The present work has as its general objective the design and application of a management model for the determination of costs for patients - pathologies and processes of cesarean delivery at the Dr. Gustavo Aldereguía Lima University Hospital in Cienfuegos, which facilitates and provides relevant elements for planning, control and decision making.
The fundamental scientific novelty lies in obtaining a cost model that links traditional systems with new trends and that focuses its attention on patients as the main entity of health services and, gathering this determining factor, accumulates information on costs for processes and activities, eradicating the main limitations of the system that is currently used to record, distribute and present health cost information.
This research has a wide spectrum of application, since it is suitable and fallible for all Cuban health institutions, since it starts from the medical care protocols for each type of patient and pathology allowing the comparison of the resources actually sacrificed with predetermined efficiency patterns, because although the premise of health workers is to save lives at the cost that is necessary, if this is achieved with an efficient use of resources, it contributes to saving the large budget that the country allocates to Health Public.
Introduction
Until now, the definitions of public health used in the different publications and scientific forums have been diverse and varied, and, among them, probably the most up-to-date is that of Milton Terris, a prominent American public health worker, who states that: “it is science and art of preventing ailments and disabilities, prolonging life, and promoting physical and mental health and efficiency, through organized community efforts to sanitize the environment, control infectious and non-infectious diseases, as well as injuries, educate individual in the principles of personal hygiene, organize services for the diagnosis and treatment of diseases and for rehabilitation,as well as developing the social machinery that ensures each member of the community an adequate standard of living for the maintenance of health… ”Very much in keeping with this concept, the fundamental work of public health in Cuba is aimed at playing the role corresponding rector in the health sciences, and make the necessary changes to perfect the National Health System (SNS).
Cuban health boasts world-class results, backed by low infant and maternal mortality rates, the life expectancy of its population, massive prevention and vaccination campaigns among thousands of other reasons that make this nation a true medical power in the hands of the people.
However, this service is very expensive for the Cuban Revolutionary government, since maintaining medicine at current levels implies acquiring cutting-edge technology and medicines produced abroad that, due to the blockade and globalization, makes it difficult and expensive to enter the island. For this reason, it is vital to know the behavior of the costs incurred for each health service provided.
The cost accumulation system that exists today at the University Hospital
Dr. Gustavo Aldereguía Lima de Cienfuegos, does not respond to such interests, since it does not allow determining how much is invested in each patient for pathologies, which constitutes an obstacle to a better assessment of the expenses incurred, which facilitates adequate control and taking decisions.
The cost system that is applied today at the Dr. Gustavo Aldereguía Lima University Hospital in Cienfuegos is insufficient for the planning, control and decision-making needs that are so necessary in any sphere of production or services, since the costs by processes and reports them by cost centers, which does not respond to the characteristics of health costs, since in order to determine the costs of medical care for patients and pathologies it is essential to first assess the individual characteristics of each patient and of the pathology itself, and then it can be paid for by following the processes or activities through which it passes.
For this health institution as for all, it is necessary to know how much is invested by patients in each pathology. Specifically, this study is carried out for the medical care of cesarean delivery since this pathology constitutes the second with the highest incidence within the Group Related to Diagnosis in the province of Cienfuegos.
In this way, it will be possible to define an efficiency range or a cost standard following the protocol for medical care in cesarean deliveries that allows comparisons to be made, the variations to be determined and analyzed. That is why the scientific problem of this research can be defined as the non-existence of a model in the Dr. Gustavo Aldereguía Lima University Hospital in Cienfuegos that allows the determination of the costs of the pathology Cesarean Delivery and provides elements for a successful decision making.
To solve the scientific problem, the following hypothesis is formulated :
With the design of a cost accumulation model for the determination of costs by patients in the Cesarean Delivery pathology, the Dr. Gustavo Aldereguía Lima University Hospital is provided with relevant information that allows it to know how much is invested per patient in this pathology.
This hypothesis is validated through the design and implementation of the cost accumulation model for patients, pathologies and processes at the Dr. Gustavo Aldereguía Lima University Hospital for cesarean delivery where it is possible to know how much is invested per patient in this service., providing accurate and timely information that facilitates the decision-making process.
The General Objective of the research is to design and apply a model for determining costs for patients in the Cesarean Birth pathology at the Dr. Gustavo Aldereguía Lima University Hospital in Cienfuegos, which has an impact on successful decision-making.
To fulfill this objective, it is necessary to carry out the following Specific Objectives:
- Assess the state of science on cost accounting, its evolution, traditional cost systems and its link with new trends. Specify the characteristics of cost systems applied to health in Cuba and at the Dr. Gustavo University Hospital Aldereguía Lima de Cienfuegos and design the model for the accumulation of these by patient pathologies and processes. Validate the proposed model for the determination of costs by patients, pathologies and processes for the pathology delivery by Cesarean in the University Hospital Dr. Gustavo Aldereguía Lima de Hundred fires.
REFERENTIAL THEORETICAL FRAMEWORK
Accounting is as old as civilized humanity itself, it is the basis on which managerial decisions are based and therefore financial decisions. There is no economic activity outside the registration and involvement of accounting science techniques.
Accounting is an applied science of a social nature and of an economic nature that provides financial information of the economic entity to be later qualified, presented and interpreted with the purpose of being used to control resources and take appropriate measures to avoid a deficit situation that puts survival danger.
Generally and attending to the fundamental purpose of accounting to provide financial information regarding an economic entity related to the measurement, registration and reporting of information to various groups of users, the field of accounting can be divided into Financial and Cost or Management.
Financial Accounting, which is also called General Accounting, is aimed at external users, who have various information needs, according to their characteristics and objectives.
