BOOKS OF RtfiDIfGS - PAHO/WHO

Klarman
- 367 -
At the other pole, if all beds built tend to be used under conditions of prepayment, u
Roemer(91,92) first suggested, there is no automatic criterion for an optinum bed
supply. In the absence of evidence that low hospital use has an unfavorable effect oa
health status, the appropriate public policy is to dcamp a tight lid on bed supply (79). The
applUcation of more or lens technology ia the hospital is beside the point, although it does
mem preferable to operate any extra beds as cheaply as possible.
Patient census a a function of bed supply in the long run; combined with patient mix,
it seta the requirement for nursing personnel, which may be viewed largdy au a
requirement for personal services, with little or no substitution of equipment permitted.
However, substitution is possible among levels of nursing personnel. The extent of actual
substitution of low-paid for high-paid staff is perhaps overstated by the failure of hospital
budgets to incorporate expenditures for special duty nurses.
Housekeeping Services. 1 do not see any problems of sophisticated analysis in the area
of supporting housekeeping services. Here the appropriate criterion for decision making is
that of cost minimization. Bed sheets and towels are to be washed as cheaply as possible,
for a given specification of whiteness. Patients' rooms and corridors are to be kept clean
as cheaply as possible. Meals of a given quality-nutrition, calories, hot or cold-are to
cost as little as possible.
Once it is recognized that certain products or services need not be produced by the
hospital but can be purchased from the outside, the problem is that of developing valid
comparisons of unit cost. In addition, some administrators may wish to allow for certain
risk factors. In the absence of competition among suppliers, the sales price may be quoted
artificially low at the outset, only to be raised later. Also, in the absence of competition,
purchases from the outside may increase the risk of running out of inventory.
Apart from an allowance for lower risk associated with production within the hospital,
estimates of internal cost of production should include only differential cost. No portion
of overhead cost should be attributed, because this would continue in entirety after
internal production ceased. Moreover, top management will perform the same role as
coordinator, whether some goods and services are produced inside the hospital or
acquired by purchase.
In fact, the rise in hospital wages and gains in productivity attainable in large-scale
manufacturing have led hospitals to increase the purchase and use of disposable items and
ready packaged supplies. As Flagle (93) reports, gains in productivity from investment in
large-scale plant have been achieved outside the health care system, which shares in them
through purchase.
If the objective of cost minimization is for a given level of cleanliness or nutrition, how
this level is to be deterrnmined must be established. I doubt whether much would be
accomplished by searching for effects on the health of patients. Rather, the criteria must
be either patients' satisfaction or acceptability to management. Expressions of
satisfaction are somewhat suspect, since patients are likely to be impressed by any display
of interest in their opinions. A more practicable approach would be to compare
alternative standards of service, none of them falling below adequacy, with the additional
cost of attaining successively higher leveis.
In some respects the computer partakes of a supporting housekeeping service and in
other respects, when participating in diagnosis, it is akin to an ancillary medical
service (94). The computer is a housekeeping service when it processes the payroll and
issues bills to patients and insurance plans. As a substitute for older ways of bookkeeping