09 fiscal planning

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Mr. Channabasappa.K.M
UNIT – IX
FISCAL PLANNING
1. BUDGETING IN NURSING PRACTICE
INTRODUCTION
Budget, as a control device is an extension of planning. After the planning and
programming decision, the approved programme is translated into a totaled statement of
monetary requirements and financial consequence.
Budgeting, though primarily recognized as a device for controlling, becomes a major
part of the planning process in any organization budgeting is done for indicating the expected
results of the business and the possible future lines of action to be followed for the attainment
of such results. Expected results are projected either in financial terms or in other numerical
terms like units of products person-hours machine hours.etc
MEANING OF BUDGET
The word ―budget‖ derived from the old English word ―budget tee‖ means a tack or
pouch which the Chancellor of the Exchequer use to take out his papers for lying before the
parliament, the government, financial scheme for the ensuring year.
DEFINITION
―Budget is a concrete precise picture of the total operation of an enterprise in
monetary terms‖ (HM Donovan)
―Budget is a operation plan, for a definite period usually a year- Expressed in
financial terms and bused an expected income and expenditure‖
PURPOSES
The purposes of budgeting are:
1. Budget supplies the mechanism for translating fiscal 1-year objectives into
projected monthly spending pattern.
2. Budget enhances fiscal planning and decision marking.
3. Budget clearly recognizes controllable and uncontrollable cost areas.
4. Budget offers a useful format for communicating fiscal objectives.
5. Budget allows feedback of utilization of budget.
6. Budget helps to identify problem areas and facilities for effective solution.
7. Budget provides means for measuring and recording financial success with the
objectives of the institution.
FEATURES OF BUDGET
 It should be flexible
 It should synthesis at past, present and future.

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 It should be product joint venture, cooperation of executives / department heads at
different levels of management.
 It should be in the form of statistical standard laid down in the specific numerical
terms.
It should have a support at top management throughout the period of its planning and
implementation.
PRINCIPLE OF BUDGET
 Budget should provide sound financial management by focusing on requirement of
the organization.
 Budget should focus on objectives and policies of the organization. It must flow from
objectives and give realistic expression to the way of realistic such objective.
 Budget should ensure the most effective use of scarce financial and non financial
resources.
 Budget requires that programme activities planned in advance.
 Budgetary process requires consistent delegation for which fixed duties and
responsibilities are required to be allocated to managers at different level for framing
and executing budget.
 Budget should include co-ordinating efforts of various departments establishing a
frame of reference for managerial decision and providing certain criteria for
evaluating managerial performance.
 Selling budget target requires an adequate checks and balance against the adoption of
too high or too low estimate, almost care is a must for fixing targets.
 Budget period must be appropriate to the nature of business or service and to type of
budget.
 Budget is prepared under the direction on the supervision of the administration or
financial officer.
 Budget are to be prepared and interpreted consistently throughout the organization in
the communication in the planning process
IMPORTANCE OF BUDGET
 1. Budget is needed for planning for future course of action and to have a control
over all activities in the organization.
 2. Budget facilitates coordinating of various departmental and selection for
realizing organizational objectives
 3. Budget serves as a guide for action in the organization.
 4. Budget helps one to weigh the values and to make decision when necessary on
whether one is of greater values in the programmes than the other.
TYPES OF BUDGET
Since budget express plans and an organization may have different types of plans, there
may be different types of budgets. These may be classified on the basis of

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1. Coverage of functions master and functional budgets.
2. Nature of activities covered – capital and revenue budgets
3. Period of budgets – long term and short-term budgets
4. Flexibility adopted – fixed and flexible budgets.
1. Masterand Functional budgets
A master budget is prepared for the entire organization incorporating the budget of
different functions. For example when we refer to the annual budget of government of India,
it incorporates the budget outlays of different ministries. In the business organizations, the
maser budget incorporates various functions and units and their outlays. It generally includes
sales, production, costs.
A functional budget is prepared incorporating a major function and its sub- functions.
Since an organization may have a number of functions, numerous functional budgets are
prepared. Eg. Production budget, cash budget in an organization.
2. Capital and Revenue budgets
An organization activity involves two processes- creating facilities for carrying out
activities and actual performance activities. Creating facilities for carrying out activities
include capital expenditure whose returns accrue over a number of years. For such activities,
capital budget is prepared which is essentially a list of what management believes to be
worthwhile projects for acquisition of new assets together with the estimated cost of each
project.
Revenue budget involves the formulation of target for a year or so in respect of various
organizational activities such as production, marketing, finance, etc. Thus, a revenue budget
includes expenditure and earning for a specific period like one year.
3. Long term and short-term budgets
Many organizations integrate their yearly budgets with long-term projections of
business activities and along with yearly budgets; they prepare budgets for a longer period of
2 – 3 years. When one budget period is over, budgets are prepared for the next year and
subsequent 2 -3 years.
The short term budget is for a year and is divided into a number of periods for
effective implementation. For eg. Cash budgets are on yearly basis as well as on monthly or
quarterly basis to facilitate better cash management.
4. Fixed-celling and flexible budgets:
Generally, organizations prepare which certain to only certain projected fixed volume
of operations for a year or so. Such budgets are known as fixed of static budgets. When an
organization’s volume of business can be predicted with fair amount of precision, the fixed
budget is satisfactory.

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A budget which is designed to change in accordance with the activities of the
organization is known as flexible budget. It considers several level of activity and assumes
that labour, material or facilities used in production and hence cost vary with a known
relationship to the actual of activity.
OTHER TYPES OF BUDGET
1. INCREMENTAL BUDGET
It is one based on estimated changes in present operation, plus a percentage increase
for inflation, all of which is added to previous year budget.
2. OPEN ENDED BUDGET
Is a financial plan in which each operating manager presents a single cost estimate for
each programme in the unit, without indicating how the budget should be scaled down if less
funding is available.
3. FIXED CEILING BUDGET
Is a financial plan in which the upper most spending limit is set by top executive
before the unit and divisional managers develop budget proposals for their areas of
responsibility
4. FLEXIBLE BUDGET
Consist of several financial plans, each for a different level of programmes activates.
It is based on the fact that operating conditions rarely conform to expectations.
5. ROLL OVER BUDGET
Is one that forecasts programmed revenues and expanses for a period greater than a
year. To accommodate programmed that greater target than annual budget cycle.
6. PERFORMANCE BUDGET
It is one based on functions, which allocate function, not division. Eg. Direct Nursing
care, in service education, quality improvement, nursing research.
7. PROGRAMMED BUDGET
Is one which costs are computed for a total programmed, i.e, grouping total coasts for
each services programmed eg. MCH, FP and UIP etc. These base budgets requires the nurse
manager to examine, justify each cost of every programmed both old and new in every annual
budget preparation.
8. SUNSET BUDGET
It is designed to ―Self Destruct‖ within a prescribed time period to ensure the
cessation of spend in by a predetermined date.

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9. SALES BUDGET
Is the starting point in a budgetary programmed, since sales are basic activates which
give shape to all other activities. Sales budget are compiled in terms of quality as well as of
values.
10. PRODUCTION BUDGET
It is the budget that aims at securing the economical manufacture of products and
maximizing the utilization of production facilities Revenue and expanse Budget.
It is expressed in financial terms and takes the nature of a perform income statement
for the future. It may use prepared in a detailed form or in an abstract statement showing the
items of profit and loss under classified headings.
APPROACHES TO DEVELOP AN ORGANIZATION WIDE BUDGET
Organizations adopt different approaches for preparing their budgets. One of the most
common approaches is in the form of traditional budget in which the current year’s budget is
taken as a base with the provisions of some additions and deductions in the next year’s
budget. The traditional approach of budgeting does not eliminate the draw back of the past.
Therefore, newer approaches of budgeting have emerged. These have resulted into three
types of budgeting.
1. Performance budgeting
2. Zero base budgeting
3. Strategic budgeting
1. Performance budgeting’s
A performance budget is an input / output budget or costs and results budget.
Performance budget emphasis on non-financial measures of performance, which can be
related to financial measures in explaining changes and deviations from planned
performance. Performance measurements are useful for evaluating past performance and for
planning future activities. Performance budgeting, results into the following.
 It correlates the financial and physical aspects of every programme or activity.
 It improves budget formulation, review and decision making at all levels of the
organization.
 It facilitates better appreciation and review of organizational activities by the top
management.
 It makes possible more effective performance audit.
 It measures progress towards long-term objectives.
2. Zero base budgeting
This was applied for the first time in preparing the divisional budgets of Texas
instruments of the USA in 1971.

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Zero base budgets is based on a system where each function, irrespective of the fact
whether it is old or new, must be justified in its entirety each time a new budget in detail from
scratch that is zero bases.
The process of zero bases involves four basic steps:
 Identification of decision units, that is cluster of activities or assignments within a
manager’s operations for which he is accountable.
 Analysis of each decision units in the context of total decision package.
 Evaluation and ranking of all decision units to develop the budget request.
 Allocation of resources to each unit based
Benefits of zero base budgeting:
1. effective allocation of resources
2. improvement in productively and cost effectiveness
3. effective means to control costs
4. elimination of unnecessary activities
5. Better focus on organizational objectives.
6. Saving time of top management.
3. Strategic budgeting
It is used as a tool of resource allocation to various strategic business units and
other units of an organization. Under strategic budgeting, in determining the resource
needs of various units
Formation of a budget committee:
Budgeting is a cooperative undertaking. In smaller organization, the task of budget
preparation may be entrusted to the accountant who works in close cooperation with the
general management and department heads.
But in bigger concerns, the budget should be prepared by each departmental/division
manager. The accounts department assists in providing necessary background information
and coordinates the budget of different departments.
There may be a budget committee in an organization comprising of the departmental
heads and finance manager or a budget officer.
The function of the budget committee is to
a) receive and approve all forecasts, departmental budgets, periodic reports showing
comparison of actual and budgeted income and expenditure.
b) the committee may also request for special studies of deviations from the budget and
consider revision of budget to meet changed conditions.
Essential requirements for budget preparation:
1) sound forcasting:
2) an adequate and well conceived accounting system
3) a well devised cost accounting system
4) a soundly constructed organization with fixed lines of responsibility.

