Summer Placement In

P.D. HINDUJA NATIONAL HOSPITAL & MEDICAL RESEARCH CENTRE (April 12- June 5, 2010) KARAN DAVE

Post- graduate Programme in Hospital & Health Management 2009-2011

Institute of Health Management Research, Jaipur 2010

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Acknowledgement
The successful completion of any given task requires a lot of hard work and sincere efforts. Hard work and efforts are only the building blocks of an assignment, but the plinth has to be inspiration, suggestion, support and guidance. Experience in a hospital environment was an important part of our course and this we have achieved from one of the esteemed health care organization, P D HINDUJA NATIONAL HOSPITAL & MEDICAL RESEARCH CENTER. These two months of training has added a valuable and knowledgeable exposure in the development of my career and achievement of my objectives, for which I am highly grateful to the organization. I am gratified to Mr. Joy Chakraborty, Director Administration & Mr. Ankush Gupta manager HR, who found me suitable as Management Trainee in this organization and gave me permission for two months training and doing project work. I express my heartfelt thanks to Dr. Preeti Goraksha Manager Operational Excellence Mr. Purnendu Chattaraj Executive Head Radiology Department, Mrs. Durga Kawthankar Assistant Manager-Nursing, Mr. Yogendra Awadhiya Manager Support Services, Miss Neha Mussadi Executive OPD and Miss Shweta Dixit Executive Nursing who has helped me in all aspects in completing the various projects. My heartfelt gratitude remains with Dr. Preeti Goraksha Manager Operational Excellence, for inspiring me towards a meaning full learning and directing my thoughts, goals and objectives towards the attitude, that drives to achieve, exploring profundity about hospital functioning and other aspects that one as a novice needs to be acquainted with. I pay lot of thanks to all the departmental heads and working staffs whoever came as source of help in completion of the project. Special thanks to all the working staffs of this organization for all the assistance and information. I am glad to acknowledge Dr. S. D. Gupta, Director and Mentor IIHMR, Dr. (Brig) S. K. Puri, Dean, Academic and Students Affairs, IHMR and Dr. Nutan P. Jain Assistant Professor and Mentor, IHMR, for incorporating right attitude in me towards learning and for helping and supporting whenever required. I am grateful to them for giving me an opportunity to learn administrative tricks and styles, so that I come to know how a hospital caters their patients successfully and how a hospital gives quality treatment to patients. I genuinely thank my parents, family and friends for their blessings and support. Last but not the least I am thankful to God, for getting an opportunity to learn from this organization.

TABLE OF CONTENTS

A. PROFILE OF P. D. HINDUJA HOSPITAL AND MRC a) b) c) d) e) f) g) h) i) j) k) l) m) n) Introduction History Organogram of hospital Department list Outpatient department Admission and billing Accident and emergency Imaging department Laboratory Medical records department Support services Information technology Engineering department The knowledge core

B. PROJECT STUDY Cumulative Projects: a) b) c) d) e) Study on Patient Discharge Process Medicine Audit OPD Turn Around Time for appointment unregistered patients Comparative Analysis of Report Turn Around Time Bio Medical Waste Management

Individual Project: a) Patient Satisfaction Survey for CT and MRI Patients C. ANNEXURES a) b) c) d) e) Data sheet of Lean Six Sigma Patient Discharge Process Data sheet of OPD Turn Around Time for appointment unregistered patients Data sheet of Report Turn Around Time Data Sheet of Bio Medical Waste floor wise Data Sheet of Patient satisfaction Survey of CT and MRI Patients 3

ABBREVIATIONS
A&E AKD AERB AMO ALOS BMD BRIT BMC CE CT SCAN CSSD CDC CMO CEO CCC DA DPS DN DIR Accident and emergency Artificial kidney dialysis Atomic energy regulatory board Assistant medical officer Average length of stay Bone mineral densitometry Board of Radiation and Isotope Technology Bombay municipal corporation Chief executive Computerized tomography scan Central sterile supply department Child development centre Casualty medical officer Chief executive officer Customer Care Centre Director administrator Deputy professional services Director nursing Director 4

DSA E&M ENT EEG FSD GLP GCP HH HRCT HK HR HOD IPD ICU

Digital Subtraction Angiography Engineering and maintenance Ear nose throat Electroencephalography Food service department Good Laboratory Practices Good Clinical Practices Hinduja hospital High resolution scanning House keeping Human resource Head of department In patient department Intensive care unit

ID IRB

Identity card Indian regulatory board

ICD IT LIC MRD MRA

International classification of diseases Information technology Life insurance corporation Medical record department Magnetic Resonance Angiography

MRI

Magnetic resonance induction

NOC NABH OPD OT MLC PACS TPA

No objection certificate National accreditation for board of hospital and health Out patient department Operation theatre Multileaf collimator Picture archiving and communication system. Third party assurance

SECTION - A

PROFILE OF

P.D. HINDUJA NATIONAL HOSPITAL AND MRC

P.D. HINDUJA NATIONAL HOSPITAL AND MRC Introduction The late Sh. Paramanad Deepchand Hinduja had in 1951 established a charitable hospital under auspices of The National Health and Education Society. Later the Hinduja foundation under the patronage of Sh. S.P. Hinduja, launched an U.S. $30 million (about Rs35 crore) project to develop this into a modern, technologically advanced Tertiary care Hospital Medical Research complex. The Hospital project with 342 beds inclusive of 53 critical care beds was dedicated to the memory of late Sh. P.D. Hinduja and opened in August 1986. Today it is one of South Asias most modern centers for health care. It has a unique collaborations program with Massachusetts General Hospital, Boston and the Washington Hospital Centre, Washington D.C., U.S.A.