Administrative Accounting, also called Management or Cost Accounting, is aimed at the internal users of the organization, so its design must respond to the specific needs of management, since the information obtained is used for planning, control of management and decision-making, which is why each accounting system must be designed based on the characteristics of the company or institution in which it will be applied and not necessarily external regulations or standards.
Cost Accounting is a subsystem designed to establish the bases that allow identifying, calculating, measuring and evaluating the values that are incurred to carry out a certain operation proper to the management of the entity, for example, the manufacture of a product or the provision of a service. Thus, Cost Accounting must contemplate the collection, registration, analysis and interpretation of the expenditures necessary to obtain a product or carry out a specific activity.
Cost Accumulation Systems
A cost system is the set of procedures, techniques, records, and reports structured on the basis of double-entry theory and other technical principles, which are intended to determine unit costs of production and control of manufacturing operations. carried out.
To develop a production cost system, two important aspects must be considered:
- The characteristics of the company The environment in which costs are determined.
Cost accounting systems can be classified as follows:
According to the system to accumulate costs:
- Cost system for work orders. Cost system for manufacturing process. Combined system.
Depending on the nature of the costs:
- Real or historical cost system. Default cost system.
- Dear Standard
Cost systems are not independent of financial accounts, but rather represent a reworking of the accounting system within which it is integrated. Costs can be accumulated by accounts, jobs, processes, products and by subsystems or segments of the economic entity's organizational structure.
In general, the costs that are collected in the accounts destined for this purpose serve three fundamental purposes:
- Provide cost-related reports to measure profit and evaluate inventory (income statement and balance sheet). Offer information for administrative control of company operations and activities (control reports). Provide information to management to support the planning and decision making (analysis and special studies).
A cost system integrated in the general accounting allows to operate with the perfect security offered by the balancing of the accounts.
In every organization, it is necessary for the management level to be informed about all the operations that make up the entity's management, in order to coordinate and direct efficiently. As a consequence, it is necessary to have an information system that documents both the entity's relations with the surrounding world as well as those that occur within the company itself, so that the precise information is generated to be used in the decision-making process.
Hospital costs have peculiarities and specific characteristics for obtaining, accumulating and presenting them, motivated by the heterogeneity, intangibility and irregularity of the health services.
Hospital costs are the set of indicators that allow evaluating the efficiency of the hospital's work, since they show how much it costs to perform the activities that are inherent to it according to its level of medical care. The analysis reflects the level of productivity achieved, the degree of efficiency with which Tangible Fixed Assets are used, as well as the optimal use of medications and other material resources.
The complexity of hospital costs is determined by the multiple and diverse actions that occur in hospital activity. This determines the need for any cost system that is implemented in hospitals to be fully integrated with the accounting record.
This implies that the application of hospital costs has technical rigor; therefore, there must necessarily be agreement between the sum of the total costs of the final activities of the institution, with respect to the total expenses accounted for as execution of the budget in and up to the reporting period.
Given the increase in the amounts of investments in new units and equipment, as well as in the amounts allocated to health actions, the need to know the costs of different types of health institutions is becoming increasingly important.
Costs are a working instrument of administrative management, both for the hospital as an institution and for the different levels of the National Health System as an organization. The need for your knowledge is based, among others, on the following aspects:
- Know precisely the relationship between health actions and their cost. Improve the use of human, material and financial resources. Make timely decisions to correct deviations in budget execution. Establish policies to achieve greater efficiency in hospital management.
Undoubtedly, obtaining the real costs of hospital activity is of singular importance even when it is framed in a non-productive sector; because their knowledge is what will allow the optimization of the social expenses incurred, in order to meet the health needs of the population.
Information on health costs should be classified according to various purposes, with the aim of making it more truthful, accurate, relevant and timely.
Cost Accounting classifies them in different ways, according to the purpose pursued by their study. However, only those costs will be considered below, which really have or may have in a future relationship with hospital activity. (Figure No 1)
Figure No 1 Classification of Costs in Hospital Activity.
Source: self made.
The Cost System for Hospitals has the following objectives:
- Enable the hospital institution, by knowing the real costs of its actions, to take the measures required to increase the efficiency of its management. Allow the different levels of management of the National Health System, by knowing the costs of the different actions that are carried out by hospitals, economically control their activity, as well as establish norms and develop indexes that allow improving the planning process of these institutions. Bring leaders and workers the necessary economic education, informing them how much the actions cost that are executed in your work area and give participation for the analysis of expenses.
In general, all cost systems have the purpose of adapting the general principles established by the System of Direction and Planning of the Economy, to the particular characteristics of each economic activity.
It can be said of economic work in general, as well as cost in particular, both in Public Health and in any other branch of the national economy, which must be based on the Law of Optimal Planning. This law in its formulation proposes in essence, to obtain in the interest of society the best results with the minimum of expenses; that is, those socially necessary expenses. This means that hospital institutions in their management must be able to maintain a system of economy of resources of all kinds assigned to them.
For the Ministry of Public Health, the Cost System has been established in
Hospitals with the following classification. (Figure No 2)
- General and Administrative Services Auxiliary
According to the ordinance for Medical - Assistance Centers, the costs are divided into: Final Teaching Centers and
Research Other final centers
Figure No 2 Classification of Cost Centers.
Source: self made.
The General and Administrative Services Centers are made up of all those dependencies of the hospital that fulfill functions of direction and administration, material assurance and non-medical or paramedical services; collaborating in this way with the rest of the cost centers. The Auxiliary Centers are made up of those that cooperate with the so-called medical-assistance centers in the provision of patient care (whether they are ambulatory or hospitalized), as well as those of Teaching and Research in the execution of their actions.
Medical - Assistance Centers are those in which their activity is directed towards the direct care of patients, including both hospitalization services and external services provided by the institution.
The Teaching and Research Centers are those that can be fundamentally identified based on these activities; unlike other centers where research and teaching may be present, but not as the main objective.