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5) Statistical informations
6) Support of top management
7) Length of budget period.
PLANNING THE BUDGET
Planning yields forecasts for one year and several years. The budget is an annual
plan, intended to guide effective use of human and material resources, products or service and
managing the environment to improve productivity. Budgetary planning ensures that the best
methods are used to achieve financial objectives.
In nursing, budgetary planning helps to ensure that clients or patients receive the
nursing services they want and need from satisfied nursing workers. A nursing budgeting is a
systematic plan that is an informed best estimate by nurse administrators of revenue and
nursing expenses.
Managing the financial end of nursing through an operational budget obviously can
create a new dimension for nurse. The budget can be a strong support for developing written
objectives for the nursing division and for each of its units.
2. STEPS IN THE BUDGETARY PROCESS
The nursing process provides a model for the steps in the budget planning.
1. Assessment
The first step is to assess what needs to be covered in the budget. Historically, top-
level managers frequently developed the budget for institution without input from middle or
first level managers. Because unit managers who participate in fiscal planning are more up to
be cost conscious an better understand the institutions long and short term goals, budgeting
today generally reflects input from all level of the organizational hierarchy. Unit managers
develop goals, objectives and budgetary estimates with input from colleagues and
subordinates. Budgeting is most effective when all personnel using the resources are involved
in the process. Managers therefore must be taught how to prepare a budget and must be
supported by management throughout the budgeting process.
2. Developa plan
The second step is to develop a plan. The budget plan may be developed in many
ways. A budgeting cycle that is set for 12 months is called a fiscal year budget. This fiscal
year which may or may not coincide with calendar year, is then usually broken down into
quarters or subdivided into monthly, quarterly or semiannual periods. Most budgets are
developed for a one-year period, but a perpetual budget may be done on a continual basis
each month. So that 12 months of future budget data are always available. Selecting the
optimal time frame for budgeting is also important; a budget that predicted too far in advance
has greater probability for error. If the budget is short sighted, compensating for unexpected
major expenses or purchasing capital equipment may be difficult.

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3. Implementation
The third step is implementation. In this step, ongoing monitoring and analysis occur
to avoid inadequate or excess funds at the end of fiscal year. In most health institutions,
monthly-computerized statements outline each department’s projected budget and any
deviations from the budget. Each unit manager is accountable for budget deviations in their
unit. Most units can expect some change causes and remedial actions must be taken if
necessary .some managers artificially inflate their department’s budgets as a cushion against
budget cuts from a higher level of administration. If a major change in the budget is
indicated, the entire budgeting process must be repeated. Top-level managers must watch for
and correct unrealistic budget projection before they are implemented
4. Evaluation:
This is last step. The budget must be reviewed periodically and modified as needed
throughout the fiscal year. With each, successive year of budgeting, managers can more
accurately predict their unit is budgetary requirements.
BUDGET STAGES:
The nursing budget follows three stages of development.
1. Formulation
2. Review and enactment
3. Execution
1. Formulation stage
It is usually a set of number of month before the beginning of the fiscal year for the
budget. One of the first steps in writing a budget is gathering data for accurate prediction of
expenses and revenues (income). Primary sources of data are the objectives for the division
of nursing and each cost center .other data include programmes from other departments that
will require use or expansion of nursing resources, expansion of nursing clinics and client
teaching programmes, incentive awards, library requirements, clinical and office supplies and
equipments etc.
2. Review and enactment stage
Review and enactment stage are budget development process that pull all the pieces
together for approved of a final budget. Once the cost center managers present their budgets
to the budget council, the chief nurse executive will consolidate the nursing budget. The chief
executive officer of the organization and the governing broad will then give their approval.
Throughout this process, conferences will be held at which budget adjustments are made.

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3. Execution stage
Execution of the budget involves directing, executing, and evaluating activities. The
nurse administrator and managers who planned the budget execute it. Revisions in execution
of the budgets are scheduled at stated intervals, frequently once or twice during fiscal year.
Certain procedures are followed for evaluating the budget at cost center levels.
Steps in the preparation of an operating budget:
1) Collection of past data (historical data) as a background material for the preparation
of budget in a cumulative form.
2) Examining the expressed objectives of the previous years and to note in each instance
the extent to which these objectives have been achieved or exceeded. Before setting
programs for future, it is necessary to assess the successes and failures of the past.
Budget time is ideal for such reviews.
3) Setting objectives for the forecast year. These objectives might include ways to
increase the utilization of existing facilities and personnel.
4) Stating the objectives in terms of units of production or services or activities. The
indicated units are increased or decreased by the effect of expected achievements.
5) Consideration of salary of wages adjustments. A complete schedule of cost of living
increase and merit increase must be prepared of all cost centres, detailing the persons
and months and the amount of adjustments. However these increases should not
exceed the ceiling salary/ wages established under the job evaluation study.
6) Preparation of report on the expenses related to insurance, taxes, supplies, services,
maintenance and repair costs etc to be included in the budget schedule.
7) Preparation of budget report: this report comprises of a) narrative section
summarizing the budget of explaining the budget plan for the year ahead, including
the anticipated operating result and principal factors entering into increases and
decreases in income and expenditure b) budget statements and supporting schedules
in a concrete manner c) a comprehensive presentation of budget informations by
activities and cost centres.
8) Review of the budget report by the administrator of the organization who ultimately
presents it to the board of trustees.
9) Evaluation of the budget as an operating plan, incorporating any changes and
presenting it to the finance committee.
10) The finance committee may further initiate any changes or modifications before
finally presenting to the board for its consideration and decision.
11) Final approval by the board.
THE BUDGET CALENDAR
Formulation stage:
1. Develop objectives and management plans
2. Gather all financial, historical and statistical data and distribute

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to cost center managers
3. Analyze data
Review and enactment stage:
4. Prepare unit budgets
5. Present unit budgets for approval
6. Revise and combine into organization budget.
7. Present to budget council
8. Revise and present to governing board
9. Revise and distribute to cost center managers
Execution stage
10. Direct and evaluate expenses and receipts
11. Review budgets if indicated
BUDGETING CYCLE:
The nurse administrator should use a system approach in designing and implementing a
planning program budgeting cycle as follows
1. Agency goals are reviewed to identify activities of highest priority, because these are
most likely to receive funding.
2. Objectives are reviewed for existing programs and written for proposal programs to
ensure that achievement of these objectives will support agency mission.
3. Existing programs are revised and proposed programs designed to maximize goal
achievement.
4. Labour, capital and operating expenses are computed for each program, old and new.
5. Alternative methods are identified for realizing designated objectives and price of
each alternative is determined.
6. Comparisons are made to determine which alternative is most cost –effective
7. A budget request is developed that details a fiscal plan for the preferred program,
indicates alternative methods for meeting the same objective and explain why the
recommended program is preferred.
Cost expenditure:
Cost can be defined as the value of economic resources used for producing a
commodity or for carrying out the activity for providing services, which consist of two
components, i.e quantity used and price fixed.
Cost is the expenditure required to achieve a desired object. The total cost of a budget,
service or program includes all significant elements-monetary property and personnel
resources that are consumed to acquire or achieve the object service or program. Total cost
can be direct or indirect labour cost.

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1. Direct labor costs are wages paid to employees who are directly engaged in
productive output, e.g. services to client.
2. Indirect labor cost includes all labor costs not included in direct costs, such as salaries
to supervisors on above categories,e.g. services to ANO.
3. Semi variable costs are expenses that change as volume of output changes but not in
direct proportion to the change in output, e.g. IJE.
4. Period costs are expenses that are associated with a period of time rather than with a
level of activity,e.g. insurance premium.
5. Committed costs are expenses that are required to maintain an agencies legal and
physical existence, e.g. license fee, application fees.
6. Programmed costs are expenses that are subjected to managerial control but relatively
unconnected to current activities, e.g. research costs.
7. Overhead costs are expenses that are essential to agency operations but cannot be
directly related to work volume or service delivery, e.g. cost of housekeeping or basic
amenities.
3. Audit:
Audit is an independent appraisal activity within an organization for review of
accounting, financial and other operation as a basis of services to the management. It is
monitoring the budget process. Here, the budget reports are needed to monitor expenditure
and keep the budget process focused on long- range objectives. The most common tools are
Capital inventory is an itemized list of current capital asset that enumerates each piece of
capital equipment, together with items serial number, current valuation, and physical
location, e.g.checking stock register and inventory.
Supply inventory is itemized list of available supplies. It is needed to implement the
operating budget for each unit.
Position control systemis a status of each budgeted position. The serial number assigned to
each budgeted position should indicate both the job classification and the budget unit and cost
centre which the position is assigned it should be documented, dated and identified the nature
of transactions and facilitates later retrieval information.
Monthly account reports are reports of the amount spent and remaining per item, e.g salary,
T.A.etc
Cost accounting is process of linking each expenditure to its purposes.
Variance analysis a variance is a discrepancy between the amount of funds intended to be
spent for particular purpose and the amount of funds actually used for that purpose.
Variance analysis is a process that has the following four steps
1. Founds required for each budget item or expenditure are calculated for the expected
level of activity.
2. For each budget item, the difference between actual and planned expenditure is
calculated.