History Behind the ultra modern and internationally acclaimed in extending world class medical services which are offered at P. D. Hinduja National Hospital & Medical Research Centre, lies a 50 years old dream. A mission to assimilate the finest in medical and surgical talent and technique, to bring them closer to the common man., it was nurtured in the heart of great founder, Shri Parmanand Deepchand Hinduja a hard working philanthropist, who laid the foundation of the National Hospital, way back in 1951. Today, the P.D. Hinduja National Hospital stands as a concrete testimony to the fulfillment of his dream. Hinduja Hospital is an ultramodern multi specialty tertiary care hospital with a Medical Research Centre in collaboration with Massachusetts General Hospital (MGH), Boston. The hospital has an inpatient capacity of 381 beds inclusive of 57 critical care beds in different specialties. As a tertiary care hospital, the services offered are comprehensive covering investigation & diagnosis to therapy, surgery & post - operative care. The inpatient services are complemented with a day centre, out-patient facilities and an exclusive centre for health check for executives Location Located in Mumbai, the heart of the financial and commercial capital of India, it is landmark in itself. Situated in Mahim, Veer Sarvakar Marg, its unique structure and immensity of size and its color white and yellow edifice immediately distinguishes its from rest of the surrounding. The OPD block (Hinduja Clinic) and IPD (West block) is connected through a bridge over the road. The hospital is well connected through roads, railway and air. Philosophy The Hospitals philosophy is `To provide World Class Quality Health Care Services to all sections of the society' with emphasis on philanthropy. To fulfill this objective the hospital

has highly qualified & dedicated medical professionals, paramedics and managerial support staff who regularly enhance their skills to the most contemporary world standards. Mission To create Hinduja Hospital as a world class medical institution by delivering quality medical care to all patients as well as continuing medical education to all doctors and training to nurses and by under taking basic and clinical research with a focused on the needs of the country. Vision Quality healthcare for all. Quality policy To our patients we commit our best we aim to Assure best outcome Build seem less services. Create values. Satisfied with personalized care. Pledge to set and practice high standards through an effective quality management system and ensure that our services always meet the expected requirement of our clients and patients. Quality Objectives To create a safer environment for the patient as well as staff by reducing the errors. Involvement of staff in the quality improvement to take the working to higher level continuously. Continual Improvement in every area of the hospital services.

Achievements

Hinduja hospital was the first disciplinary tertiary care hospital to have been awarded the prestigious ISO 9002 certification from KEMA of Netherlands for quality management system.

Hinduja Hospital was recently awarded the prestigious Golden Peacock Global Award for Philanthropy in Emerging Economies 2006. The First Hospital Laboratory in India to be accredited by the College of American Pathologists. P.D. Hinduja Hospital is the second hospital in the city to receive the NABH accreditation, on July 1, 2009. Hinduja Hospital was recently awarded the IMC Ramakrishna Bajaj Award for Quality.

Medical Expertise With over 86 hospital based Consultants; which is a unique feature of the hospital, there is always an experienced specialist available to initiate treatment without delay. The various specialties covered are Cardiology, Cardiothoracic Surgery, Neurology, Neurosurgery, Orthopedics, Oncology, Ophthalmology, Rheumatology, Endocrinology, ENT, Gastroenterology, Pediatrics, Pediatric Surgery, Pediatric Neurology, Urology, Nephrology, Dermatology, Dentistry, Plastic Surgery, Gynecology, Pulmonology, Psychiatry, General Medicine & General Surgery. Technology Upgrade 1. Gamma Knife - gold standard in Radio surgery, a non invasive neurosurgical tool 2. Twin Speed MRI, a revolutionary technology in neurovascular and cardiology imaging. 3. Bactec NR 730 analyzer for micro culture. 4. Gamma Camera / PET scan which redefines the treatment in cancer management, orthopedics, neurology and cardiology. 5. Digital Linear Accelerator Clinac 2300 C/D with MLC & micro MLC with portal vision along with CT stimulator, dedicated 3D computerized planning system for achieving a high tumor dose and increased cure rate and a low normal tissue dose to reduce toxicity. 10

6. Vacutainer system for blood collection. 7. Holmium laser, thus replacing surgeon scalpel. 8. Synchrom CX- 7 fully automated for pick- up, delivery and analysis of the sample and Reagent. 9. Computerized Humphreys perimeter for early diagnosis of glaucoma. 10. Digital Subtraction Angiography for cerehaed angiography, peripheral and renal angioplasty, biliary drainage and nephrectomy. 11. Viewing wand navigation system to conduct minimal invasive neurosurgery Procedures. 12. GE Volume Light Speed CT, which captures images of the heart in just 5 heartbeats at the speed of light. 13. GE-INNOVA 2000 Cath Lab machine for better visibility of blood vessels. 14. The Radial Lounge, First of its kind in India, is a unique concept for carrying out Coronary Angiographies and Angioplasties procedure. In support of the Nephrology services at the hospital.

