A Field Trip to Uong Bi Vietnam-Sweden Hospital

During the week 7th-11th September 2009 I had the opportunity to join 24 students of the Master in Hospital Management course of HSPH, together with Dr. Bui Thi Thu Ha, Ms. Thuy Dong and Ms. My Anh, for the initial week of their 2 month exercise program to prepare and report on a practice project in a hospital. The week was dedicated to a number of presentations with general information and descriptions of the functions and activities of a number of departments and faculties of Uong Bi Hospital – a hospital that was built under Swedish sponsorship and leadership in 1973-1976. For me, participation was important, as it was my first chance to get an inside view of a hospital in Vietnam.

We were accommodated at a rather pleasant “rehabilitation facility”, a special accommodation compound which was built for the Swedish experts that built the hospital in the mid-seventies and also worked there for many years. A number of simple but comfortable Swedish wood houses grouped around a swimming pool with pleasant grounds, at about 2 km from the hospital.

At the hospital, all the presentations were prepared and delivered in Vietnamese only, and it was Ms. My Anh and Ms. Thuy Dong who had to try and interpret the most important issues to me. Any questions I had could be asked in English, but responses were also usually in Vietnamese. This said in advance, meaning that I might not have understood everything that would have been important for the speakers to convey, I will try to summarize my impressions as follows:

Uong Bi Vietnam-Sweden hospital is a district hospital with about 600 beds, an average occupancy rate of over 100%, serving about 30.000 inpatients and 130.000 outpatients per year. There is a number of internal medicine and surgical departments, pediatrics, obstetrics (5000 births per year), urology, ENT, others (?). Among the important functional departments the general examination department, the emergency unit, the laboratory, the training department and the pharmaceutical department should be mentioned.

The Hospital Manager, Dr. Tiep, gave a very comprehensive overview of the history, development and current situation of the hospital. While substantial additions have been made since 1976, most of the buildings and a great deal of the technical equipment are still the Swedish installation. A good and competent technical department keeps them in good shape, but of course after more than 30 years the hospital is confronted by an impressive wave of replacement needs. Recent changes in legislation give the hospital leadership more autonomy regarding economic activity, but it may be doubted whether it will have the strength to raise the immense amounts of money that will be necessary. And even today Dr. Tiep quoted the good standard of equipment as one of the major assets of the hospital.

An important institution of the hospital presented itself as the Planning Unit. With a staff of 15 people, including 3 physicians, this unit seems to have a broad array of responsibilities: Working out and monitoring the implementation of all development plans for management and clinical departments, accumulation, analysis, evaluation and communication of controlling data on the medical services, the development of the institution and the economic situation, patient satisfaction surveys, patient file documentation storage and retrieval, deployment of information technology are the more important. The examples shown gave the impression that a host of controlling data is available, but that the techniques to aggregate these data into a comprehensive set of management data seem underrepresented. However, the existence of such a unit, even with so much manpower, seems justified.

The Personnel Division presented itself with a surprisingly small staff of 3 persons. It did not become comprehensive to me how such a small department could be able to take care for the complete spectrum of human resource management (without the calculation and payment of salaries), including monitoring yearly staff assessment process for the whole hospital. But it is noteworthy, that such a process seems to be well established throughout the hospital, leading to a sophisticated scheme of paying additional bonuses to the salaries depending on the results of these assessments. (Surprising aspect: One overwhelmingly important factor of the assessment of a unit’s achievements seems to the amount of electric energy that was used during the year. This importance is not evident to an external view.)

The Technical and Equipment Division gave an impressive overview on how a team of 40 people maintains the high technical standard that was provided by the Swedish government initially. It claims that it takes care of the complete technical maintenance, including medical equipment, without contracting out a relevant proportion of the activities. It cannot be judged from the visit, whether the medical equipment, like X-ray, CT, laboratory automats and ultrasound imaging really get the service they need in order to be safe, consistent and delivering certifiable results. A computer-based MAD system allows full documentation of all technical activities for each piece of equipment.

The Laboratory Division gave an impressive overview of its hematology, biochemistry, microbiology and pathology facilities, which include an adequate amount of modern equipment for automation of tests. The blood bank seemed small for a hospital of this size, but was said to be adequate. The division also assumes responsibility for overall hygiene and infection control in the hospital, but it was not clear to me how far that goes.

The Finance Division, with a staff size of 21, described its responsibility as comprising the collection of all income and the facilitation of all payments (including payroll) of the hospital. The different types of funding (government budget, income from fees, income from health insurance, other income) are planned, accepted, monitored and reported in the appropriate ways. All the relevant rules and regulations, including the standards for hospital autonomy are being observed. The economic results 2008 showed a sufficient surplus to allow the payment of interesting bonuses to the staff. The accounting system of the hospital, following government rules, is a simple in-out system, double-entry book-keeping (which would allow the use of depreciation to accumulate funds for the replacement of equipment) is not in use.

The Pharmaceutical Department is one of the important sources of revenue for the hospital, as it is licensed to retail pharmaceutical products to inpatients and outpatients. For reasons of quality, the hospital procures the products only from government wholesalers. A comprehensive documentation system is in place which allows online ordering, inventory control and monitoring for expiry dates, Some projects on adverse drug effects are under way, and instances of accidental false medication are under close surveillance. The official list of available pharmaceuticals is remarkably short (350 positions) for a hospital of this range of medicine, which is taken as a token of good management.