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3. These differences or variances are examined and the cause of each variance is
identified.
4. Each positive variance (amount expended that exceeds the amount budgeted) is
corrected either by increasing the funds allocated for the item or decreasing
expenditure for it.
The common causes of budget variance are:
1. Unanticipated increase in supply or equipment price.
2. Bills received in a different month from when purchases were made.
3. Higher-than- expected inflation rate.
4. Failure to calculate the cost of disposable supplies needed for new equipment.
5. Professional practice charges that entail additional purchase.
6. Unforeseen technological improvement demanded by patients and doctors.
7. Reimbursement changes that alter the type and volume of service delivered.
8. New medical staff members who implement new treatments requiring new equipment
and supplies.
9. Changes in safety or injection –control standard.
10. Excessive breakage of equipment by untrained staff.
11. Opening or closing of nursing unites.
12. Improperly budgeting unproductive time.
The responsibility of nursing administration in budget includes the following.
1. Participation in planning budget.
2. Consult and take assistance of his /her subordinate in determining the needs of the
unit for ensuing year on the basis of information received.
3. Request sufficient funds to suggest a sound programme such as provide for
developing programme provision, expansion of programme, to attract and hold
qualified staff to provide for expansion of physical facilities, supplies, equipment, for
improving instruction (school and college) and also to carry out adequate functions of
the institution.
4. Submit budget request with justification with proposed expenditure. The
administrators define his/her budget so that nursing unit will have enough money to
conduct programme effectively. Money must be available to allow experimentation
also.
5. He/she should support the budget and interpret the subordinates, any changes that
may affect instruction services for the adopted budget. He/she secures for the adapted
budge and responsibility of the administrator to see that expenditure should not
exceed the appropriation made.
6. Nurse administrator also is responsible for budget, and covers the routine budget
control.

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To sum up the general rules and functions administrator/manager in budgeting are as
given below:
Rules: He/she:
1. Is visionary in identifying or forecasting short and long term unit needs, thus inspiring
proactive rather than reactive fiscal planning.
2. Is knowledgeable about political, social and economic factors that shape fiscal
planning in health care today.
3. Demonstrates flexibility in fiscal goals setting in a rapidly changing system.
4. Anticipates, recognises and creativity problem-solves budgetary constraints.
5. Influences and inspires group members to become active in short and long range
fiscal planning.
6. Recognises when fiscal constraints have result in an inability to meet organisational or
unit goals and communicate this insight effectively, following the chain of command.
7. Ensures that client safely is not jeopardised by cost contents.
Functions:
1. Identifies the importance of, and develops short and long range fiscal plans that reflect
unit need.
2. Articulates and documents unit needs effectively to higher administrative levels.
3. Assess the internal and external environment of the organizations in forecasting to
identify diving forces and barriers of fiscal planning.
4. Demonstrates knowledge of budgeting and uses appropriate techniques.
5. Provides opportunities for subordinates to participate in relevant fiscal planning.
6. Co-ordinates unit level fiscal planning to be congruent with organisational goals and
objectives.
7. Accusatively assesses personal needs using predetermined standards or an established
patient classification system.
8. Co-ordinates the monitoring aspects of budget control.
9. Ensures that documentation of clients need for services rendered in clear and
complete to facilitate organisational reimbursement.
Advantages of clinical budgeting:
1. Head of the clinical units are involved in planning, allocation of resources and
achievement of objectives.
2. Head of the clinical units seeks specific resources, personnel and equipment to
perform optimally the services.
3. Each clinical unit is responsible for expenditure including referrals, investigations,
drugs and materials and services from other departments.
4. Clinical budgeting leads to cost containment and control over wastage.
Conclusion:
The budget is very important in management of patients in health care setting .proper
planning of budget will improve the quality of services provided in the organization. So the
nurse should know about types, steps, and cost containment.

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4. COST EFFECTIVENESS AND COST ANALYSIS
INTRODUCTION
Cost-effectiveness analysis (CEA) is a form of economic analysis that compares the relative
expenditure (costs) and outcomes (effects) of two or more courses of action. Cost-
effectiveness analysis is often used where a full cost-benefit analysis is inappropriate e.g. the
problem is to determine how best to comply with a legal requirement. Typically the CEA is
expressed in terms of a ratio where the denominator is a gain in health from a measure (years
of life, premature births averted, sight-years gained) and the numerator is the cost of the
health gain. The most commonly used outcome measure is quality-adjusted life years
(QALY). Cost-utility analysis is similar to cost-effectiveness analysis.Cost-effectiveness
analysis is generally not equivalent to cost-benefit analysis (CBA). Cost is money expended
for all the resources used, including personnel, supplies, and equipment.
COST
DEFINITION
The total amount of money that needs to be spent by an organization or a person or
government.
TYPES OF COST
1. Fixed cost: Fixed costs are those costs which stay the same regardless of the level of the
activity. They are not related to volume. They remain constant as the volume increases
and decreases over the period of time. Among fixed costs are deprivation of equipments
and buildings, salaries, benefits, utilizes, interest on loans or bonds, and taxes.
Example: Fixed costs are those which would exist even if the organization were ―shut down‖.
2. Variable cost: Variable costs are those cost that change depending on the level of
volume. They do relate to volume and census (patient days). They include items such as
meals and linen. The cost of supplies varies by patient census, physician orders and
diagnosis.
Example: the cost of surgical dressings increases when the patient’s wound has drainage and
dressings to be changed frequently.
3. Sunk costs: Sunk costs are fixed expenses that cannot be recovered even if program is
canceled.
Example: Advertising
4. Accounting cost:
―A measure of cost based on a number of simplifications such as an assumed useful
life for a price of equipment.‖

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5. Average cost:
―Full cost divided by the number of units of service or patients‖
6. Cost center:
―A unit of department in an organization for which a manager is assigned
responsibility for costs.
7. Direct costs – direct costs are those expenses that directly effects patient care
Ex: salaries for the nursing personnel who provide hands on patient care is considered as
direct cost.
8. Indirect costs – indirect costs are the expenditures that are necessary but don’t effect
patient care directly.
Ex: salaries for dietary or housekeeping personnels.
9. Economic cost:
―The amount of money required to obtain the use of a resource.‖
10. Joint cost:
Costs that is required for the treatment of several or more types of patients. The cost
would not incur unless the organization stopped treating all of those different types of
patients.
11. Opportunity costs:
A measure of cost based on the value of the alternatives that are given up in order to
use the resources as the organization has chosen.
STAGES OF COSTS:
Costs have two stages:
1) Acquisition cost: when some asset or service is purchased, the resource given in
exchange represents the acquisition cost.
2) Expired cost: once the asset is fully consumed, it becomes an expired cost or an
expense.
FACTORS AFFECTING COST
The volume of service provided is the greatest factor affecting costs. Other factors
include length of patient stays, salaries, price of the material, case mix, seasonal factors, and
efiiciencies (such as simplification of procedures and quality management to prevent errors
that increase patient complications and increase costs). Still other factors that have an impact
on cost are regulation and competition for market share; third party payers; the age and size
of the agency; type and amount of services provided; the agency’s mission; and relationships
among nurses, physician and other personnel.

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COST CONTAINMENT
The goal of the cost containment is to keep cost within acceptable limits for
volume inflation, and other acceptable personnels. It involves the following:
1. Cost awareness.
2. Cost monitoring.
3. Cost management.
4. Cost avoidance.
5. Cost reduction.
6. Cost control.
COST AWARENESS:
It focuses the employees attention on costs. It increases organizational awareness of
what costs are, the process available for containing them, how they can be managed, and by
whom.
COST MONITORING:
It focuses on how much will be spent where, when and why. It identifies, reports and
monitors costs. Staffing costs should be identified. Recruitment, turnover, absenteeism, and
sick time are analysed, and inventories are controlled.
COST MANAGEMENT:
It focuses on what can be done by whom to contain costs. Programs, plans,
objectives,a nd strategies are important. Responsibility and accountability for the control
should be established. A committee can identify long and short range plans and strategies.
COST AVOIDANCE:
It means not buying supplies, technology, or services. Supply and equipment cost should
be carefully analyzed. Costs and effectiveness of disposable versus reusable items are
compared. The receipts, storage and delivery of disposables and labour and processing cost of
reusable items are part of the analysis. The least expensive and most effective supplies,
equipment, and services should be identified and expensive and less effective items avoided.
COST REDUCTION:
It means spending less for goods and services. The amount of reduction depends on the
size of the agency, previous efficiency, skills of managers, and cooperation of employees.
COST CONTROL:
It is effective use of available resources through careful forecasting, plaaning, budget
preparation, reporting and monitoring.
COST ANALYSIS
It is the system of analyzing the relationship between the fixed and the variable cost.