Human Touch 1. Hospital provides charity to 20% of patients, spending approx 80 million for this purpose every year. 2. It ensures equal care and service to the Charity and Paying patients without discrimination in its OPD and Wards.

Milestones Achieved by Hinduja Hospital The Firsts to Hinduja Hospital Credits to: One of the first hospitals in India to perform laparoscopic gall bladder surgery. 11

One of the few hospitals in India to perform Cochlear Implantation. The first hospital in India to start a Pain Management Clinic. For the first time in India awake craniotomy for an epilepsy surgery was performed at the hospital . It offers the facility for Therapeutic drug monitoring for the highest number of drugs in the India. Started the first screening Centre for breast cancer in Mumbai The first private hospital in Mumbai to perform cadaver kidney transplant & peripheral blood stem cell transplant. The first one in Mumbai to introduce high resolution scanning (HRCT) of the lungs. The first few in Mumbai to introduce MR Angiography and popularize non invasive screening protocols combining color Doppler and MRA for indications like carotid screening.

The first hospital in Mumbai to install Digital Video EEG which is capable of recording the electrical events of the brain The first hospital in Mumbai to start Home Care, which is a service of nursing care at your doorstep. The first in India to set up Vulvar Clinic. The first hospital in Mumbai to start a Sleep Laboratory.

Basic Facts about P.D.Hinduja Hospital: Bed Strength = 381 beds inclusive of 57 critical care 100% 5.1 days 35 death/month 6:1

Bed occupancy Rate = ALOS Mortality Rate = =

Patient to Nurse Ratio =

Number of Discharges/month = 2000 Number of OPD patient /day = 900-1000 Number of emergency case = 45- 50/ day Building of Hinduja Hospital = 3 12

Hinduja Clinic (OPD) = 4 floors (3 + 1 floor) West Block (IPD Block) = 16 floors Lalita Girdhar Block = 8 floors

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DEPARTMENTS
CLINICAL SERVICES: OPD Admission and Billing Accident and emergency Cath Lab CLINICAL SUPPORTIVE SERVICES: Lab Medicine Telemedicine Poison and Drug information center Imaging CSSD House- Keeping CLINICAL ADMINISTRATIVE SERVICES: Ambulance Services Nursing department Laundary Mortuary ADMINISTRATIVE SERVICES: Main Administration Medical Record Department Materials Engineering Information Technology Purchase

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CLINICAL SERVICES

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OUT PATIENT DEPARTMENT

Introduction: Patients, who in the considered view of a competent Medical Professional, do not immediately require Hospital admission, and who can be satisfactorily treated on a domiciliary basis, are classified as Ambulatory Patients, and are commonly referred to as Out Patients. Hence the Department of Ambulatory Care is also commonly known as Out Patient Department. The Hinduja Clinic aims to provide 1. High quality ambulatory care services to the community in a secure environment, 2. Ensuring safe, appropriate interventions, treatment and care which are delivered humanely and efficiently.

Location and Layout:

Floors

Wing 1

Wing 2

Wing 3

Ground Floor

Medical/Surgical Oncology.

Radiation Oncology.

AKD Dept.

Wing 4 Gamma knife, Medical reports delivery counter and OPD Path Lab. Consultants Dental and Consultants. Executive health checkup

First Floor Second Floor

Consultants Consultants, Neurology Dept Blood Donor Room, Blood Bank & Stat lab.

General Radiology and Ophthalmic. Consultants Endoscopy Bronchoscopy & Urodynamic.

Third Floor

ENT and Medical Records. Consultants, CDC and Physiotherapy. Cardiac, PFT Lab, Consultants.

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Following services are offered in the OPD i. Medical / Surgical Consultations. ii. Preventive Health Check packages. iii. Laboratory Investigations. iv. Imaging services. v. Cardiology investigations. vi. Neurology investigations. vii. Pulmonology investigations. viii. Pain management. ix. AKD (Artificial Kidney Dialysis). x. Gamma knife. xi. Endoscopy. xii. Bronchoscopy. xiii. Urodynamic study. xiv. Physiotherapy. xv. CDC (Child Development Centre). xvi. ENT (Ear, Nose, Throat). xvii. Ophthalmology. xviii. Dental procedures. xix. Oncology. xx. Radiation Oncology. Sections and Timings of OPD: OPD is divided into (a) Hinduja Clinic, where patients have to pay for the services rendered (Timings: 07.00 hrs to 22.00 hrs - From Monday to Friday 07.00 hrs to 20.00 hrs - On Saturdays) (b) Free OPD where patients get free Consultations (Timings: as per Consultant schedule) 18

(c) Report delivery (Timings: 08.00 hrs to 22.00 hrs - Monday to Friday 08.00 hrs to 20.00 hrs - Saturdays)