The Surgery Faculty comprises 3 departments: Trauma, including neurosurgery, visceral surgery including oncology, urology. Besides, ENT and gynecology also use the operating facilities, which provide 5 operating rooms. The Traumatology Department (overall staff 21, of which 6 are physicians) claims to be working on the basis of SOPs (DIN Iso system), has overutilized its 40 beds at 103%, and services about 12.000 patients per year, including 2.700 inpatients. Average LOS is reported at 6.5 days, total surgical interventions at 1700 per year. Soft criticism was voiced regarding the importance of electricity use as major factor in the hospital’s internal scoring system, and also regarding the standardized annual planning process. An acquired infection rate of 2,67% did not seem to cause major concern. The Visceral Surgery Department reported 2000 inpatients and 1000 surgical interventions per year, bed utilization is 100%. Urology has about 1000 inpatients and 650 operations per year, of which about 200 are kidney stone extractions. This will be reduced in the future, as a new ESWL has been established. All surgery departments report shortage of medical staff, as they all have to participate in the central examination and emergency units’ duties. A second problem is the age of medical equipment, which is up to 30 years old

The Central Imaging Department has been established to concentrate all major imaging techniques under one responsibility. A CT, X-ray equipment, the urology x-ray workplace, 3 ultrasound machines and the endoscopy unit are available for all diagnostic needs of the clinic and emergency departments. It was pointed out, that radiation safety and monitoring of staff exposure is an issue of constant observation, the government rules being fully observed. A staff of 13, including 5 physicians, seems well utilized. Consistency and radiation safety is checked regularly by external providers, utilizing national benchmarks. Equally, maintenance for the department’s technical equipment has been contracted out, also the cleaning services. Activity figures: Up to 100.000 X-rays, 6000 CT-scans, 14.000 endoscopies and 50.000 USI per year. The management of the department seems well organized.

The General Operating Facility which was visited to watch a urological intervention (transurethral stone extraction) has a standard layout with a clean and an unclean corridor, a preparation room servicing three operating rooms, standard changing and staff rooms. A small recuperation room can service 3-4 patients; central ICU is adjacent to receive the patients afterwards. Additional operation rooms are under construction. A problem which might also be responsible for intra-operative infections is the lack of modern air conditioning and airflow: We observed two standard household electric fans in operation during the intervention (one obviously mainly to cool down the “Storz” operating machine.) General hygiene standards seemed acceptable but not exceptional. Anaesthesia was well administered. From this one observation it seems that general turnover in intervention figures could be improved, if the preparation of the patient was done prior to bringing him to the surgery room: It took at least 15 minutes until the patient had been put to sleep, with the complete surgery room staff including 2 surgeons looking on and waiting.

Internal Medicine has been divided into 4 departments: Vascular/cardiology Department (only conservative diagnostics and treatment, no PCI, stenting or vascular surgery is established at Uong Bi), Digestive System Department, Respiratory System Department (which also houses the dialysis unit?), Endocrinology and Nervous System Department (which includes a unit for traditional medicine.) These departments all have about 40 beds (and overutilize them), about 6 physicians, the necessary nursing and supporting staff. All physicians have to participate in the duties of the central examination and emergency units, thus the departments seem understaffed. 24-hour duties seem inevitable but do not make the positions attractive. The Faculty takes pride in presenting a concept of patient-centered cooperation between the internal medicine departments, but has not seen the possibility to establish one central hematology/oncology unit including palliative care: Each department cares for its own oncological patients. The visited ward (cardiology) showed the expected crowded patient rooms (4 beds seem more than the rooms can accommodate), documentation system and staff communication seemed well organized. We were shown one intensive care room, but it had no monitoring or respiration equipment. The online system for ordering pharmaceuticals was functional. Unusual crowding of the ward (from Western point of view) came from the fact that family members assume a lot of nursing care duties (which explains a low nursing staff ratio of 11 for 40 patients.)

The Central Examination Unit comprises 3 divisions: Emergency admittance, General Examination and Physical Examination. The emergency unit has its own medical staff (2), any medical staff on top of this has to be provided by the clinical departments. CEU provides diagnostics, teaching and prevention medicine; emergency has triage as additional responsibility (deciding if the patient can be treated as outpatient or inpatient, and whether a transfer to another hospital is necessary). 10 Beds are available to accommodate patients during diagnostics prior to admittance to the inpatient wards, these beds are not utilized at night. There are two waiting rooms (with waiting line numbering system), a good number of examination rooms and resting rooms for outpatients before they go home. The imaging diagnostics department is adjacent, laboratory as well. The activity figures quoted over 9000 emergencies during the first 6 months (of which only 30% were seen as “real” emergencies) and 44.500 general examinations.

A short visit was possible to the Central Intensive Care Unit (ICU). It seems to be under the supervision of the Emergency Unit Dean (but that was not quite clear to me). The unit, with 14 beds in 3-6 bed rooms is suitably placed next to the Operation Unit, but unseemingly far away (on another floor) from the emergency unit. The rooms and layout seemed adequate, but a lack of modern monitoring systems was obvious. Respirators seemed sufficient in number, I cannot judge their condition.

Of course, the visit was also documented by some pictures. They can be found here.