17
TYPES OF COST ANALYSIS
1. Cost benefit analysis [CBA]
2. Cost benefit ratio [CBR]
3. Cost effectiveness analysis [CEA]
4. Cost-of-illness analysis
5. Cost-minimization analysis
6. Cost utilization analysis
7. Cost consequences analysis
1. COST BENEFIT ANALYSIS [CBA]
Cost benefit analysis [CBA] is measurement of the relative costs and benefits
associated with a particular project or task.
The cost benefit analysis is a tool which is useful in setting priorities for various
sources of action to meet objectives, and provide an estimate of the net financial value
associated with each course of action (eg. Manpower and labour, material and equipment,
facilities). All the inputs and outputs have to be converted into momentary terms because all
inputs (ie costs) and all the outcomes (ie benefits) are valued in money terms.
OR
It is a procedure by which all the costs resulting from installing and operating a system
are determined and converted to a money amount and the ratio is calculated to reflect the
relationship of costs and benefits.
OR
Cost benefit analysis [CBA] is tool with great potential for the decision makers so long
as he or she recognizes the difficulty in determine the true costs and benefits of various
alternatives. This tool can especially useful when trying deciding between alternative
expenditure of money.‖
BASIC APPROACHES OF COST BENEFIT ANALYSIS
Two basic approaches for cost-benefit analysis (CBA) are-
 Ratio approach
 Net benefit approach.
Ratio approach: The ratio approach indicates the amount of benefits (or outcomes)
that can be realized per unit expenditure on a technology vs. a comparator. In the ratio
approach, a technology is cost beneficial vs. a comparator if the ratio of the change in costs to
the change in benefits is less than one.
Net benefit approach: The net benefits approach indicates the absolute amount of
money saved or lost due to a use of a technology vs. a comparator. In the net benefits
formulation, a technology is cost-beneficial vs. a comparator if the net change in benefits
exceeds the net change in costs.

18
2. COST BENEFIT RATIO [CBR]
―It is the numerical relationship between the value of the financial cost of a program
and the value of benefits‖
―It is defined as the ratio of the Value of benefits of an alternative to the value of
alternative cost.‖
Z= present value of economic benefits
Present value of economic cost.
Cost benefit analysis is often used in the public sector where there is no net income to
serve as a guideline.
In order to determine the ratio, it is necessary to assign value to both the cost and the
benefits in monetary terms. In practice, it is difficult to assign monetary values to health care
outcomes. It is difficult to measure the value of life and even more difficulty in measuring the
difference in health outcomes that do not involve life or death.
Cost benefit analysis is designed to consider the social cost and benefits attributable to
the project. The benefits are expressed in monetary terms to determine whether a given
program is economically sound, and to select the best out of several programs.
3. COST-OF-ILLNESS ANALYSIS: A determination of the economic impact of an illness
or condition (typically on a given population, region, or country) e.g., of smoking, arthritis
or bedsores, including associated treatment costs
4. COST-MINIMIZATION ANALYSIS: A determination of the least costly among
alternative interventions that are assumed to produce equivalent outcomes
5. COST-UTILITY ANALYSIS (CUA): A form of cost-effectiveness analysis that compares
costs in monetary units with outcomes in terms of their utility, usually to the patient,
measured, e.g., in QALYs
6. COST-CONSEQUENCE ANALYSIS: A form of cost-effectiveness analysis that presents
costs and outcomes in discrete categories, without aggregating or weighting them
7. COST EFFECTIVENESS ANALYSIS [CEA]:
―A technique that measure the cost of alternatives that generate the same outcome‖
OR
Cost effectiveness analysis is the technique for choosing, from alternative courses
of action, a preferred choice when objectives are not clear in such areas as sales, costs or
profits.
OR
It is a desired effect of careful planning.
OR
It means getting the most for your money.
OR
The product is worth the price.

19
Cost effective methods are those search for the last costly way of
achieving a defined result. Cost effective analysis are easier to make as that is clear. It helps
the administrator in managing his health resources. The problem is to find the way of
achieving the objective at lower cost‖
A more cost effectiveness analysis [CEA] oriented approach would consider
different approaches to save a life, and find out which one cost least, that would be the cost
effective that generate similar outcomes.
For ex: suppose a hospital has been treating a certain type of patient using a particular
approach is cost effective, we must first establish that the clinical money than the old
approach. If a new approach generates the exact outcome for less money then it is cost
effective.
STEPS IN COST EFFECTIVENESS ANALYSIS:
1. Identify the program goal or client outcome to be achieved.
2. Identify at least 2 alternatives means of achieving the desired outcomes.
3. Collect baseline data on clients.
4. Determine the cost associated with each program activity.
5. Determine the activities of each group of clients will receive.
6. Determine the client changes after the activities are completed. Combine the cost,
amount of activity and outcome information to express costs relatives to outcome of
program goals.
7. Compare cost outcome information for each goal to present cost effectiveness
analysis
COST EFFECTIVENESS ANALYSIS BASICS
A general misconception is that CEA is merely a means of finding the least
expensive alternative or getting the ―most bang for the buck.‖In reality, CEA is a comparison
tool; it will not always indicate a clear choice, but it will evaluate options quantitatively and
objectively based on a defined model. CEA was designed to evaluate health care
interventions, but the methodology can be used for non health economic applications as well.
It can compare any resource allocation with measurable outcomes to any other resource
allocation with measurable outcomes.
CONDUCTING, EVALUATING, AND USING ANALYSES
Increasing numbers of analyses are conducted in academia or research
organizations and published in peer-reviewed journals. Government organizations use
analyses to help shape public policy. Health insurers use CEAs to determine which kinds of
health interventions to cover.
COST-EFFECTIVENESS RATIO
The cost-effectiveness ratio is simply the sum of all benefits divided by the sum of all
costs. This is comparable to a return on investment calculation; however, the benefits are not
measured in terms of just dollars, but in a ratio that incorporates both health outcomes
and dollars.

20
Cost-Effectiveness Ratio = ∑ (All benefits)
∑(All costs)
WHY EMPLOYERS USE CEA?
✓Supports objective decision making: Decision makers can consider options in a
comparable and objective way that provides support for the final decision.
✓Brings clarity to data sources and outcomes: CEA evaluates options in similar terms to
avoid ―comparing apples to oranges.‖
✓Allows for strategic review of organizations: CEA might justify some operational
centers operating at a loss to increase overall return on investment, employee health,
or both.
✓Can be used in a host of operational and benefits areas including:
o Screening coverage
o Pharmacy
o Strategic Planning
o Labor Relations
o Disease Management
o Disability Management
o Wellness and Prevention Programs
✓Presents evidence that can help gain support for changes in benefits plans or
employer-sponsored health programs.
STRATEGIC TIPS FOR INTERPRETING A CEA
✓ Consider perspective. Which parties are incurring costs and which parties are
receiving benefits? Many studies take a broad societal perspective; they are usually
not
written for an employer audience.
✓Identify the strategies under comparison. Does the study compare different
alternatives (treat using drug A vs. treat using drug B) or examine incremental
changes in the same health intervention (screen every two years vs. screen every four
years)?
✓Be aware of the analytic horizon. When are costs incurred and when are benefits
received? Most studies use a 3-5% annual discount rate to adjust both costs and
benefits to a present value, but if a benefit is not received until 10 years after an
intervention begins, this is important information to note.
✓Analyze all stated assumptions. Are the assumptions built into the economic model
clearly defined, and are they valid for employers?
✓Examine the sensitivity analysis. How do differences in data inputs affect the
outcome? Think how this relates to the health characteristics of your employee
population.
✓Understand all metrics. How did the author present the cost-effectiveness ratio?

21
Most studies measure the costs of increased quality of life ($/quality adjusted life year
gained), disability prevented ($/disability adjusted life year prevented) or of life saved
($/life year gained). A study that measures quality adjusted life years is called a
cost-utility analysis, a specific type of CEA.
COST EFFECTIVENESS IN IMPROVING HEALTH CARE
Cost-effective care is that judged to provide good health value for expenditure. Health
value refers to the benefits of a particular medical intervention, which might include longer
life, better quality of life, or both. Expenditures should include not only the costs of a test or
treatment itself, but the subsequent costs it might cause, including additional medical
interventions, work disability, costs of longterm care, and so forth.
Cost-effectiveness analysis is a method for assessing the gains in health relative to the
costs of different health interventions. It is not the only criterion for deciding how to allocate
resources, but it is an important
one, because it directly relates the financial and scientific implications of different
interventions. The basic calculation involves dividing the cost of an intervention in monetary
units by the expected health gain measured in natural units such as number of lives saved.
PRINCIPLES WHICH ARE BASIC TO COST EFFECTIVENESS IN HEALTH
CARE:
 Government health care programs should be screened for cost effectiveness.
 Health education and physical fitness should be primary curricular items in our entire
educational system from elementary through secondary schools. Healthy life-styles for
adults should include continued health education, disease prevention and physical
exercise.
 Health promotion and disease prevention must receive primary emphasis on all health
care plans with payment for such medical care being equal to or greater than that
provided for acute medical care.
 Major efforts must be made throughout the profession to promote and emphasize
quality ambulatory care provided by those best trained to provide such care -- the
family physician.
 There should be incentives provided to both physicians and patients to maximize value
in health care: highest quality at lowest costs.
 Medical education should emphasize cost awareness and cost effectiveness at all levels
of education -- undergraduate, graduate and continuing medical education programs.
 Patients must be educated regarding the necessity of their involvement in cost-effective
medical care and in cost containment. This can be achieved through informational
programs emphasizing personal responsibility for healthy life-styles and cost-effective
medical care. The use of health insurance deductibles and co-payments are also useful
tools in emphasizing cost containment but these should not be prohibitive in achieving
access to quality health care.