OPD Organogram:

DIRECTOR ADMINISTRATION

NURSING DIRECTOR

SENIOR MANAGER OPD

MANAGER NURSING- SPECIAL DPT

MANAGER HEALTH CHECK

EXECUTIVE-OPD

OPD HEAD NURSE

SUPERVISOR HEALTH CHECK HEALTH CHECK CLERK

TYPING STAFF

SENIOR PARAMEDICAL SUPERVISOR STAFF OPD

STAFF NURSE

FRONT OFFICE STAFF OPD ATTENDANTS

NURSING ASSISTANTS

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ACCESS TO OPD SERVICES

Hinduja Hospital Card (HH Card)

All patients who visit the Hinduja clinic or Free OPD for the first time for consultation/other services are issued a card. This card is known as the HH card and is attached to the registration form and is issued to the patient at the time of registration. The HH number is present on the card. The HH card and number are important, for it is only with the help of the HH number, that the patients Medical Record folders can be accessed. Patients are advised to always carry their HH card number whenever they come for follow up visits to the OPD or when they have to be admitted as inpatients. Allotment and serial number control of HH numbers is the responsibility of Medical Records Department. MRD send sufficient quantity of files with the HH card to the OPD.

Patient Card- Staff All full time employees of the Hospital and their dependent family members are entitled to free treatment, as one of the staff welfare measures. For this purpose the employees are issued a card known as PATIENT CARD- STAFF.

External Patient Token Number Out patients visiting OPD for the first time, as referrals from external sources, and requiring only investigations, are not issued a HH card. The system generates an EX No (External Number) for that particular transaction only.

OPD Appointment Appointments can be fixed over the telephone to the HTMT call centre (facility for patient appointments have been out sourced) or personally across the Reception counter. Fax and e-mail facilities are also available.

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Non- Appointment Patient In the normal course, consultants in the Hinduja Clinic see the patients only by prior appointment. However exceptions are made to this system in the interest of the patients, and Non appointment or Walk-in patients are given appointment if a time slot is available. Patients, who have come as Non appointments are normally seen by the consultants after all the other waiting patients with prior appointments, are seen (except in emergency cases).

Health check up The Executive Health check up department, a part of the OPD services, is a wing of this Multispecialty Hospital dedicated to the diagnostic and preventive side of patient care. The Executive Health check up department is a place where healthy patient come in for prognosis of disease or to know about the preventive and curative aspect of Conditions they may already have. This system facilitates the patient to get all the required investigations/consultations done without having to pay for either consultation and/or for each individual item of Pathological or Imaging Investigations. It is a centre point where the potential customers come directly in contact with the hospital services. This department therefore can be a point to draw in patients to become in-patients or for them to come even for follow-up OPD consultations. The packages in this Health check programme have been developed by a team of highly qualified and experienced medical personnel and are designed to offer a complete medical check-up and within their limitations detect any latent health problems. In addition, these packages are offered at special discounted rates that make them truly worthwhile. At the end of the day, candidates leave the hospital with all their reports. The Health check department is dependent on various other Hospital departments and Consultants to ensure a smooth process flow. Therefore Co-ordination is a key factor in smoothly running the department. The departments with which the Health check team works in co-ordination are: Pathology, Cardiology, ENT, Ophthalmology, Dental and Radiology. 21

The visiting consultants are from the following faculties: Physicians, Surgeons, and Gynecologists. ADMISSION & BILLING DEPARTMENT Introduction: Admission & Billing Department in its endeavor ensures: 1. To provide excellent quality health care to all sections of society. 2. To provide a friendly, compassionate, humanely, & satisfactory atmosphere during the stay of the patient at the hospital. 3. To create an environment of high quality patient care, treatment, & management delivered effectively & efficiently starting from admission to discharge. Following are the services offered ----1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Registration of the new patient Booking / Reservation Bed & Operation Theatre Admission Billing Discharge Corporate / T.P.A. Help Desk T.P.A. Deficiency Outstanding Counseling & Recovery Lobby Reception Accident & Emergency Counter

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Organogram

CEO DA

MANAGER- A&B

OFFICER SUPERVISOR

CLERK

ATTENDANT

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Registration

Patients want to avail in- patient service requiring registration.

Patient fills the registration form (available at Lobby reception and accident and emergency counter).

Hands over registration form to any of the above counters.

-H H No. Issued -HH Card issued - Registration folder is issued to relative and later on sent to MRD.

Service vouchers generated (ODE).

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Discharge Process

Cash paying patient

Credit party patient

T.P.A Patient

Indigent & Indigent & weaker weaker

Patients relative is asked to pay the requisite bill amount.

Patients relative is asked to pay the non medical expenses.

Patients relative is asked to pay the non medical expenses & excess & above amount than sanction amount.

As per PRD instructions, patients relative is asked to pay patients the requisite amount or relative is refundto pay to the asked is given patient. the requisite amount or refund is given

Service voucher is generated in 3 copies.

Service voucher is generated in 3 copies.

Service voucher is Service voucher is generated in 3 copies. generated in 3 copies.

