For long-time now, we have been listening to and reading about overcrowding of our tertiary healthcare centre namely SKIMS. We have been impressed and even sometimes frightened by the share numbers of emergency attendance, outpatient visits, inpatient admissions, lab tests, imaging procedures and operations performed at SKIMS. Many times numbers spoken of or documented are alleged to be at variance with those referred to at another occasion and not confirmed/backed by validated medical record figures. Many viewers told me that a recent NDTV appearance spoke of SKIMS attendance to outpatient during last five months of Kashmir protest as so exorbitant that it was unbelievable.  Why are we listening to and reading this phenomenon repeatedly? These figures are used at different occasions for differing reasons and values. Sometimes these are projected for SKIMS credibility as an Institution which delivers. At other times overcrowding overshadows SKIMS non-performance.

Unfortunately the same phenomenon is being used for mudslinging at alleged inefficient health delivery at primary and secondary healthcare level.  Still at other times this is conduit for demand of more finance flow.  Recently the same numbers are used for expansion of the facility. I am sure we will see more ingenious outcomes from these numbers, true or false. Now the situation has reached that we have started believing and accepting all of the above as these number-events are being repeatedly shot at us.

Several questions have to be addressed? Is this overcrowding true or a myth? Is it real or artificially created? Why should a tertiary centre of this magnitude so well-designed get overcrowded? How can we impress upon SKIMS administrators to address many other healthcare delivery policies and health delivery practices and bring what is good in system and what do we lack for improvement. I believe this scarcity of thoughts in administration is a major threat to SKIMS as an Institution.

SKIMS was, is, and shall remain as no ordinary tertiary centre. In fact this was the only institution of this kind built in that era at national level. Before SKIMS facility, manpower and functioning came in to operation, hundreds of top medical brains of the country and the West debated for years. Every aspect of Institute, physical and functional, were drafted and approved. That is how SKIMS turned in to an apical Institution of excellence in shortest possible period in early nineties. Unfortunately the impetus did not sustain for reasons well known to all. However, Institute drafting, building, functionality and future have some important facts somewhere decaying in its files. First SKIMS was built for a series of specific health delivery activities and not beyond. SKIMS had to conduct on excellent tertiary management for specific disease state facing the State and no more. These treatment protocols had to be updated to the best continuously to keep with changing practices anywhere in the World. SKIMS had to do original research in diseases facing the State and bring Kashmir at International medical scene.   SKIMS had to involve in inventing new medical practices and outreach these to primary physicians and practitioners so that primary healthcare gets a boost.

SKIMS building was built with clear instructions - “Not for Expansion”. I attended some of these sessions from these highly reputed experts and I felt how much passionately these experts spoke “Not to Expand” physically as it shall lose the basic concept of SKIMS. SKIMS was build that it shall deliver for what it is meant for all times to come.  If State health wanted other health delivery programs, these experts stressed for building alternative institutions, not under SKIMS control. This was done to avoid diluting SKIMS concept.  The manpower of over 5000 employees housed in one building was created with remunerations which were much higher than those available to State health employees. These were upgraded later to level with those of AIIMS and PGIMER, intuitions of national importance.  This was done so that employees work period and time schedule be at par with International standards and no time be spent outside SKIMS activities. That is how SKIMS became a full time institution for faculty and for all employees. SKIMS expert committee deliberated and stressed that this facility shall never get overcrowded with what was conceived.

Let us turn to our basic point namely overcrowding. In early eighties I questioned these SKIMS experts on the viability of this facility for times to come. They had a simple answer and that came in two sentences. First, constantly look at your load and limit it to the minimum. Second, expand your work schedule to cater to the load. Both these aspects had to be constantly debated to strike a balance and to keep this balance, system had to be responsive.