The other final centers are those that do not correspond to activities carried out by the previously defined centers
The efficiency of health services is focused from the economic, medical and social points of view. Economic efficiency is the positive contribution that these health services provide to the national economy using resources rationally, with the lowest expenses maintaining the quality of care, medical efficiency is given by the quality of the health service provided and the social one lies on the impact it has on society
The cost or management information system constitutes one of the fundamental criteria in the evaluation of economic efficiency, has its main field of application in health service units and constitutes one of the most important instruments used in the programming and management of health services.
To assess the economic efficiency in the use of the resources used, it is necessary to know their cost. This is expressed through the value in pesos, as a result of the execution of the current expenses budget. The cost system is precisely one of the most effective instruments to identify the degree of use of the resources used by health personnel, of course, its application is governed by the principle that the patient receives everything necessary to restore their health.
Pathology Costs
According to Mc Greevey (1967) , "Physicians caring for patients are expected to offer all the help that medical science can provide regardless of cost." In the Cuban social system as a principle, such a statement is made practical, without ceasing to analyze all those factors that intervene in costs.
In pathology costs, Montico and Velarde (2003) state that “it is not only a matter of calculating costs by departments, rooms, cost centers or activities, nor of what is spent to attend a specific pathology, but they must be included and also take into account the specific characteristics of the patient and the processes, activities and tasks that the patient goes through and accumulate all that information so that the cost accounting truly reflects what happened in each health care or service. ”
A health company is a complex organization from every point of view. Although there are different types of institutions, products / services are "manufactured" in the same way, since they all share the same characteristics, namely:
- They are intangible, perhaps the elements used to provide them are tangible (medicines, materials, plates, etc.) but the product itself is not. They are not homogeneous, that is, the same product can vary in costs depending on the pathology of each patient; and in turn the same pathology can cause different expenses. They are manual, that is, they cannot be manufactured in a production chain, but they are made by human hands. It is not easy to find a unit of measurement, that is, to quantify their production.
Of course, each product / service is created through a process, which must be paid for through a certain methodology to obtain the cost per patient-pathology and process.
More than a cost system, the application of patient-pathology and process costing undoubtedly leads to the reorganization of a health institution, notably improving both its healthcare and administrative management.
After reviewing and consulting a wide and updated national and international bibliography, we proceed to characterize the object of study and design the model for determining costs by patients - pathologies and processes for subsequent validation in caesarean delivery attended in the Dr. Gustavo Aldereguía Lima University Hospital in Cienfuegos.
Characterization of the study object and model design for determining the cost of cesarean delivery at the Dr. Gustavo Aldereguía Lima University Hospital in Cienfuegos
To be in charge of satisfying the demands of specialized medical attention of the people and to contribute to the training and continuous improvement of Human Resources necessary for them; recognizing that the satisfaction of the population is the most important value to cultivate and Total Quality is the best strategy to achieve it, it constitutes the Mission of this Cienfueguera institution, while its Vision consists of:
- Achieve that the people of Cienfuegos feel satisfied, safe and confident in their Hospital. Be able to stay ahead of technology. Be sure that the other institutions and health authorities in the country identify the Cienfuegos Hospital as a center of excellence for their level of care and type of Hospital. Achieve that everyone recognizes the same as a deeply human and committed collective, which has the energy and intelligence necessary to continually improve what it does.
Among the services currently provided by the General Hospital of Cienfuegos is the care of pregnant women where they are properly followed up from the beginning of the pregnancy until its end. For these purposes the Cienfuegos hospital has, among others, the Puerperio Inmediato 8B room.
Characterization of the Puerperio Mediato 8B Room
The Puerperio Mediato 8B room is located on the 4th floor of the Dr. Gustavo Aldereguía Lima University Hospital in Cienfuegos. This has a staff of 25 workers with the following distribution, 2 specialists from the 1st grade, 17 nurses, 2 ward and department assistants, 1 service assistant and 3 patient care assistants and it has a total of 38 beds. This room provides care to Calves, Cesariates and septic cases, it shows a mortality rate of zero, since babies with complications during delivery go directly to Neonatal 7A or Immediate Puerperium 7B to be attended.
The Mission of the Obstetrics Service, Puerperio Mediato 8B has been defined as follows: Offer specialized, hospitalized and / or ambulatory medical care to pregnant women and puerperal women, which due to their characteristics or resolution of the Primary Health Care system should not be attended to in the same, as possible emergencies that may determine the need for a more complex intervention.
Offer diagnosis, therapy and progressive monitoring of maternal-fetal well-being in entities associated with pregnancy, acting on the time and manner of ending the pregnancy and monitoring the latency phase of childbirth.
The final aspiration consists of the family and social benefit by obtaining a graduate newborn with the best quality of life and the preservation of maternal health, ensuring perceived satisfaction. That takes into account economic savings and an adequate policy of use, conservation and protection of resources.
The Vision of its workers and managers responds to the interest that their patients and families feel satisfied, safe and confident with the assistance group, to recognize in them humanism, ability and intelligence to continuously improve the care provided, as well as be seen as reference service and excellence in Obstetric Care in Cuba.
The Puerperio Mediato 8B room cares for all calves, including caesarean sections, this term, that is, cesarean section, has a certain complexity, so it is necessary to know its evolution in the history of medicine.
Cesarean section within the Health System
Operation Cesarean section has been a subject of much debate since time immemorial, since it is the surgical technique with which man attempted to solve one of the most dramatic problems presented by dystocia. in childbirth and its complications and it took almost two millennia to fully achieve its domain. Much has been written about caesarean section, being recognized as the oldest and most modern of obstetric interventions. Various theories try to explain the origin of the name that has been given to this type of intervention.