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PURPOSE OF COST ANALYSIS
1. The administrator utilizes data provided by a cost study to interpret the needs
of the nursing units and to gain financial support for the unit.
2. It can be used to show the portion of the requested funds being used for
research programs.
3. It will show the relationship of the faculty salaries to the cost per student.
4. It assists the administrator in measuring change and provides the necessary
data which can serve as a guide in modifying the program.
5. It gives the supporting data when the board of trustees, central administrators,
legislators, foundations and other groups question the high cost of nursing
education.
6. It provides valuable information for institutions questions of higher learning
that wish to establish a new baccalaureate program.
STEPS OF ANALYSIS:
1. A clear statement of objectives.
2. Identifying all alternative actions that can achieve the objectives.
3. Identifying all the costs and all benefits with each alternative.
4. Converting all costs and all benefits for each alternative to momentary value,
and quantitive evaluation of costs and benefits of each.
5. Selection of the best cost- effective approach.
THE ROLE OF THE ADMINISTRATOR IN COST ANALYSIS
1. Understanding methods of cost analysis and participating with cost study of
nursing units and for the college. The administrator needs to know the cost of
operating the nursing education unit in order to make wise education
decisions. A school of nursing should operate economically and efficiently.
2. The administrator interprets the cost analysis to the faculty and others, and she
gains support for the study. She interprets findings to the personnel at the
college and at the health services agencies.
3. The administrator participates in the cost analysis committees: the cost
analysis committee is composed of the finance officer, dean of the college, a
nurse faculty member, the administrator of the school of nursing,
representatives from the central administrator of the health service agencies
and directors of nursing service for the various agencies involved.
4. The administrator encourages and leads to members of the overall study staff.
CONCLUSION:
Cost-Effectiveness in Health and Medicine is the product of over two years of
comprehensive research and deliberation by a multi-disciplinary panel of economists,
ethicists, psychometricians, and clinicians.
This study published in the Journal of the American Medical Association shows that nicotine
patch therapy, in conjunction with physician counseling, is a cost-effective approach to
smoking cessation. This is an example of information in published CEAs that can support
coverage decisions and justify health improvement programs.

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5. COST ACCOUNTING
Cost accounting is a process that supports the budget reporting system and agency
efforts for cost containment.
Cost accounting is a set of techniques for associating cost with the purpose for which
in curred.
In accounting the only facts recorded are those that can be pressed in monitory terms.
Advantages of Cost accounting:
1) The accumulated data enable a head nurse or divisional nursing director to assess
the cost of cost extra demand imposed on the nursing unit, such as abortion, oral
surgery.
2) It enables a manager to identify the interaction between different expenditures.
3) Through Cost accounting a manager can determine whether hiring additional
operating room or clinical care employees. Increase the unit expenditure for scrub
clothes, sterile supplies and bed linen.
4) It enables the manager to identify popular services program that receive hidden
founding in the form of voluntary time contributions by professionals from the
other units.
5) In some health care agencies, in house clinical nurse experts who are assigned to
various clinical specialty units, serve as volunteer teacher for in service programs.
Disadvantages of Cost accounting:
1. It is difficult to associate some cost with particular program
2. A cost incurred at one point in time may facilitate service programs over an
extended period.
3. It is the fact that it is difficult for a manager to justify the cost of a nursing care
program. When quantifiable measures of all patients outcomes of not variable.
Cost reduction:
Cost reduction means spending less for goods and service. The amount of reduction
depends on the size of the agency, previous efficiency, and skill of manager and cooperation
of employees. Safety programs that reduce the costs of workers, compensation and safety
programs that reduce the costs of workers compensation and absenteeism program that
reduce sick time, absenteeism and turn over reduce costs.
Factors influencing need for cost reduction
The capital funding availability for hospitals is not as attractive as industry. No doubt,
the financing institutions are ready to finance the hospitals today to the tune of several
croups, but the hospital project can never be as financially available as an industrial project.
Inability to generate finds through donation

24
The tax benefits available to a donor for making contribution to the hospital are not at
par with the tax benefits for donations to religious, educational, and other programs or
institutions. Therefore, it is difficult to attract donations.
Demographic factors
Due to uncontrolled population there is an increased demand for services for longer
periods. This is more critical for public hospitals, public sector industrial hospitals, and
missionary hospitals. Of course, private sector would benefit.
Inflation
Due to higher inflation there is an erosion of purchasing power. Financial resources of the
country are tight. The budgets of the public hospitals are not going, increased appreciably for
few years. The administrators would have to manage with tight budget. As a result, there
would be limited materials and equipment.
Increased demand and expectations.
Due to health education and awareness, there is an increased demand and expectations
on the [part of the pubic and employees in industrial hospitals. Since there is greater
possibility of treatment of chronic and degenerative diseases, open- heart surgeries, organ
transplantations, dialysis treatment, there is great demand and expectations for treatment.
Capital cost of building and materials
The capital cost of construction of buildings and materials have increased
considerably even the maintenance of the buildings require higher budget.
Maintenance of equipment, materials and vehicles
Cost of spare- part, serving of the equipment, diagnostic and therapeutic materials,
maintenance of the vehicles are continually increasing. The above are some of the factors
influencing the increased cost necessitating cost reduction.
Area of cost reduction in hospitals
There are 4 input variables in health care
1. physicians – professionals – technical inputs
2. patients and relatives of the patients as consumers
3. therapy- drugs, super equipment, ect- raw materials
4. Para-medical and administrative staff-support services

25
6. CRITICAL PATHWAYS
Clinical Pathways: multidisciplinary plans of best clinical practice. Many synonyms
exist for the term Clinical Pathways including: Integrated Care Pathways, Multidisciplinary
pathways of care, Pathways of Care, Care Maps, and Collaborative Care Pathways.
Clinical Pathways were introduced in the early 1990s in the UK and the USA, and are being
increasingly used throughout the developed world. Clinical Pathways are structured,
multidisplinary plans of care designed to support the implementation of clinical guidelines
and protocols. They are designed to support clinical management, clinical and non-clinical
resource management, clinical audit and also financial management. They provide detailed
guidance for each stage in the management of a patient (treatments, interventions etc )
with a specific condition over a given time period, and include progress and outcomes details.
Clinical Pathways aim to improve, in particular, the continuity and co-ordination of care
across different disciplines and sectors. Care Pathways can be viewed as algorithms in as
much as they offer a flow chart format of the decisions to be made and the care to be
provided for a given patient or patient group for a given condition in a step-wise sequence.
Clinical Pathways have four main components (Hill, 1994, Hill 1998):
1. A timeline
2. The categories of care or activities and their interventions
3. Intermediate and long term outcome criteria
4. The variance record (to allow deviations to be documented and analysed).
Clinical Pathways differ from practice guidelines, protocols and algorithms as they are
utilised by a multidisciplinary team and have a focus on the quality and co-ordination of care.
Critical pathways, also known as critical paths, clinical pathways, or care paths, are
management plans that display goals for patients and provide the sequence and timing of
actions necessary to achieve these goals with optimal efficiency. As competition in the
healthcare industry has increased, managers have embraced critical pathways as a method to
reduce variation in care, decrease resource utilization, and potentially improve healthcare
quality. Cardiovascular medicine in particular is an area in which critical pathways have been
embraced. This is due in part to the high volume and high cost associated with cardiovascular
diseases and procedures. In addition, the relatively mature guideline process has also
contributed to the growth in use of critical pathways in cardiology.
Clinical guidelines :Although anchored in clinical guidelines, the critical pathway is a
distinct tool that details processes of care and highlights inefficiencies regardless of whether
there is evidence to warrant changes in those processes. Clinical guidelines, on the other
hand, are consensus statements that are systematically developed to assist practitioners in
making patient management decisions related to specific clinical circumstances. Although
clinical guidelines can and should be used in pathway development, the majority of processes
included in a pathway have not been rigorously tested and are generally not addressed in
guidelines.

26
Clinical protocols: Another term that should also be distinguished from critical pathways is
clinical protocols. Protocols are treatment recommendations that are often based on
guidelines. Like the critical pathway, the goal of the clinical protocol may be to decrease
treatment variation. However, protocols are most often focused on guideline compliance
rather than the identification of rate-limiting steps in the patient care process. In further
contrast to critical pathways, protocols may or may not include a continuous monitoring and
data-evaluation component.
Critical pathway techniques were first developed for use in industry as a tool to
identify and manage the rate-limiting steps in production processes. In industry, any variation
in production process is suboptimal. Thus, by defining the processes and timing of these
processes, managers could target areas that were critical, measure variation, and try to make
improvements. Once steps were taken to improve the process, there would be a
remeasurement. In time, variation would decrease, the time it took to complete the pathway
would decrease, costs would decrease, and quality of production would improve.
When applied to health care, the technique of critical pathways has obvious concerns.
First, unlike in manufacturing, not all variation in patient care is negative. Individual patient
factors may contribute to variation that cannot and should not be controlled by the system. For
example, if postoperative extubation occurred within a prespecified time period based on a
pathway, there would be early extubations with potential for harm. Also unlike in
manufacturing, in which the products are standardized, patients are different and may not fit
within a pathway. Second, there exists concern that streamlining care may have a negative
impact on patient outcomes. For example, if a care pathway suggests a 2-day stay in the
cardiac care unit, a provider may alter care against his or her best judgment to stay within the
plan. Finally, physicians have objected to "cookbook medicine" and have felt an erosion of
professional autonomy with the critical pathways. Without physician support of the pathway,
it is unlikely to achieve any of the stated cost-saving or quality goals.
Despite these obvious limitations, the use of critical pathways is being embraced in
many systems. Although designed as a tool for both cost savings and improved quality of
care, it is the former that has been emphasized by managers. Interest in critical pathways has
increased because anecdotal reports of cost savings have been disseminated. These reports are
best described as case studies and in general have not followed careful study designs.
Implementation of the care pathways has not been tested in a scientific or controlled fashion
No controlled study has shown a critical pathway to reduce length of stay, decrease resource
use, or improve patient satisfaction. Most importantly, no controlled study has shown
improvements in patient outcome.
Lack of careful evaluation has not limited the development and implementation of
critical pathways in multiple healthcare settings. It is important for cardiovascular
practitioners to understand the goals, development, and implementation of critical pathways.
In addition, physicians must take an active role in the development of critical pathways. By
understanding the strengths and limitations of the critical pathway process, physicians and
other practitioners can ensure appropriate use of these methods. In a review of critical

