Acute shortage of nurses, gaps in out-patient services and wide-ranging delay in installation of acquired equipment at Jawaharlal Institute of Postgraduate Medical Education and Research (Jipmer) are among the key observations of the latest report of the Comptroller and Auditor General of India (CAG).
In its report recently tabled in Parliament, the CAG found the institution to be struggling on many fronts to deliver diagnostic and therapeutic services on a par with its tertiary care mandate, based on an audit conducted (July 2016) covering the period 2012-13 to 2015-16 to examine the adequacy of procurement practices and tertiary health care services provided by Jipmer.
Shortage of staff
According to the CAG, while adequate manpower in medical services is a critical component having a direct bearing on patient care, the audit observed that the number of patients attended per specialist was on an increasing trend (6% to 585%) every year in different super specialty departments during the period from 2013-14 to 2015-16.
It was also observed that the increase was more than 100% in five departments and more than 200% in two departments. While the patient attendance was increasing every year, the super specialist doctors’ strength was decreasing.
The doctor patient ratio which was 1:5,998 in 2013-14 worsened to 1:12,094 in 2015-16. The only patient satisfaction survey conducted (cardiology department in 2015-16) so far by the Institute revealed that the patients were unable to get enough time from the doctors in the OPDs due to huge patient load, the audit noted.
Further, Jipmer is yet to conduct the study on Maximum Handling Capacity of any of the OPD to ascertain the quality of care received by the patients .
In reply, the Ministry stated (November 2016) that there is a proposal to create 100 more faculty posts but repeated attempts to fill up even sanctioned post have proved futile because of corporate sector hospitals, the CAG said.
On the nurse shortage, the CAG noted that while as per the Staff Inspection Unit (SIU) norms of the Ministry of Health and Family Welfare, the requirement of nursing personnel for 2,131 bedded hospital works is 2,34,424, the present sanctioned strength and persons-in-position were 1,450 and 1,320 respectively.
Consequently, Jipmer had a shortage of 1,024 nurses as on June 2016. The institute had recommended creation of 81,526 additional nursing personnel posts.
OPD services
The audit observed non-compliance of various norms prescribed under Indian Public Health Standards for patients in OPD services such as non-availability of X-ray view box, non-availability of complaint box, non-availability of patient calling system, non-availability of potable drinking water and toilets and inadequate seating arrangements in different departments.
Around 7,500 patients approach Jipmer daily for general/common, specialty and super specialty treatment. Screening OPD approved in 2012 for patients to ensure the availability of services of specialties/super specialties is yet to be made operational and OPDs remain overcrowded.
The CAG audit also noted that three wards in paediatric ICU complex with 18 general beds, 6 isolation beds and 10 ICU beds and delivery room with two VIP suites in WCH block with construction cost of ₹1.61 crore were not opened for patient care services since its establishment in April 2013 resulting in creation of floor beds and accommodating of new born infants on that floor beds.
The Ministry stated that the work would be completed during November 2016.
However, Jipmer had informed that due to paucity of fund, the work would be completed only by September 2017.
“Thus, Jipmer, a tertiary care hospital, was lacking in amenities for patients in OPD... The Ministry stated that the issues are being taken care of during modernisation programme. The fact remained that Jipmer failed to provide the required facilities as per the norms,” the CAG said.
Equipment installation
Some cases noticed in audit included non provision of required space on the part of Jipmer. This had resulted in delayed installation of 15 equipment costing ₹9.49 crore (delay ranging between 15 and 34 months). Delay in completion of civil renovation/electrical modification work resulted in delayed installation of 5 computed radiography equipment costing ₹2.28 crore. One hundred and ninety-nine medical equipment valuing ₹38.91 crore received during May 2010 to January 2013 were installed in Women and Children Hospital and Academic Centre between July 2012 and October 2015 with a delay ranging between 4 and 39 months though the building for installation were ready in June 2012.
The Ministry’s reply (November 2016) that the delay was due to delay in getting power supply was not acceptable as there was further delay in installation of equipment by 1 to 30 months even after the power supply was obtained in March 2013, the CAG noted.
Operation theatre
The audit observed that inadequate Operation Theatre (OT) schedule allotted to each surgical department remained unchanged since 2014 due to shortage of nursing staff and postoperative recovery unit despite department’s frequent requests to increase OT services/time to clear waiting time of patients.
The Ministry’s response that all OTs were utilised six days in a week from 8 a.m. to 6 p.m. was not tenable since no order was issued allotting additional OT days and OT time.
Fully equipped Laparoscopic OT established (April 2013) in WCH Block and one Trauma OT (October 2014) in EMS Block were non-functional due to shortage of anaesthetist.
The waiting time for patients awaiting surgery ranged between two weeks to 36 months excluding the likely waiting time for taking Ultra Sound Scan (up to two months), C.T. Scan (up to 20 days), MRI Scan (up to 5 months).
The Cardiothoracic & Vascular Surgery department stated that the waiting period had direct bearing on the patient’s condition and would have an impact on the overall outcome of the treatment and around 200 patients in the waiting list died every year for want of timely treatment.
Departments stated that the waiting list was due to non-availability of OT beds and increased hours would be possible only if staff strength was doubled.
Details of sanctioned beds and functional beds for the period from 2012-13 to 2015-16 indicated that though the number of functional bed strength increased every year, it did not reach the sanctioned bed strength (2,059) for the year 2012-13. Further 2,85,020 bed days were un-utilised resulting in referring patients waiting for surgery, to other health centres, the CAG said.
The audit observed that many advanced laboratory investigations in Biochemistry, Clinical, Immunology, Microbiology, Pathology and Anatomy Departments were not available due to shortage of consumables and technicians. ‘“Nonavailability” certificates were being issued despite availability of well-equipped departments and laboratories, compelling patients to approach private labs.
No PET/CT scan
Unlike in other Institutes of National Importance, Jipmer did not have PET/CT scan despite sanction of ₹16.53 crore for its establishment in January 2012. ‘
Hence, Jipmer was referring patients to private lab centres for taking PET/CT scan where the patients had to pay different rates for similar scans — a fundamental deviation from Jipmer’s vision and mission to be a model for health care systems in India and to provide service of the highest order, the CAG noted.
The main kitchen run by the Department of Dietetics suffered from space constraints and other facilities. Further, the Institute had no testing facilities for food items before supply to patients.
No action had been taken (July 2016) either to construct a new modular kitchen or to renovate the existing one.
Thus, the kitchen continued to operate with outmoded, unhealthy and unhygienic working conditions, the CAG reported.
Meanwhile, a Jipmer official said that since the completion of the audit by the CAG, many of the deficiencies — such as improving staff strength, ramping up OPD services and modernisation of the kitchen —had been addressed.