The increase in cesarean section has stimulated the search for alternatives to try to reduce its frequency, including post-cesarean vaginal delivery. In Cuba, for the first time, work has been done on this controversial topic, and since 1995 a Specialized Cesarean Section has been operating at the "Clodomira Acosta Ferrales" Gyneco-Obstetric Teaching Hospital, in which cases are selected with the antecedent of having undergone a cesarean section., who meets the conditions required to attempt transpelvian delivery.
Cesarean section is of high risk when compared to transpelvian physiological delivery. Hence, obstetricians perform caesarean section only when this operation is based on scientific criteria defined for it, since it is known that this surgical procedure is closely linked, for various reasons, to maternal mortality. Expectant mothers should know that cesarean section, more than benefits, brings risks that endanger their own life and that of the child. Cesarean section has different types of classifications, which are shown below.
- Primitive caesarean section is the one performed for the first time. Iterated (repeated) caesarean section is performed in a pregnant woman with a history of caesarean section and repeated with more than one caesarean section. Elective and scheduled caesarean section is the one that is executed before the start of labor.
To avoid abuse of this operation, three premises must be kept in mind that will guide the decision regarding this intervention.
- Cesarean section is not an absolutely safe procedure for the mother (the risk of death is much higher than with vaginal delivery). The indication must be scientifically established. The opinion of more than one specialist should always be taken into account and, if possible, the of the head of the Obstetrics Service.
Reasons for a Cesarean Birth
Cesarean delivery can be done for reasons such as: prolonged labor (more than 24 hours), the fetus coming in the pelvic position, macro fetus, multiple pregnancy, fetal distress, maternal diseases that can put at risk the health of the fetus or that of the mother, placenta previa, previous caesarean sections, among others. Cesarean section can be planned in advance when certain conditions are known. In some cases, when problems arise, the decision is made during labor.
Treatment of Cost Information at the Dr. Gustavo Aldereguía Lima University Hospital in Cienfuegos.
The economic events that occur in the execution of the activities of the hospital institution are recorded chronologically based on the accounting accounting techniques, based on the provisions of the National Accounting System. These events are reflected in the primary documents, with which an entire accounting process is started to prepare the daily receipts that are supported by them; which are written down in different subdiaries or registers, such as: payments, operations and others, for their classification in accounts and subaccounts. Subsequently, their results are passed on to the General Ledger and to the corresponding submajor ledgers, including Expenses.
It is in this sub-major, where the detailed execution of the expenses incurred by the hospital is shown, coded by headings and items; as established by the expense classifier defined by the National Accounting System. However, this sub-major expense although it reflects in detail the execution of the expenses of the hospital activities from a general aspect; In itself, it is not directly usable for determining the particular costs of each of the organizational areas of the hospital. For this, it is necessary to carry out a reformulation of said expenses, by means of the breakdown or disaggregation of their amounts in correspondence with the area or the organizational areas that have shown them.
To carry out the primary distribution of costs, three worksheets are systematized, allowing the breakdown and summary of the amounts of expenses corresponding to each cost center, which are the following:
Worksheet No. 1 (HT - 1): Summary of Material Consumption.
The purpose of this sheet is to record all the material outputs, according to the dispatches made to the cost centers.
Worksheet No. 2 (HT - 2): Summary of Wages and Contribution to Social Security.
The objective of this sheet is to record all the wage expenses accrued by the workers of each cost center; as well as reallocate the salaries that proceed to other centers, motivated by the participation of said workers in their activities. It includes the corresponding calculations of the accumulated paid rest and the established percentage that the institution must contribute to the State Budget as a contribution to Social Security.
Worksheet No. 3 (HT - 3): Summary of Services and Stipends.
The objective of this sheet is to write down all the expenses incurred by the institution, for diets, services received, social benefits and others that are not material; according to the different cost centers that have originated them, it will also allow to reformulate for costs all the expenses accounted for, making the disaggregation to each of the cost centers; as well as specifying for each one of them, the expense concepts that it includes.
After the primary distribution has been carried out, the secondary distribution of costs for indirect costs must be carried out. Secondary distribution is the particular process in determining costs, in which the amounts of accumulated expenses are sequentially distributed in the cost centers that represent the activities of general, administrative and auxiliary services, which ends when all The expenses of the hospital institution have been conveniently distributed in the centers that correspond to the fundamental activities of the hospital.
To systematize this indirect cost distribution process, Worksheet No. 4 (HT -4) will be used: Indirect cost distribution sheet.
This distribution sheet is closely related to the Cost Register; The latter also includes the indirect costs that each cost center receives and the amounts that correspond to its distribution base. In other words, after the indirect cost distribution process is finished, all the resulting information is duly incorporated into said registry.
This constitutes the way in which costs are recorded, accumulated and reported in the Cuban Health Institutions and in the Dr. Gustavo Aldereguía Lima University Hospital in Cienfuegos, as part of this system, respecting the provisions of the Ministry of Public Health at the national, which is very feasible if you want to know how much is invested or spent in each cost center for general, administrative, auxiliary or final services.
However, being able to determine the unit cost of providing a health service is impossible under these bases, since there is no single level of activity that allows the total cost to be distributed among the patients served, which prevents the development of planning, control and decision-making processes with the required depth.
That is why we proceed to the design of a model to determine the costs for patients - pathologies and processes of cesarean delivery at the Dr. Gustavo Aldereguía Lima University Hospital in Cienfuegos that allows us to quantify the reality of costs per patient and provide to the institutional, territorial and national administrations the necessary elements to carry out a successful management process based on the functions of planning, controlling, making decisions and evaluating.
Design of a model for determining costs by patients, pathology and processes in the Puerperio Mediato 8B room of the General Hospital of Cienfuegos.