27
pathways, Pearson et al examined the goals of critical pathways, optimal pathway
development, and implementation strategies
Critical Pathway Development
Select a Topic .
Topic selection in general should concentrate on high-volume, high-cost diagnoses and
procedures. Critical pathway development has focused on several cardiovascular diseases and
procedures because of volume and costs. These include bypass surgery, diagnostic
catheterization, coronary angioplasty, acute myocardial infarction, and unstable angina. These
diagnoses and procedures tend to be more suitable for critical pathway development because
of the predictable course of events that occur during the hospitalization. In addition, marked
variation in care has been observed in these conditions, which makes the goal of decreased
variation and reduction in resource utilization possible. Furthermore, there has been evidence
of noncompliance with guideline recommendations. In this case, the pathways might improve
guideline compliance and potentially improve quality of care.
Select a Team .
It is important to develop a multidisciplinary team for critical pathway development.
Historically, critical pathway development has been a nursing initiative. Although this has
been a successful model in some institutions, one fault of this process is lack of physician
commitment to the pathway. Active physician participation and leadership is crucial to the
development and implementation of the pathway. In addition, it is important to include
representatives from all groups that would be affected by the pathway, for example, house
staff, physical therapy personnel, and dietary personnel. The lack of involvement of
physicians has been cited as a reason for failure of a pathway.
Evaluate the Current Process of Care .
In this step, data, rather than anecdotal reports, are key to understanding current
variation. For systems with electronic medical records, this process may be more automated.
For other systems, a careful review of medical records is necessary to identify the critical
intermediate outcomes, rate-limiting steps, and high-cost areas on which to focus.
Evaluate Medical Evidence and External Practices .
After key rate-limiting steps have been identified, the critical pathway team must evaluate the
literature to identify evidence of best practices. For most rate-limiting steps, there are few
data available to define optimal processes of care. The critical pathway development team
will often lack answers to specific questions such as appropriate observation period or
length of stay. In the absence of evidence, comparison with other institutions, or
"benchmarking," is the most reasonable method to use.
Determine the Critical Pathway Format .
The format of the pathway may vary widely. Important features include a task-time
matrix in which specific tasks are specified along a timeline. There is a spectrum of pathways
that range from a form that takes the place of the medical record to a simple checklist. A
reduction in charting that may occur with more complicated pathways is a benefit. However,

28
if the pathway format is too difficult to follow, it will not be used. Critical pathways have
become widely available in electronic format, where electronic charting and pathway
compliance are obtained simultaneously. One disadvantage to this method is the absence of a
standard medical record. This may result in duplication of efforts and possible noncompliance
with the pathway. This is particularly true among physicians who are likely to be resistant to
novel charting methods. For some systems, a simple checklist at the front of the paper chart
may be an optimal method for implementing the pathway. These checklists would have areas
to be filled in by different staff members active in patient care.
Document and Analyze Variance .
Variances are patient outcomes or staff actions that do not meet the expectation of the
pathway. In general, variance in clinical pathways is a result of the omission of an action or
the performance of an action at an inappropriate (often, a late) time period. Because the
critical pathway is a series of time-associated actions, this analysis of variance can be
overwhelmed by multiple data points. Computer-assisted pathway analysis can help with this
issue. Another approach is for the pathway team to concentrate on a few critical items in the
pathway that have been identified in advance, such as extubation time after cardiac surgery or
length of stay in the intensive care unit. These are critical intermediate outcomes that may
have a substantial number of important contributory factors. Arguably, the selection of areas
to analyze and the analysis of variance are among the most important processes in the critical
pathway. Identification of factors that contribute to variance and interventions to improve
those factors are the key features in process improvement.
Critical Path Analysis and PERT Charts
Critical Path Analysis and PERT are powerful tools that help you to schedule and
manage complex projects. They were developed in the 1950s to control large defense
projects, and have been used routinely since then.
As with Gantt Charts, Critical Path Analysis (CPA) or the Critical Path Method (CPM) helps
you to plan all tasks that must be completed as part of a project. They act as the basis both for
preparation of a schedule, and of resource planning. During management of a project, they
allow you to monitor achievement of project goals. They help you to see where remedial
action needs to be taken to get a project back on course.
Within a project it is likely that you will display your final project plan as a Gantt Chart
(using Microsoft Project or other software for projects of medium complexity or an excel
spreadsheet for projects of low complexity).The benefit of using CPA within the planning
process is to help you develop and test your plan to ensure that it is robust. Critical Path
Analysis formally identifies tasks which must be completed on time for the whole project to
be completed on time. It also identifies which tasks can be delayed if resource needs to be
reallocated to catch up on missed or overrunning tasks. The disadvantage of CPA, if you use
it as the technique by which your project plans are communicated and managed against, is
that the relation of tasks to time is not as immediately obvious as with Gantt Charts. This can
make them more difficult to understand.

29
A further benefit of Critical Path Analysis is that it helps you to identify the minimum length
of time needed to complete a project. Where you need to run an accelerated project, it helps
you to identify which project steps you should accelerate to complete the project within the
available time.
How to Use the Tool:
As with Gantt Charts, the essential concept behind Critical Path Analysis is that you
cannot start some activities until others are finished. These activities need to be completed in
a sequence, with each stage being more-or-less completed before the next stage can begin.
These are 'sequential' activities.
Other activities are not dependent on completion of any other tasks. You can do these at any
time before or after a particular stage is reached. These are non-dependent or 'parallel' tasks.
Drawing a Critical Path Analysis Chart
Use the following steps to draw a CPA Chart:
Step 1. List all activities in the plan
For each activity, show the earliest start date, estimated length of time it will take, and
whether it is parallel or sequential. If tasks are sequential, show which stage they depend on.
For the project example used here, you will end up with the same task list as explained in the
article on Gantt Charts (we will use the same example as with Gantt Charts to compare the
two techniques). The chart is repeated in Figure 1 below:
Figure 1. Task List: Planning a custom-written computer project
Task Earliest
start
Length Type Dependent
on...
A. High level analysis Week 0 1 week Sequential
B. Selection of hardware platform Week 1 1 day Sequential A
C. Installation and commissioning of
hardware
Week 1.2 2 weeks Parallel B
D. Detailed analysis of core modules Week 1 2 weeks Sequential A
E. Detailed analysis of supporting
modules
Week 3 2 weeks Sequential D
F. Programming of core modules Week 3 2 weeks Sequential D
G. Programming of supporting
modules
Week 5 3 weeks Sequential E

30
H. Quality assurance of core modules Week 5 1 week Sequential F
I. Quality assurance of supporting
modules
Week 8 1 week Sequential G
J.Core module training Week 6 1 day Parallel C,H
K. Development and QA of
accounting reporting
Week 5 1 week Parallel E
L. Development and QA of
management reporting
Week 5 1 week Parallel E
M. Development of Management
Information System
Week 6 1 week Sequential L
N. Detailed training Week 9 1 week Sequential I, J, K, M
Step 2. Plot the activities as a circle and arrow diagram
Critical Path Analyses are presented using circle and arrow diagrams.
In these, circles show events within the project, such as the start and finish of tasks. The
number shown in the left hand half of the circle allows you to identify each one easily.
Circles are sometimes known as nodes.
An arrow running between two event circles shows the activity needed to complete that task.
A description of the task is written underneath the arrow. The length of the task is shown
above it. By convention, all arrows run left to right. Arrows are also sometimes called arcs.
An example of a very simple diagram is shown below:
This shows the start event (circle 1), and the completion of the 'High Level Analysis' task
(circle 2). The arrow between them shows the activity of carrying out the High Level
Analysis. This activity should take 1 week.
Where one activity cannot start until another has been completed, we start the arrow for the
dependent activity at the completion event circle of the previous activity. An example of this
is shown below:

31
Here the activities of 'Select Hardware' and 'Core Module Analysis' cannot be started until
'High Level Analysis' has been completed. This diagram also brings out a number of other
important points:
 Within Critical Path Analysis, we refer to activities by the numbers in the circles at
each end. For example, the task 'Core Module Analysis' would be called activity 2 to
3. 'Select Hardware' would be activity 2 to 9.
 Activities are not drawn to scale. In the diagram above, activities are 1 week long, 2
weeks long, and 1 day long. Arrows in this case are all the same length.
 In the example above, you can see a second number in the top, right hand quadrant of
each circle. This shows the earliest start time for the following activity. It is
conventional to start at 0. Here units are whole weeks.
A different case is shown below:
Here activity 6 to 7 cannot start until the other four activities (11 to 6, 5 to 6, 4 to 6, and 8 to
6) have been completed.