- In patient final bill (summary) - In patient final bill (detail) - Settlement voucher - All diagnostic reports - Discharge card - Discharge slip

- In patient final bill (detail) - All diagnostic reports - Discharge card - Discharge slip - Service voucher for non medical expenses paid

- In patient finalpatient final bill - In bill (detail) (summary) - Xerox of allAll diagnostic reports - diagnostic reports & discharge cardcar & discharge - Discharge -slip Discharge slip Service voucher for non - Service voucher for medical expenses & excess any payment made & above amount paid than sanction amount - Settlement slip for T.P.A -Security deposit

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Final Bill Generation

Unit clerk brings the Ward Billing Folder if comprises of admission paper ward copy/ O.T/ Scopy/ procedure charge sheet/ Investigation requisition slip/ Anesthesia charge sheet/ consumable sheet

- Billing heads - Anaesthesia - Bed charges - Doctors fees - Cardiology - Hospital services - Lab medicine - Imaging - Material management - O.T - Pharmacy - Surgery charges

Billing counter Billing staff audits & verifies the entries of services rendered in the care billing module

Final bill (summary) / Final bill (detail) / Credit note / Debit note / Supplementary bill Generation

Final bill (summary) / Final bill (detail) / IPT for cash payment / Staff / Staff dependents patients

Final bill (summary) / Final bill (detail) / ICR for credit party / T.P.A patients

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SHORT STAY SERVICE UNIT (SSSU) -4th Floor, West Block

STAGE I Patient Selection The patient concerned will be seen by the Consultant on an OPD basis. For a new patient, there would be necessarily Registration followed by vouchering. In the event that the patient meets the selection criteria for Short Stay surgery, the patient has to precede with Pre admission procedures. STAGE II -Pre Admission Procedure The patient would proceed to do OT / Bed booking in SSSU Completion of relevant Lab investigations STAGE III Pre Operative Stage Based on the consultants decision for Preoperative anesthetists work up, fitness for surgery would be given by the anesthetists. Patient would follow up with concerned surgeon with lab reports / relevant investigation reports / fitness certificate In the event that the patient is fit to operate, the consultant can choose to give Consent for the same at this stage. STAGE IV - Pre Admission Patients will be asked to report at the Reception desk in Casualty area 1 hr prior to schedule timing. A designated CCC will then escort the patient to the SSSU billing area STAGE V- Admission Following billing formalities, the patient will be taken into the SSSU. The nursing staff will inform the OT desk / concerned Consultant / Registrar about the arrival of the patient. The SSSU staff nurse will coordinate transport of the patient to the OT at the scheduled time. Following surgery the recovery area staff nurse will keep the SSSU staff nurse informed on the patients status. 27

After the patient has been shifted to the recovery area, concerned surgeon would need to visit and complete the discharge formalities including preparation of discharge. Admitting Consultant / nominated medical officer will examine the patient and will give the order to physically discharge the patient. The SSSU nursing staff would discharge the patient, based ONLY on written order from the concerned authority. STAGE VI- Discharge Following recovery in SSSU and discharge, the patient will be shifted in wheel chair / stretcher; herein the patient will be accompanied by the CCC till Casualty exit. The CCC will also enquire on the necessity of clinical care for the patient, and if so, details of Care @ Home will be given.

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ACCIDENT & EMERGENCY Introduction: 1. The A& E Department is the face of any hospital, which works around the clock through the year. 2. Department is manned by highly trained medical & paramedical staff & it serves all the immediate emergency medical interventions. 3. It can be divided into following areas - Accident and Emergency, Casualty centre and Minor OT. 4. 4 bedded Accident & Emergency department along with 2 casualty centre beds is an ultra modern facility well -equipped with sophisticated & advanced equipment specialized &skilled doctors and nurses is highlight of the department. Scope of services: The department is responsible for treatment of emergency cases. The department is responsible for informing the police in cases of traumas, poisoning, suicide, homicide, rape, assault, etc. Notification of all notifiable diseases to BMC. A&E is also a centre for all immunizations for staff as well as patients. The needle stick injury protocol for all staff is also carried out here.. A & E is a very important constituent of the disaster management team internal as well as external. Transfer of patients. First aid camps/ teams Responsible to arrange for the ambulance services for transportation or transfer of patients. It also in arranging Hearse services.

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Organogram

DPS Section Co- coordinator

DA

DN

ADN Executive -A & E

Head Nurse - A

AMO CMO Clerk Barbers Attendant Staff nurse

Staffing Categories of staff numbers: 1. 2. 3. 4. 5. 6. 7. Executive Administration CMO Nurses Nursing Assistant Clerks Attendants Barbers 01 08 16 02 02 15 03

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Triage Process Flow

Patient approaches casualty Triage nurse receives patient

Vitals, Chief complaint and History of illness is assessed Patient Triaged based on criticality and urgency

Red-Act Immediate within 5 mins, significant injury/illness

Yellow-Act within 15 mins, not requiring immediate intervention

Green-Act within 30 mins, can wait sometime

Based on code a color coded wrist band is applied

Send to casualty for management

Send to OPD

Triage: Triage is a French word meaning classify or sort. The Triage Desk is strategically situated in the lobby of the Accident & Emergency Department. Staff deputed at the desk is a Triage Nurse Purpose: To ensure a standardized system whereby patients seeking medical Care in the Accident & Emergency are seen in order of priority based on Acuity level. 31

Casualty centre booking

Patient Appears in OPD

Minor procedure/ in hospital treatment observation is advised

Patient referred to casualty centre for the same

Request for casualty centre for the same

Slot is blocked for the patient as available

Patient is informed by staff nurse and consulting doctor if slot not available

Entry is made in casualty centre booking daily by staff nurse.