For the calculation of the cost of a pathology, taking into account the characteristics of the cost systems that are governed by the Ministry of Public Health in Cuba, and based on its deficiencies to determine the cost of a specific health service, is that it is necessary to design a model to calculate the cost of each health service, assessing the characteristics of each service and the variations that each treatment, patient and pathology requires.
Below is the model for determining costs for patients - pathologies and processes at the Dr. Gustavo Aldereguía Lima Provincial University Hospital in Cienfuegos, specifically for cesarean delivery.
STAGE TARGET PHASES
- Elaboration of the protocol Obtain the protocol of the Compilation of the management of pathology. pathology management necessary information on cesarean delivery. pathology.
- Determine the unit costs of the auxiliary examinations required by the pathology. Define the treatments required by patient categories (Therapeutic management)
Know the different
- Definition of the Determination of
processes why you should processes why general processes
transit a patient in his transit the patient
pathological management
- Classification of
Assign each patient the
- Distribution of costs costs attending to
costs attending to patient-pathologies and volume.
activities in which processes for childbirth by 2. Determination of
incurred for its cesarean section. costs per patient -
pathological pathologies and processes Table No. 1 Model for determining costs by patients - pathologies and processes for cesarean delivery
Source: self made.
Below are the steps to follow to determine the cost of the Cesarean Birth pathology, which correspond to the development of each of the previous stages
The pathology management protocol is a detailed characterization of the pathology itself, and includes everything that is required, under normal conditions, for its treatment. These criteria for the diagnosis and treatment of pathology must be characterized according to the reason for the caesarean section. This protocol will serve as a tool to measure the behavior of economic indicators in medical treatment without abandoning the premise of achieving efficient health services.
The pathology management protocol will have the following aspects: Pathology Name: The name of the pathology will include the scientific and popular name of the pathology.
- Definition: The definition will reflect the characteristics of the pathology as well as other important questions for understanding it. Diagnostic Criterion: The diagnostic criteria will expose the characteristics and symptoms that the patient presents, also establishing diagnostic criteria according to the reason for the caesarean section.. For these criteria, all the symptoms that may appear will be recorded.
To develop this step, all the types of examinations that can be performed on the patient with this pathology are collected throughout her treatment, and criteria are also drawn up according to the reason for the caesarean section.
Table No. 2 Cost of Auxiliary Examinations carried out on Patients undergoing Cesarean Delivery Source: Own Preparation
The average standard costs of direct materials are taken to calculate the unit cost of each auxiliary exam, while those corresponding to direct labor and other indirect costs are distributed according to the most representative activity levels of each exam.
The level of activity in this case will be the number of auxiliary exams performed in a month under normal conditions, that is, the average number of auxiliary exams that can be performed in that period. To calculate the total cost of direct labor and indirect costs of the service, the following mathematical operation will be performed.
Total MOD Cost = Monthly Direct Salary Expense / Activity Level
Total Indirect Service Cost = Monthly Indirect Costs / Activity Level
Therapeutic management will be specified for each type of cesarean that can be performed.
For the therapeutic management of cesarean delivery pathology, it is essential to list all the general measures that must be adopted to treat the pathology at the required stages. Each of the medications, care, examinations and other elements that are applied according to the reason for the caesarean section, according to its characteristics, must also be listed, as well as all the possible treatment alternatives that can be applied to the patient from her Entrance to the health institution until its exit fully restored. The therapeutic management of the pathology constitutes the guide or the treatment plan that should be followed. Valuing all possible alternatives for all possible cases.
This element will explain all the characteristics that the patient must have to be discharged, the terms of the same and the complications that could alter these terms.
This step is aimed at presenting a narration of all the processes that the patient goes through in a general and particular way, constituting the guide for the preparation of the Process Flow Diagram
This diagram will then be the basis for the allocation of costs to each of the processes or activities through which the patient transits, thus achieving that upon leaving the health institution it is possible to know how much has been invested in their treatment., recovery and restoration; For this, it is essential that the clinical history truly reflects all the steps that the patient is developing within the institution, that is, that it is a faithful reflection of her medical treatment.
In the health cost system currently in place in Cuba, it is essential to have a clear determination of whether each cost item maintains a fixed, variable or mixed behavior, since there are elements that will always remain fixed even if 100 or 500 services are provided. of health, elements such as salary, which is not in correspondence with the level of activity worked in the month. In this sense, and for calculating the costs of cesarean delivery pathology, these elements must be well defined, because they cannot be directly acted upon to reduce costs, but rather to achieve efficiency in the Cuban health service.
For the classification of costs in relation to the level of activity, that is, in fixed, variable or mixed, experts from the accounting, economic and financial areas of the health institution will be consulted and, using the Delphi method, these will be endorsed as experts and then they will decide the classification of costs in this regard. Which are listed in Table No. 3.
Table No 3 Classification of hospital costs in relation to the volume of production or services Source: Own Preparation
In the existing cost systems in Cuban health institutions, which are governed by the cost manual designed by the Ministry of Public Health, there are elements of cost that do not depend on the level of activity with which they work, they are therefore, independent of this, so it becomes essential to define allocation inducers for the distribution of these costs among the different services provided in a given period. For this, Table 4 will be used and inductors will be assigned to all the fixed costs defined in the previous Step, for this the experts defined above will be required.