32
Click the link below for the full circle and arrow diagram for the computer project we are
using as an example.
Figure 5: Full Critical Path Diagram
This shows all the activities that will take place as part of the project. Notice that each
event circle also has a figure in the bottom, right hand quadrant. This shows the latest finish
time that's permissible for the preceeding activity if the project is to be completed in the
minimum time possible. You can calculate this by starting at the last event and working
backwards.The latest finish time of the preceeding event and the earliest start time of the
following even will be the same for ciircles on the critical path.
You can see that event M can start any time between weeks 6 and 8. The timing of
this event is not critical. Events 1 to 2, 2 to 3, 3 to 4, 4 to 5, 5 to 6 and 6 to 7 must be started
and completed on time if the project is to be completed in 10 weeks. This is the 'critical path'
– these activities must be very closely managed to ensure that activities are completed on
time. If jobs on the critical path slip, immediate action should be taken to get the project back
on schedule. Otherwise completion of the whole project will slip.
'Crash Action'
It is the need to complete a project earlier than the plan Critical Path Analysis says is
possible. In this case one need to re-plan the project.
Here, one has a number of options and would need to assess the impact of each on the
project’s cost, quality and time required to complete it. For example, one could increase
resource available for each project activity to bring down time spent on each but the impact
of some of this would be insignificant and a more efficient way of doing this would be to
look only at activities on the critical path.
As an example, it may be necessary to complete the computer project in Figure 5 in 8
weeks rather than 10 weeks. In this case one could look at using two analysts in activities 2 to
3 and 3 to 4. This would shorten the project by two weeks, but may raise the project cost –
doubling resources at any stage may only improve productivity by, say, 50% as additional
time may need to be spent getting the team members up to speed on what is required,
coordinating tasks split between them, integrating their contributions etc.
In some situations, shortening the original critical path of a project can lead to a
different series of activities becoming the critical path. For example, if activity 4 to 5 were
reduced to 1 week, activities 4 to 8 and 8 to 6 would come onto the critical path.
As with Gantt Charts, in practice project managers use software tools like Microsoft
Project to create CPA Charts. Not only do these make them easier to draw, they also make
modification of plans easier and provide facilities for monitoring progress against plans.

33
PERT (Program Evaluation and Review Technique)
PERT is a variation on Critical Path Analysis that takes a slightly more skeptical view
of time estimates made for each project stage. To use it, estimate the shortest possible time
each activity will take, the most likely length of time, and the longest time that might be
taken if the activity takes longer than expected.
Use the formula below to calculate the time to use for each project stage:
shortest time + 4 x likely time + longest time - 6
This helps to bias time estimates away from the unrealistically short time-scales normally
assumed.
Importance
Critical Path Analysis is an effective and powerful method of assessing:
 What tasks must be carried out.
 Where parallel activity can be performed.
 The shortest time in which you can complete a project.
 Resources needed to execute a project.
 The sequence of activities, scheduling and timings involved.
 Task priorities.
 The most efficient way of shortening time on urgent projects.
An effective Critical Path Analysis can make the difference between success and failure on
complex projects. It can be very useful for assessing the importance of problems faced during
the implementation of the plan.
PERT is a variant of Critical Path Analysis that takes a more skeptical view of the time
needed to complete each project stage.
CPM - Critical Path Method
In 1957, DuPont developed a project management method designed to address the
challenge of shutting down chemical plants for maintenance and then restarting the plants
once the maintenance had been completed. Given the complexity of the process, they
developed the Critical Path Method (CPM) for managing such projects.
CPM provides the following benefits:
 Provides a graphical view of the project.
 Predicts the time required to complete the project.
 Shows which activities are critical to maintaining the schedule and which are not.

34
CPM models the activities and events of a project as a network. Activities are depicted as
nodes on the network and events that signify the beginning or ending of activities are
depicted as arcs or lines between the nodes. The following is an example of a CPM network
diagram:
CPM Diagram
Steps in CPM Project Planning
1. Specify the individual activities.
2. Determine the sequence of those activities.
3. Draw a network diagram.
4. Estimate the completion time for each activity.
5. Identify the critical path (longest path through the network)
6. Update the CPM diagram as the project progresses.
1. Specify the Individual Activities
From the work breakdown structure, a listing can be made of all the activities in the project.
This listing can be used as the basis for adding sequence and duration information in later
steps.
2. Determine the Sequence of the Activities
Some activities are dependent on the completion of others. A listing of the immediate
predecessors of each activity is useful for constructing the CPM network diagram.
3. Draw the Network Diagram
Once the activities and their sequencing have been defined, the CPM diagram can be drawn.
CPM originally was developed as an activity on node (AON) network, but some project
planners prefer to specify the activities on the arcs.

35
4. Estimate Activity Completion Time
The time required to complete each activity can be estimated using past experience or the
estimates of knowledgeable persons. CPM is a deterministic model that does not take into
account variation in the completion time, so only one number is used for an activity's time
estimate.
5. Identify the Critical Path
The critical path is the longest-duration path through the network. The significance of the
critical path is that the activities that lie on it cannot be delayed without delaying the project.
Because of its impact on the entire project, critical path analysis is an important aspect of
project planning.
The critical path can be identified by determining the following four parameters for each
activity:
 ES - earliest start time: the earliest time at which the activity can start given that its
precedent activities must be completed first.
 EF - earliest finish time, equal to the earliest start time for the activity plus the time
required to complete the activity.
 LF - latest finish time: the latest time at which the activity can be completed without
delaying the project.
 LS - latest start time, equal to the latest finish time minus the time required to
complete the activity.
The slack time for an activity is the time between its earliest and latest start time, or between
its earliest and latest finish time. Slack is the amount of time that an activity can be delayed
past its earliest start or earliest finish without delaying the project.
The critical path is the path through the project network in which none of the activities have
slack, that is, the path for which ES=LS and EF=LF for all activities in the path. A delay in
the critical path delays the project. Similarly, to accelerate the project it is necessary to reduce
the total time required for the activities in the critical path.
6. Update CPM Diagram
As the project progresses, the actual task completion times will be known and the network
diagram can be updated to include this information. A new critical path may emerge, and
structural changes may be made in the network if project requirements change.
CPM Limitations
CPM was developed for complex but fairly routine projects with minimal uncertainty in the
project completion times. For less routine projects there is more uncertainty in the completion
times, and this uncertainty limits the usefulness of the deterministic CPM model. An

36
alternative to CPM is the PERT project planning model, which allows a range of durations to
be specified for each activity.
Benefits
 Support the introduction of evidence-based medicine and use of clinical guidelines
 Support clinical effectiveness, risk management and clinical audit
 Improve multidisciplinary communication, teamwork and care planning
 Can support continuity and co-ordination of care across different clinical disciplines
and sectors;
 Provide explicit and well-defined standards for care;
 Help reduce variations in patient care (by promoting standardisation);
 Help improve clinical outcomes;
 Help improve and even reduce patient documentation
 Support training;
 Optimise the management of resources;
 Can help ensure quality of care and provide a means of continuous quality
improvement;
 Support the implementation of continuous clinical audit in clinical practice
 Support the use of guidelines in clinical practice;
 Help empower patients;
 Help manage clinical risk;
 Help improve communications between different care sectors;
 Disseminate accepted standards of care;
 Provide a baseline for future initiatives;
 Not prescriptive: don't override clinical judgement;
 Expected to help reduce risk;
 Expected to help reduce costs by shortening hospital stays
Issues with Critical Pathways
There are many issues in critical pathway development and implementation that are of
concern to practitioners who care for patients with cardiovascular disease. The first issue is
that critical pathways address processes in the "ideal" patient and in some cases do not
address issues in the majority of patients who enter the path. Identification of appropriate
patients to enter the pathway is an important issue in implementation. In general, critical
pathways are more applicable to patients with uncomplicated illnesses who are undergoing
procedures or surgery. For patients treated with medical conditions such as acute coronary
syndromes, it is difficult to define "appropriate" treatment for the majority of patients.
Therefore, critical pathways will tend to identify a great deal of variance in the care of these
patients that may or may not be wasteful or potentially harmful. The goal of placing most
patients within pathways may not benefit the individual patient.
A second issue is how to evaluate critical pathways as an effective tool in improving patient
care. As we have mentioned, little controlled research has been performed on the
effectiveness of pathways. One reason for this is that at any one medical center, "pathway"

37
care cannot be easily differentiated from "usual" care because of contamination from the
pathway intervention. Randomized trials with the unit of randomization at the medical center
would be the optimal evaluation method.
Finally, it is important that physicians and practitioners be key players in any pathway
development and implementation. There is a real danger when critical pathways are brought
in from external sources and implemented on the basis of administrative attempts to reduce
costs.
Issues - potential problems and barriers to the introduction of ICPs
 May appear to discourage personalized care
 Risk increasing litigation
 Don't respond well to unexpected changes in a patient's condition
 Suit standard conditions better than unusual or unpredictable ones
 Require commitment from staff and establishment of an adequate organizational
structure
 Problems of introduction of new technology
 May take time to be accepted in the workplace
 Need to ensure variance and outcomes are properly recorded, audited and acted upon
Conclusions
Critical pathways are being implemented in a broad range of patients with cardiovascular
disease.
Although cost savings can and should be evaluated with the critical pathway, the goal of
improving guideline compliance and overall quality of care should be the primary focus.
Additional rigorous research into the cost of pathway development and implementation, as
well as the outcomes of critical pathway use, is essential before further dissemination of this
tool.
Clinical protocols can and should be used to decrease variation in care, improve guideline
compliance, and potentially improve overall quality of care in patients with cardiovascular
disease.
Practitioners and administrators should work together to incorporate similar and compatible
features of clinical protocols and critical pathways. This may result in improved quality and
reduced costs.
Issues for discussion
 The differences between clinical practice guidelines and care pathways
Paper-based ICPs versus electronic ICPs

