinic management should come up with a proper staff motivation system so as to boost the morale of the staff hence reducing the chances of turnover
  • The human resources manager should restructure the organization chart. Some of the idle aides should be laid off and in their stead, the most required staff should be added
  • Make constructive use of the unused space in the rental property. This could be used to position some more physicians or to place some more beds, to facilitate better service to patients

5. COST SAVINGS PROTOCOL

The most workable method of cost control is controlling the relevant incremental costs. This will mean that the relevant costs need control. The following table shows some proposed cost reduction. I suggest you consult your internal cost Accountant for some more realistic scenarios

6. IMPLEMENTATION PLAN

Since these recommendations are short term and long term, it would be wise to implement in phases. A suggested implementation plan would be as follows:

7. IMPORTANT MISSING INFORMATION

 

There is some unavailable information that would have improved greatly the quality of this study. In case of a second study, the following information would be important:

 

  • Age and qualifications of staff
  • The cost of drugs
  • A list of all the books of accounts maintained in the clinics
  • The general ledger
  • The Bank and other reconciliations
  • The Comparative Balance Sheets, Cash flow statements and Profit and loss accounts for the last five years

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