To carry it out, it is essential to reconcile with the patient's medical history the entire process from her entry to her departure from the health institution and it is of utmost importance that absolutely everything that has been used to restore her is recorded:
- Medications that have been applied, with their respective doses and cost. Auxiliary exams that have been performed with all the cost of direct materials, direct labor and other indirect costs (calculated the standards in Phase I, Stage 2, Step 1). Personnel who have attended you directly (doctors, specialists, nurses, bodyguard personnel, etc.) assigning basic salaries and induction allowances to each patient, and the costs corresponding to the contribution of the tax to Social Security and the Contribution by the Workforce. Personnel who have assisted you indirectly (support staff, office workers, room secretaries, admission staff, etc.) consigning basic salaries and inducers of allocation to each patient and the costs corresponding to the contribution of the Social Security tax and the contribution by the Workforce. Food that has been provided to the patient. If you have taken a specific and different diet to the rest of the patients in your cost center (room), record the feeding costs as real as possible, otherwise assign this cost according to the inductors and distribution rates. they have supported and have been necessary in their treatment at the institution. Assigning each patient according to the rates or inducers defined in Step No. 2, Phase III, stage 1 and in correspondence with the days on which they were used, as well as all other costs that have been present in the process. Food that has been provided to the patient. If you have taken a specific and different diet to the rest of the patients in your cost center (room), record the feeding costs as real as possible, otherwise assign this cost according to the inductors and distribution rates. they have supported and have been necessary in their treatment at the institution. Assigning each patient according to the rates or inducers defined in Step No. 2, Phase III, stage 1 and in correspondence with the days on which they were used, as well as all other costs that have been present in the process. Food that has been provided to the patient. If you have taken a specific and different diet to the rest of the patients in your cost center (room), record the feeding costs as real as possible, otherwise assign this cost according to the inductors and distribution rates. they have supported and have been necessary in their treatment at the institution. Assigning each patient according to the rates or inducers defined in Step No. 2, Phase III, stage 1 and in correspondence with the days on which they were used, as well as all other costs that have been present in the process.otherwise assign this cost according to the inductors and distribution rates. Medical equipment and effects that have supported and have been necessary in their treatment in the institution. Assigning each patient according to the rates or inducers defined in Step No. 2, Phase III, stage 1 and corresponding to the days they were used by it, as well as all other costs that have been present in the process.otherwise assign this cost according to the inductors and distribution rates. Medical equipment and effects that have supported and have been necessary in their treatment in the institution. Assigning each patient according to the rates or inducers defined in Step No. 2, Phase III, stage 1 and corresponding to the days they were used by it, as well as all other costs that have been present in the process.
All this information will be reflected in Table No. 5, where it will be made as a kind of a cost sheet that will summarize at cost price all the material, human and all kinds of resources taken to monetary resources that have been incurred for the medical care of each patient.
Table No 5 Summary of costs incurred in a health care service Source: Own Elaboration
In this way, the cost per patient-pathologies and processes for cesarean delivery is obtained at the Dr. Gustavo Aldereguía Lima University Hospital in Cienfuegos
Validation of the proposed model for determining costs by patients - pathologies and processes in cesarean delivery pathology and their care at the Dr. Gustavo Aldereguía Lima University Hospital in Cienfuegos.
For the validation of this cost management model at the Dr. Gustavo Aldereguía Lima University Hospital in Cienfuegos, the described procedure has been followed and the information corresponding to the year 2006 in the cesarean delivery pathology has been taken, which is attended directly and only in room 8B "Puerperio Mediato" of the referred institution
To carry out this phase, medical materials were consulted, specifically cesarean delivery, specialists in the field were consulted and a review was carried out by them of the information collected. Pathology name: Cesarean Birth
Definition:
Cesarean section is the surgical intervention that allows the exit or birth of a fetus through an abdominal incision. A cesarean section is performed when vaginal delivery is not possible or carries any risk to the mother or fetus. Surgery is normally performed with the mother awake but pain-free using anesthesia from the chest to the legs (epidural anesthesia or spinal anesthesia). An incision is made above the pubis in the lower abdomen. When the uterus (womb) is exposed, it is opened through another incision and the amniotic fluid is released, then the baby is removed. The baby's mouth and nose are cleaned of fluids and the umbilical cord is tied (tied) and cut.
Diagnostic criteria:
In order to give a diagnostic criterion, the indications for cesarean section must be clearly understood. A classification that highlights the factors or causes that have a greater or lesser proportion in its indications is considered useful. The objective is to know towards what factors should actions be directed to improve obstetric work and reduce, as far as possible, the indicator of primitive caesarean sections.
- Maternal causes: (uterine scars, previous tumors, maternal diseases that imply risk according to the particular characteristics, some uterine malformations) Fetal causes: (twins, fetal risk, maternal death with live fetus (post-mortem cesarean)) Adnexal Causes: (placenta, cord, membranes)
In this phase, medical specialists were consulted, surveys were carried out on these and patients, and an extensive updated bibliography was reviewed to define the types of exams that can be performed on patients who will carry out this health service.
After defining all the exams, standard calculations were carried out to determine their costs, relating the required materials to the real cost, while direct labor and other indirect costs were distributed according to the activity levels defined in each case.
Determining an average cost for each auxiliary exam.