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CATH LAB
Introduction: Cath Lab is located on the second floor of IPD building. It is well equipped to perform various heart related procedures such as Angiography, Angioplasty, Pacemaker etc. Two types of packages are provided- Radial package and Femoral Package. It has a separate admission counter, which takes admissions till 9 A.M. There are on an average 8-10 cases/ day. Scope of services: -Diagnostic Services -Therapeutic services Organogram:

Director administration

Section Coordinator Executive- Cath Lab

Director Nursing

Technicians

Receptionist

Hospital Attendants

Head Nurse Cath Lab

Staff Nurse

Categories of staff: TYPE Executive- cath lab Technicians Receptionist Hospital Attendants Nurse NOS. 1 4 2 4 3 33

CLINICAL SUPPORT SERVICES

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LAB MEDICINE
Introduction: Hinduja Hospitals fully automated Laboratory Medicine Department is the First Hospital Laboratory in India to be accredited by the College of American Pathologists in the year 2006. The laboratory has also received ISO -9002 in 1996 for quality, Ram Krishna Bajaj Award in 2007 and NABH Accreditation in 2009. The lab medicine department of Hinduja hospital covers about 13000 sq. ft. area in 2 different buildings. It includes the following1. Biochemistry 2. Hematology 3. Radio immune assay 4. Microbiology 5. Serology

6. Histopathology 7. Stat Lab 8. Blood Bank 9. OPD LAB The lab has its own Laboratory Information System, which is called the LABWARE Software. The work in lab is divided into 3 phases i.e. Pre- analytical, Analytical and Post analytical. There are 2 different teams for OPD and IPD. The lab also conducts quality assurance programs- Internal and external. 1. Central processing laboratory is spread over more than 10,000 sq ft which follows strict internal quality compliance for all analyzers. 2. Exhaustive menu of tests from routine to esoteric. 3. Excellent laboratory management system which handles both pre analytical and post analytical aspects. 35

4. Dedicated courier and logistics services 5. Stringent quality control monitoring which satisfy the quality assurance elements elaborated by GLP and GCP and readily available documented evidence of quality assurance and quality control proficiency schemes. 6. Constant improvisation and technological innovation using over 150 State-of the art equipments. 7. Quality control and quality assurance executive that monitors pre-analytical and post analytical processing of the samples. 8. Fully automated laboratory using positive identification of bar-coded specimens. 9. Trials specific specimen kits can also be customized if required and bidirectional interfacing. 10. Customized management report ( MIS - Management Information System ) 11. An active IRB and Ethics Committee which oversees clinical trials proposal when required.

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Organogram

Head of department- Lab Medicine Consultants for each sectionHistopathology-3 Biochemistry-1 Microbiology-2 Radio immune assay-1 Hematology-2 Blood bank-1

Clinical Assistants (Junior Doctors) for each section

Chief technician

Senior officers

Officers

Technical Staff Clerks

Transporters

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Process flow

Samples are collected in the OPD LAB or on the floors.

The samples are then sent to the various labs for conduction of tests via transporters.

Transporter deposits the sample in the respective labs.

Tests are performed and reports are generated.

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Reports are then signed by the consultants of that department.

Reports are sent to the reports delivery counter by the transporters in the OPD building, from where the patients collect the report.

Biochemistry

Biochemistry lab is at the 3rd floor in the Lalita Girdhar building. The department has an automatic machine to carry out various tests. A machine print out is received, entered in the register and report is generated. The biochemistry dept. also maintains a Follow up card for patients. The tests on OPD samples are conducted here, and also any special tests on OPD as well as IPD sample is also conducted here. 39

Hematology

Hematology lab is on the 5th floor of Lalita Girdhar building. The department has got an automatic machine for CBC (Complete Blood Count). It has a separate Coagulation room and Fluocytometry room, for carrying out various tests.

Histopathology

Histopathology lab is on the 5th floor of the Lalita Girdhar Building. There is no automatic machine in the department and all the tests are done manually. The department is divided into 2 sections- Surgical Pathology and Cytopathology. All the tests related to microscopy are performed here.

Microbiology

The microbiology Department is on the 5th floor of Lalita Girdhar Building. It has got a separate Mycobateriology room for tuberculosis tests, where a negative pressure is maintained. The lab has a hot room, storage area, incubators and refrigerators.

Serology

The department of serology is a part of microbiology department only. It receives the samples in test tubes and the various tests are performed. The department consists of a Laminar Air Flow machine for culture preparation.

Radio immuno assay

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The RIA lab is on the 4th floor of Lalita Girdhar building. The various radio immuno assays are carried out in the lab.