38
7. HEALTH CARE REFORMS
Health care reform is a general rubric used for discussing major health policy creation
or changes—for the most part, governmental policy that affects health care delivery in a
given place. Health care reform typically attempts to:
Broaden the population that receives health care coverage through either public sector
insurance programs or private sector insurance companies. Expand the array of health care
providers consumers may choose among
 Improve the access to health care specialists
 Improve the quality of health care
 Decrease the cost of health care
Health care reforms in India
The Ministry of Health and Family Welfare is the Indian government ministry charged with
health policy in India. It is also responsible for all government programs relating to family
planning in India.
The Minister of Health and Family Welfare holds cabinet rank as a member of the Council of
Ministers. The current minister is Shri. Ghulam Nabi Azad, who is assisted by a Minister of
States for Health and Family Welfare, Shri. Dinesh Trivedi & Shri. S. Gandhiselvan.
The ministry is composed of three departments:
1 Department of Health
2 Department of Family Welfare
3 Department of AYUSH
1. Department of Health
The Department of Health deals with health care, including awareness campaigns,
immunization campaigns, preventive medicine, and public health. Bodies under the
administrative control of this department are:
1) National AIDS Control Programme (AIDS)
2) National Cancer Control Programme (cancer)
3) National Filaria Control Programme (filariasis)
4) National Iodine Deficiency Disorders Control Programme (iodine deficiency)
5) National Leprosy Eradication Programme (leprosy)
6) National Mental Health Programme (mental health)
7) National Programme for Control of Blindness (blindness)
8) National Programme for Prevention and Control of Deafness (deafness)
9) National Tobacco Control Programme (tobacco control)
10) National Vector Borne Disease Control Programme (NVBDCP) (vector-born
disease)
11) Pilot Programme on Prevention and Control of Diabetes, CVD and Stroke
(diabetes, cardiovascular disease, stroke)
12) Revised National TB Control Programme (tuberculosis)
13) Universal Immunization Programme
14) Medical Council of India

39
15) Dental Council of India
16) Pharmacy Council of India
17) Indian Nursing Council
18) All India Institute of Speech and Hearing (AIISH), Mysore
19) All India Institute of Physical Medicine and Rehabilitation (AIIPMR),
Mumbai
20) Hospital Services Consultancy Corporation Limited (HSCC)
2. Department of Family Welfare
The Department of Family Welfare (FW) is responsible for aspects relating to family welfare,
especially in reproductive health, maternal health, pediatrics, information, education and
communications; cooperation with NGOs and international aid groups; and rural health
services. The Department of Family Welfare is responsible for:
 18 Population Research Centres (PRCs) at six universities and six other institutions
across 17 states
 National Institute of Health and Family Welfare (NIHFW), South Delhi
 International Institute for Population Sciences (IIPS), Mumbai
 Central Drug Research Institute (CDRI), Lucknow
 Indian Council of Medical Research (ICMR), New Delhi - founded in 1991, it is one
of the oldest medical research bodies in the world
3. Department of AYUSH
The Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy
(AYUSH) deals with ayurveda (Indian traditional medicine), and other yoga, naturopathy,
unani, siddha, and homoeopathy, and other alternative medicine systems.
The department was established in March 1995 as the Department of Indian Systems of
Medicines and Homoeopathy (ISM&H).The department is charged with upholding
educational standards in the Indian Systems of Medicines and Homoeopathy colleges,
strengthening research, promoting the cultivation of medicinal plants used, and working on
Pharmacopoeia standards. Bodies under the control of the Department of AYUSH are:
Various research councils
1) Central Council for Research in Ayurveda and Siddha (CCRAS)
2) Central Council for Research in Unani Medicine (CCRUM)
3) Central Council for Research in Homoeopathy (CCRH)
4) Central Council for Research in Yoga and Naturopathy (CCRYN)
5) Several educational institutions:
6) National Institute of Ayurveda, Jaipur (NIA)
7) National Institute of Siddha, Chennai (NIS)
8) National Institute of Homoeopathy, Kolkata (NIH)
9) National Institute of Naturopathy, Pune (NIN)
10) National Institute of Unani Medicine, Bangalore (NIUM)
11) Institute of Post Graduate Teaching and Research in Ayurveda, Jamnagar,Gujarat
(IPGTR)
12) Rashtriya Ayurveda Vidyapeeth, New Delhi (RAV)

40
13) Morarji Desai National Institute of Yoga, New Delhi (MDNIY)
14) Indian Medicine Pharmaceutical Corporation Limited (IMPCL), Mohan, Uttaranchal
(a public sector undertaking)
15) Professional councils
16) Central Council of Homoeopathy (CCH)
17) Central Council of Indian Medicine (CCIM)
Healthcare in India
India has a universal health care system run by the local (state or territorial)
governments. Government hospitals, some of which are among the best hospitals in India,
provide treatment at taxpayer expense. Most essential drugs are offered free of charge in
these hospitals. However, the fact that the government sector is understaffed, underfinanced
and that these hospitals maintain very poor standards of hygiene forces many people to visit
private medical practitioners.
The charges for basic in-hospital treatment and investigations are much less compared
to the private sector. The cost for these subsidies comes from annual allocations from the
central and state governments. For example, an outpatient card at AIIMS (one of the best
hospitals in India) costs a one-time fee of 10 rupees (around 20 cents U.S.) and thereafter
outpatient medical advice is free. In-hospital treatment costs depend on financial condition of
the patient and facilities utilized, but are usually much less than the private sector. For
instance, a patient is waived treatment costs if their income is below the poverty line. Another
patient may seek an air-conditioned room for an additional fee.
Primary health care is provided by city and district hospitals and rural primary health
centres (PHCs). These hospitals provide treatment free of cost. Primary care is focused on
immunization, prevention of malnutrition, pregnancy, child birth, postnatal care, and
treatment of common illnesses.[citation needed] Patients who receive specialized care or have
complicated illnesses are referred to secondary (often located in district and taluk
headquarters) and tertiary care hospitals (located in district and state headquarters or those
that are teaching hospitals).
Now organizations like Hindustan Latex Family Planning Promotional Trust and
other private organizations have started creating hospitals and clinics in India, which also
provide free or subsidized health care and subsidized insurance plans.
Health care economics
 Funding models
Universal health care in most countries has been achieved by a mixed model of funding.
General taxation revenue is the primary source of funding, but in many countries it is
supplemented by specific levies (which may be charged to the individual and/or an employer)
or with the option of private payments (either direct or via optional insurance) for services
beyond that covered by the public system.
Almost all European systems are financed through a mix of public and private
contributions. The majority of universal health care systems are funded primarily by tax
revenue (e.g. Portugal, Spain, Denmark and Sweden). Some nations, such as Germany,
France and Japan employ a multi-payer system in which health care is funded by private and
public contributions. However, much of the non-government funding is by defined

41
contributions by employers and employees to regulated non-profit sickness funds. These
contributions are compulsory and vary according to a person's salary, and are effectively a
form of hypothecated taxation.
A distinction is also made between municipal and national healthcare funding. For
example, one model is that the bulk of the healthcare is funded by the municipality, speciality
healthcare is provided and possibly funded by a larger entity, such as a municipal co-
operation board or the state, and the medications are paid by a state agency.
Universal health care systems are modestly redistributive. Progressivity of health care
financing has limited implications for overall income inequality.
 Single payer
The term single-payer health care is used in the United States to describe a funding
mechanism meeting the costs of medical care from a single fund. Although the fund holder is
usually the government, some forms of single-payer employ a public-private system.
 Public
Some countries (notably the United Kingdom, Italy, Spain and the Nordic countries) choose
to fund health care directly from taxation alone. Other countries with insurance-based
systems effectively meet the cost of insuring those unable to insure themselves via social
security arrangements funded from taxation, either by directly paying their medical bills or by
paying for insurance premiums for those affected.
 Compulsory insurance
This is usually enforced via legislation requiring residents to purchase insurance, though
sometimes, in effect, the government provides the insurance. Sometimes there may be a
choice of multiple public and private funds providing a standard service (e.g. as in Germany)
or sometimes just a single public fund (as in Canada). The U.S. Patient Protection and
Affordable Care Act is a law based on compulsory insurance.
In some European countries where there is private insurance and universal health care,
such as Germany, Belgium, and The Netherlands, the problem of adverse selection
,vercome using a risk compensation pool to equalize, as far as possible, the risks between
funds. Thus a fund with a predominantly healthy, younger population has to pay into a
compensation pool and a fund with an older and predominantly less healthy population would
receive funds from the pool. In this way, sickness funds compete on price and there is no
advantage to eliminate people with higher risks because they are compensated for by means
of risk-adjusted capitation payments. Funds are not allowed to pick and choose their
policyholders or deny coverage, but then mainly compete on price and service. In some
countries the basic coverage level is set by the government and cannot be modified.
Ireland at one time had a "community rating" system through VHI, effectively a single-
payer or common risk pool. The government later opened VHI to competition but without a
compensation pool. This resulted in foreign insurance companies entering the Irish market
and offering cheap health insurance to relatively healthy segments of the market which then
made higher profits at VHI's expense. The government later re-introduced community rating
through a pooling arrangement and at least one main major insurance company, BUPA, then
withdrew from the Irish market.

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