UNIT COST EXAMS
AUXILIARY
Bleeding $ 26.95
Coagulation $ 35.60
Serology $ 20.03
Blood count $ 39.95
Table No 6: List of auxiliary examinations for cesarean delivery
Source: self made
For this it was necessary to subdivide the cesarean delivery into the different categories that it can present:
- When Labor Does Not Progress: Approximately a third of cesarean deliveries are performed because labor does not progress normally. In these cases, the contractions cannot open the cervix enough for the baby to move through Multiple Pregnancy: Women who are having two or more babies may need a cesarean section. Many women who have twins can give birth through vaginal delivery. However, if babies are born prematurely or not well positioned in the womb, a cesarean section may be required. The likelihood of cesarean delivery increases with the number of babies a woman carries. Baby Concern: Baby may develop a problem during labor and may need to have a C-section.The reason may be that the umbilical cord is pressed or compressed or not enough blood is flowing to the baby from the placenta. Problems with the Placenta: The placenta previa is an irregularity in which the placenta is under the baby and covers all or part of the cervix. This will block the baby's exit from the uterus. Premature detachment of the placenta. This happens when the placenta separates before the baby is born and cuts off the flow of oxygen to the baby. The placenta previa occurs in about 1 in 200 pregnancies. It occurs more frequently in women who smoke, use cocaine, or are over 35 years of age. In some women, the condition is diagnosed during a routine ultrasound examination. In more than 90 percent of cases,the placenta previa is diagnosed in the second trimester and can self-correct towards the end of pregnancy. Other women experience painless bleeding from the vagina during the second half of pregnancy. If the placenta previa continues toward the end of the pregnancy, the woman can be admitted to the hospital for check-ups until the baby is born. Cesarean delivery is recommended in almost all pregnant women with placenta praevia because of the high risk of bleeding. Previous Cesarean Birth: Having had a baby via cesarean previously influences the need for another cesarean again. Many women who have previously delivered via cesarean section can deliver vaginally. However,a vaginal delivery after a cesarean delivery is not a good option for women because there is a considerable risk of rupture of the uterus. In Cuba, when a pregnant woman has undergone a cesarean section, in subsequent deliveries (at most two more) this surgical procedure must be performed. Diseases Affecting the Mother or the Fetus: If the mother has an infection such as the Human Immunodeficiency Virus (HIV) or genital herpes. It can spread to the baby during vaginal delivery, or if the mother has a disease that requires intensive or emergency treatment (such as diabetes or high blood pressure). For which the caesarean section is practiced.Diseases Affecting the Mother or the Fetus: If the mother has an infection such as the Human Immunodeficiency Virus (HIV) or genital herpes. It can spread to the baby during vaginal delivery, or if the mother has a disease that requires intensive or emergency treatment (such as diabetes or high blood pressure). For which the caesarean section is practiced.Diseases Affecting the Mother or the Fetus: If the mother has an infection such as the Human Immunodeficiency Virus (HIV) or genital herpes. It can spread to the baby during vaginal delivery, or if the mother has a disease that requires intensive or emergency treatment (such as diabetes or high blood pressure). For which the caesarean section is practiced.
In the physical examination, the patient must have a good coloration, the normal vital signs, if the wound is caesarean, it cannot be reddened, it must be healthy, the bleeding should be normal according to the days of delivery and the baby is discharged and is more than 24 hours old.
There are two fundamental types of caesarean sections, as defined above, the scheduled caesarean section and the emergency caesarean section.
When it comes to a scheduled caesarean section, an outpatient consultation is performed the day before the surgical intervention, then the anesthesiology consultation is performed and the patient goes to room 6A Obstetrics, where the medical history is made, a medical checkup and the required diet and pre-operative preparation are applied. Subsequently it passes to the Surgical Unit, from there to Immediate Puerperium 7B, after 12 hours has elapsed it passes to Puerperium Mediate 8B and when 24 hours have elapsed if no complications have occurred with the mother or the child, the patient and Your baby is discharged.
In the case of an emergency caesarean section, the patient arrives on duty, the complication is immediately diagnosed with delivery and she is admitted on admission, if she broke the bag she goes to room 8A, in case of seasonal diabetes and she is not ready for delivery, the required medication is applied, then she goes to pre-delivery, when the time is required, and from there to the Surgical Unit, where she performs the same route as the scheduled caesarean section.
The process flow diagram is drawn up according to what was stated in the previous step, and constitutes the common thread for determining costs for patients - pathologies and processes. (See Annex No. 1)
To carry out this phase, it is essential to first define and endorse the experts who will categorize each item of expenditure. After each expert selects the characteristics for which they consider meeting the requirements for it and the sources of their knowledge, the following results are obtained:
ASSESSED EXPERTS SCORE
Hospital Director 0.9530
Administrative Deputy Director Hospital 0.9231
Head of economic control 0.9150
Cost Specialist 0.9005
Head of Room 8B 0.8525
Table No 7: List of experts endorsed
Source: self made
As can be seen in Table No. 2, all those evaluated obtain an evaluation greater than 80%, therefore they are endorsed as experts. That is why they constitute qualified personnel to classify costs according to volume. They also determine, based on their knowledge, the most significant and representative cost inducers for distribution to patients - pathologies and processes. Which is shown in the following table:
VARIABLE COST ELEMENT
Table No 8: Classification of costs according to the volume and allocation of inductors for fixed costs Source: Own elaboration
After completing all the steps of the proposed model, it is already possible to determine the costs per patient that will allow administrations to make the decisions they consider pertinent, since accurate, relevant and timely information is provided on health care standards, both quantitatively. as qualitative, facilitating the analysis of variations.
However, before carrying out this task, it is necessary to define the sample size to complete the validation of the proposed cost model.
To establish a mathematical expression, in which the number of units to be sampled can be determined, in the case in which the variance of the population is unknown and its size is known, we have :
n = (Npq / ((N-1) B ² / Z ² + pq)) Where:
N - population size n - sample size p - sample or estimated proportion.
q = 1- p
B - allowable error
z - percentile value for a given level of significance
P = q = 0.50, B = 0.10, Z = 1.96 can be used with a = 0.05 (it is justified because in many investigations these values are used, the bibliography considers them very frequently) n = (838 * 0.50 * 0.50) / ((838-1) 0.10² / 1.96² + 0.50 + 0.50)) n = 209.50 / (8.37 / 4.8416) n = 209.50 / 1.728767349 n = 121 Therefore, the sample size to be calculated is 121 patients for the cesarean birth
In this way, the results obtained are presented below after accumulating at real cost the consumption of medications, food, healing materials, laboratory, radiological, medical instruments, blood and others considered variable by the experts, and distributed among the levels of activity defined all the fixed costs, which do not depend on these for their incurrence such as wages, electricity, depreciation, etc.
