11 outpatients. Roughly 72 percent of all X-rays ordered for emergency department patients were actually performed, compared to 61 percent of orders for inpatients, and only 28 percent for outpatients. The cardiology and general medicine clinics were responsible for the largest numbers of ordered X-rays. Approximately 44 percent of the X-rays ordered by physicians in the general medicine clinic were actually performed, compared to 32 percent of the radiology procedures ordered by cardiologists. Completion rates across all the outpatient departments were generally low. Chest x-rays were the most trequently performed radiology procedures.

For the noninvasive tests, once again the largest number of services were ordered for outpatients, followed by emergency patients and inpatients. Almost ninety-one percent of all special services requested for emergency patients was completed. Roughly 70 percent of the services ordered for outpatients were completed, while inpatient orders were completed only 57 percent of the time.

Major mitigating factors for outpatients are that the hospital is not necessarilv responsible for the uncompleted tests and modest fees are levied for some services. Some patients prefer to use private or other public sources and some neglect to submit the request. Thus, uncompleted tests are due to a number of factors. The hospital is responsible for providing insufficient information to patients on how to proceed, not following up on patients (i.e., setting up subsequent appointments or checking up on test results), and for shortages that prevent conducting tests. Patient preferences and behavior account for some of the uncompleted tests, but how much cannot be measured without a follow-up household survey of patients.

The conclusion from these data is that patients are not receiving the basic level of services that public hospitals are intended to provide. It suggests further that the quality of attending physicians as well as the availability of other medical inputs and diagnostic tests is sufficiently low that basic quality of care is jeopardized. The qualifications of attending physicians are low and they are largely unsupervised, which brings into question whether the appropriate inputs are even being ordered. Thus the issue is not only what the hospital lacks in nonpersonnel inputs, which has been outlined here, but whether the inputs ordered are those that are required. This is the subject of the next subsection.

# Comparison of Norms and Clinical Practices

Norms can be applied to examine how well clinical practices conform to acceptable patterns of diagnosis and treatment. They provide an objective standard to determine the frequency with which required diagnostic tests were ordered by physicians; whether patients received the specified drugs for their diagnoses; whether the proper instruments and equipment were used; and whether the appropriate amount and category of consumables was used in diagnosis and treatment. The analysis in the next subsection is confined to analyzing physician ordering of diagnostic tests and drugs.

The clinical norms for this project were developed by a group of Dominican physicians (see Appendix F in Lewis et al., 1990) for selected diagnoses, to establish a standard upon which to compare diagnostic and treatment practices of