OPD lab

It is located at the ground floor of OPD building. The lab collects samples for various tests, assign them a bar code, and send them to various labs for the tests to be conducted. All the entries are made in the LIS.

Stat lab
Stat lab is at the 3rd floor of the old building. Here all the tests are performed for the IPD patients. It also carries out emergency tests, which require immediate reports.

Blood bank
Blood bank is located on the 3rd floor of old building. It consists of a separate Donor room. The donor is assigned a donor unit no. and given a donor card. It also has an apheresis room for platelets pheresis, and a storage area with refrigerators with a central monitoring system. For the IPD patients a requisition slip from the floor of that patient is received and then the patients identification and donors details are checked in the Blood Bank and on the floors. The department maintains daily records of blood donation and dispatch.

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TELEMEDICINE
Telemedicine refers to the use of various telecommunications by physicians and medical institutions that provide health care to the patients through electronic digital means, way far in the patients homes or in other remote areas with the help of medical data transfer, still images, and live audio and video transmission. It ensures delivery of: right medical advice at the right place and right time Why is it needed? Non availability of facilities locally Non availability of appropriate skills/ technology locally Huge money wasted in travelling and searching for appropriate healthcare Huge population with inequitable distribution of resources 70% of Indias population lives in rural areas whereas 75% of qualified consultant practice in urban centers Vas t land area with difficult/ inaccessible terrain Seasonal isolation of some tracts of land e.g. due to floods, snow.

Helps in:

Remote consultation and follow up Second opinion Joint interpretation Disease management through data mining Evidence based medicine Virtual patient visits Remote and mentored Tele-surgery Medical training 42

Medical tourism Makes expertise available anywhere Early institution of appropriate treatment Decreased need for transfers Effective utilized of transports Saves cost to patient, provider, system

Entities involved in telemedicine: Telemedicine platform Telemedicine devices Clinical devices Communication media

Facility setup at Hinduja Hospital: The setup comprises of an interactive video front with voice output and polycom camera attached to a terminal for data transfer and net meetings, supported by ISDN and IP lines. What do we deliver: Online continuous medical education for doctors of different medical specialties Teaching & Training for students Expert advice in almost all medical specialties through videoconferencing Complete report analysis by online transfer of reports Post operative and follow up consultations without traveling Tele-health campaigns at remote sites for different specialties

43

Video conferencing Platform/Software Network

Remote Hospital/Clinics/ Doctors

Hinduja Hospital & MRC

44

POISON & DRUG INFORMATION CENTER

P.D. Hinduja National Hospital & MRC has now added a new dimension to fill up lacunae in the health scenario in Mumbai. One such Endeavour is the starting of a facility, the Hinduja Hospital Poison and Drug Information Center which is the first of its kind in the city of Mumbai. This facility is for the use of fraternity, hospitals and other medical centers that need information. The poison center will receive queries on Poison & drugs and will provide information on antidotes as well as information on various therapeutic and toxic drugs. The information on Poison & drugs would include treatment, monitoring side effects, adverse drug reaction and the recommended relevant lab tests using micromedex databases which is well accepted all over the world. The poison and drug information centers will liaise with various Poison centers across the world as and when required. The specific queries will be answered, once the relevant information about the patient details is made available to the pharmacists who will attend to the queries. At present, it functions from 8:00 am to 6:00pm .This center is managed by a team of pharmacists.

Sample collection details for various categories of patients:

Category of patients OPD patients Sample collection done by Lab. technician from the pathology department who is posted on duty in the sample collection room IPD Respective wards from Lab. technician in charge of where the requests for lab. sample collection investigations had originated Patients referred by general Sample collection room Lab. technician from the practitioners & other pathology department who is specialists not attached to posted on duty in the sample the hospital collection room Place of sample collection Sample Collection Room

45

Process Flow

In-patient requisition for lab investigation Phlebotomist attends patient. Samples taken to stat lab, worksheet and bar code generated Samples taken to concerned section for processing, routine Biochem reports processed in stat lab, special Biochem tests done in S1

Final printed report is dispatched by sections via transporter to stat lab Printed reports segregated into IPD and OPD reports, and IPD reports further into floor wise by attendant.

Floor wise dispatch by transporter to west block, from 16th floor down and then reports transported to S1 last. Dispatches done generally three times a day.

46

IMAGING DEPARTMENT
The Imaging Department is a diagnostic department where various investigations of the patients are done. The patient comes for the investigation and after viewing the images of the scan the radiologists report. On the basis of the reports the diagnosis is done. In the department there are 9 sections, namely MRI, CT, General Radiology, DSA, Color Doppler, Mammography, Ultrasonography, Nuclear Medicine and BMD (Dexa Scan). MRI is located at the Ground Floor and rests are on the 1st Floor of the New Building. There is separate X-ray for the OPD patients located in the OPD building. There are two reception counters, one located on the 1st Floor for the sections located on the 1st Floor and the other on the Ground Floor for MRI Both OPD and IPD patients come for the investigations either through an appointment or as a walk-in-patients. In the department walk-in-patient means the patients without having any appointment.