These costs for patients of caesarean delivery have been determined on the basis of medical records, however, it has been necessary to apply interviews, observation and follow-up to patients, since medical records are unfortunately not a true reflection of the exact attention they receive.
For the determination of the costs for patients-pathologies and processes, Table No. 5 presented in Phase III, Stage 2, Step No. 1 was used.
The variable elements have been accumulated at the real cost, while the fixed ones were distributed on the basis of the inductors or activity levels defined by the experts. (See Annex No. 1) Table No. 9
When analyzing the results of the costs per patient for the cesarean delivery pathology, these show that the ranges between which the costs of care for this service are maintained range from approximately $ 108.82 to $ 350.43 per day, which are in correspondence with the size of the therapeutic management.
This amount has been valued at cost price, which are dependent on variations that originate from changes in prices and costs of medicines, food, healing materials, radiological, medical instruments, among other variable elements, variations in activity levels. (patients attended), as well as variations in the technological facilities and other means that the hospital institution acquires, which would increase the fixed costs for these concepts.
Comparison between the current costing system and the proposed model for determining costs per patient-pathologies and processes at the Dr. Gustavo Aldereguía Lima University Hospital in Cienfuegos.
Determining the cost per patient of cesarean delivery using the information provided by the costing system of the Dr. Gustavo Aldereguía Lima University Hospital in Cienfuegos, the division of the total cost in room 8B would be applied between the activity levels defined by this institution (days- patients, days beds or graduates) and the following result would be obtained (See Table No. 10) which, when compared with the calculation made using the proposed costing model, denotes significant differences that cannot exist, since the information being provided does not It responds to the interests of the cost systems or of the hospital administrations as an institution and other higher instances, which require for successful decision-making and adequate control of resources, which they cannot develop on time.
UNIT COSTS DELIVERED BY CESAREA
University Hospital Dr. Gustavo Aldereguía Lima de Cienfuegos
Year 2006
CURRENT COSTING SYSTEM PROPOSED COSTING MODEL
Cost Center Room 8B
Total cost Activity level Cost Cost Cost Variations unit Maximum minimum
$ 82 498.00 Patient Days (868) $ 95.04 $ 108.82 $ 350.43 $ 13.78 $ 255.39
Days Beds (1178) 70.03 38.79 280.40
Graduates (391) 210.99 102.17 139.44
Table No 10: Comparison of costs by patient
(Current cost system versus proposed model)
Source: self made
This difference is mainly based on the fact that the medical attention of a pathology is not only received by a ward of the health institution that attends it, while it requires services from other cost centers, which makes it impossible for the information can be treated linearly as process costing.
The approximate total cost of care for cesarean delivery per patient calculated by the proposed Model ranges from $ 94 455.76 to $ 304 173.24
(Minimum daily cost x patient days) = $ 108.82 x 868 = $ 94 455.76
(Maximum daily cost x patient days) = $ 350.43 x 868 = $ 304 173.24
And in this range is not located the cost that reflects the current system of $ 82 498.00
Neither patient-days, bed-days nor graduates as a whole can constitute a correct level of activity, since not all patients receive equal medical attention. This denotes the imprecision of the current costing system of the Dr. Gustavo Aldereguía Lima University Hospital in Cienfuegos and its impossibility of obtaining the real cost per patient - pathology and process for cesarean delivery.
Conclusions
- The cost information must be relevant, accurate and timely for the good functional performance of the organizations. The costs in Health Institutions are accumulated by processes which prevents a real, accurate and timely presentation of the same by patients - pathologies and processes, since there is no activity level for the health service that manages to distribute the total costs among the patients treated for pathologies. - The information that reflects the current system by cost centers does not allow the determination of costs by patients - pathologies and processes, as it does not assess the characteristics of the patient and the care they receive for a certain pathology. The proposed model allows the determination of costs for patients pathologies and processes for cesarean delivery at the University Hospital Dr.Gustavo Aldereguía Lima de Cienfuegos. The real costs of the cesarean delivery service per patient range between $ 108.82 and $ 350.43, throwing differences with the one that exposes the current cost system.
recommendations
- Adapt the information provided by the current cost system at the Dr. Gustavo Aldereguía Lima University Hospital in Cienfuegos to the needs of this institution and take advantage of its positive aspects to obtain the relevance and opportunity that it requires. Make the necessary adjustments to the model of Costing currently existing at the Dr. Gustavo Aldereguía Lima University Hospital in Cienfuegos in order to obtain costs for patients - pathologies and processes, an essential factor for proper planning, control and decision-making. - Ensure that the medical records are a faithful reflection of all the care provided to each patient. Apply the proposed model to all the health institutions in the province and achieve its generalization.Automate the proposed model achieving compatibility with the existing one in health institutions, since the former uses data provided by the current one.
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APPENDIX No 1. Process Flow Diagram
Cesarean birth
SUMMARY OF COSTS PER PATIENTS LABOR BY CESAREA Year 2006
Annex No 2. Summary daily cost for pathology Cesarean Delivery
Table No 9: Summary of patient costs - pathologies and processes for cesarean delivery Source: Own elaboration
CUBA NATIONAL ASSOCIATION OF ECONOMISTS AND ACCOUNTANTS
XII PROVINCIAL ACCOUNTING, COST, AUDIT AND FINANCE EVENT
TITLE: Model for determining costs for patient pathologies and processes of cesarean delivery at the University Hospital Dr.
Gustavo Aldereguía Lima of Cienfuegos.
AUTHORS: Lic. Reynier Reyes Hernández
Cro. Eduardo Montico
MSc. Grisel Pérez Falco
When the woman begins with contractions, which can last for the first time for 18-20 hours and the rest for 16-18 hours until the dilation begins.
When forceps, spatulas or other instruments are used to extract the child.
Vicious presentation of the fetus, that is, it comes parallel to the cesarean section.
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