First SKIMS had specific health activities to do. Obstetrics, General Surgery, General Medicine, Paediatrics, Ophthalmology, ENT, Dermatology, Psychiatry, Orthopaedics and so many other medical specialities were not included in SKIMS and if represented, only for supportive care to other main objects. Second, automation was introduced so early as 1978 and constantly updated. If any activity was stretched, the system had to expand time schedule to cater to increasing need. In fact these automatic machines are so powerful and fast that these can do hundreds, hundreds-of-thousands and even millions of lab tests in a short period of time. CT scans and MRI purchased were first time introduced in State and even in country and upgraded regularly. A 64-slice CT scanner (a 5 crore baby) is so powerful and fast that if optimally used we do not need another CT scan machine either in Govt. or private sector in Kashmir. Same is true of other machines which run on automation and believe me that nothing runs manually in SKIMS as of today. Only these machines have to be kept running to fit the load.

What about surgeries. Fourteen world class highly sophisticated theatre block if optimally used from 6AM to 7PM shall do any surgery needed in State with no back log. Internationally theatre block should start at 6AM with knife on patient at 7AM and continue till 7PM and beyond. I have practised it in SKIMS and it worked as good as any other international centre. 

Outpatient and inpatient load! I believe this load is artificially created and can be looked at very simply. If a substantial percentage of faculty and senior residents involve in doing walk-in primary-care activities outside the Institute time, most of such patients find access to outpatient and inpatient clinics. This adds tremendously to the load of those genuine patients who are referred to SKIMS from primary-care. Moreover, it steals away valuable time of SKIMS medical practitioners to do what he was supposed to do-namely expand clinics and inpatient time activities to cater to load. Thus we increase load artificially and reduce time schedule intentionally to overcrowd the system.   Solution is simple-rationalize to cater to genuine load and increase time spent in facility accordingly. I practised this for 13 years of my stay in SKIMS and never found my facility overloaded and believe me my load in those days was more than what it is now in corresponding facility.

What about this emergency and the fuss around it? Emergency services were never conceived in SKIMS and in fact there was no emergency department. We had two emergency theatres to cater to receiving emergencies from other hospitals. I remember of that unfortunate day when we introduced SKIMS emergency and many of us resisted it against somebody’s erroneous ideas. The results are obvious. SKIMS had an ingenious mechanism to receive emergencies. Emergencies which could be managed by SKIMS had to be received by individual specialities so that these are best catered to and tertiary management addressed immediately. Emergency services were running so well for first many-years. Now we have emergency visits to SKIMS which are clubbed and it takes days for the tertiary facility to identify and address the individual speciality problem. There are two possible solutions-either go to original concept or make emergency services as of today as a referral service only. Building an emergency department if conceived shall make those SKIMS experts unhappy and restless. Such a facility should come up in Medical College hospitals. This way such funds I believe shall be well spend. 

Where do we go from here? First SKIMS credible load, patient care or investigative need to be published by medical record department on regular basis. It has to be used constantly by administrators, all speciality department and nursing to rationalize the load and work. This is an essential activity of all hospitals and other facilities. Exploiting it on streets must be stopped.

Overcrowding should not be used to represent delivery tool or reasons for non-performance or reasons for demand for more funds or need for expansion.   Hundreds of  health care policies including nursing practices, morbidity and mortality concept, in-service activities, fire policy, infection control policy. Narcotic policy, attendant traffic policies, drug policy, hospital cleanliness etc need to be constantly debated to keep such activities optimum. Above all we need to improve patient satisfaction by maintaining excellent patient-physician relations. I am sure most of these activities are being done in SKIMS very optimally and at places with excellence but all these are washed out by this “myth of overcrowding”.  

(Prof. Mohammad Sultan Khuroo, is Director Digestive Diseases Centre, Dr. Khuroo’s Medical Clinic, Srinagar, Kashmir. Feedback at khuroo@yahoo.com)

Lastupdate on : Tue, 2 Nov 2010 21:30:00 Makkah time
Lastupdate on : Tue, 2 Nov 2010 18:30:00 GMT
Lastupdate on : Wed, 3 Nov 2010 00:00:00 IST