Objectives of the Department

1. To do quality imaging using all necessary safety measures in radiation. 2. To perform quality reporting and interacting with clinicians on regular basis through follow ups and clinical meetings about veracity of reports. 3. Conduct teaching programmes for residents in imaging as well as for clinical branches. 4. Monitor the work of all Technicians on regular basis to maintain as well as improve quality. 5. Monitor and regulate usage of different equipments in Imaging Department. 6. Interact with Bio-medical department on regular basis for upkeep of all equipments.

47

Location and layout:

OPD x-ray: IPD x-ray: X-ray procedures: Ultrasound (USG): Color Doppler: Mammography: BMD: CT: DSA: Nuclear Medicine: MRI: 1st floor east block wing no.2 1st floor west block 1st floor west block 1st floor west block 1st floor west block 1st floor west block 1st floor west block 1st floor west block 1st floor west block 1st floor west block Ground floor west block

Categories of staff
TYPE NOS. Director Director Head of Department 2 Administration Professional Services Consultant 8 Executive 1 x-ray technician 11 Asst. Manager DSA technician Consultant Incharge2 Diagnostic technician CT Nuclear Medicine 6 Color Doppler/Mammography technician 2 Ultrasound technician 4 Executive - Radiology MRI technician 4 Nuclear medicine department technologist 5 Nursing staff 8 Receptionist Clerk 5 Typist Clerk 6

Director Nursing Services

Head - Imaging

Organogram

Consultant MRI/CT/USG/DSA/ Mammography/ General Radiology

Typist / Clerk

Hospital Attendant

Junior Medical Staff (JMS)

Sanitation Attendant

Receptionist

Staff Nurse

48

Procedures
Appointment can be given on the following basis: a) Telephone Appointment:

49

Receptionist

does

the

appointments

on

telephonic

calls

from

the

patient/relative/consultant on the basis of following details:1) H.H Card NO However appointment can also be given on basis of executive number. 2) Referral doctors name. 3) Date and description of registration/procedure. 4) Receptionist does the appointment on the basis of date and slot availability tells the patient about the same and gives the following instructions to the patient:a) c) Inform date and time of registration/ procedure. Asks to bring consultants letter. b) Inform charges of investigation/procedure. 5) Ask to bring all earlier investigation/ procedure reports and films. 6) Instructions about the diet intake specific for the investigation/ procedure. b) OPD / Walk in appointment: 1) Receptionist does the appointment on the basis of consultants letter brought by patient/ relative and available slot. 2) Inform date and time of investigation/ procedure. 3) Inform charges of the investigation/ procedure. 4) Ask to bring consultants letter. 5) Ask to bring all earlier investigation/ procedure reports and films. 6) Instructions about the diet intake specific for the investigation/ procedure. 7) She gives a manual written appointment slip having details of date/ time of appointment. 8) Appointment for nuclear medicine scan is given by receptionist from the appointment register. 9) For PET scan and some other scans deposit amount is taken at the time of giving appointment or DSA procedures. The appointment is given by DSA technician after taking patients clinical history.

In-patient appointment
50

Appointments for MRI

1) Staff floor nurse sends the MRI request from two copies by attendant to the receptionist at the MRI counter for appointment for the technician inside the department. 2) It is the responsibility of the technician to take care of the slot and the same day or any earlier slot available. 3) Receptionist enters the patients name and demography details/ date and description of the procedure in the request form. 4) Receptionist gives the white and blue copies of the MRI request to calling up of the patients for the procedure.

Appointments for x-ray procedures / USG / Colour Doppler/ Nuclear Medicine/ Mammography/ C.T
1) Staff floor nurse does the online entries of registration for any above investigation of the system. 2) In every 30 minutes receptionists check the outer floor. Wise request statement after the details in the same; she does the booking in the molecule (system).

Pacs- picture archival communication system

It is an image management system. Under this system, the pictures generated in various departments of radiology are uploaded in the system, to make them available to the consultants. Login and passwords are given to all the departments. The consultants can view them from any computer in the hospital using intranet. These pictures are also available on internet in read only mode. This system saves time and improves efficiency.

51

Legal requirements and guidelines

1. All sections in the Imaging department follow various legal guidelines set by Government of India. (Refer to Annexure for the list of Certificates and Guidelines). All Imaging Services follow regulation by the AERB and all new interaction are subject to approval by AERB before commencement of services. 2. For all Radiation emitting (or) generating equipments in medical use, whether it is in

diagnosis (or) treatment purpose [such as X-ray (low energy), X-ray (high energy), Brachy therapy units, CT, Fluoroscopy, Dental X-ray Units, PET CT, and Gamma Camera etc.], the hospital should get first authorization from AERB to use the above units in the hospital. 3. Next, hospital should get NOC from AERB for importing the units/ radioactive source from BRIT/ outside country/ private it is valid only for 1 year and for subsequent usage the hospital needs to apply for the NOC for each units. 4. Next after importing units/ radioactive source the hospital should send the form for registration units (of installation) with plan. Type approval certificate of unit, QA details, Survey details to AERB/ RSD. In the case of radioactive source, the hospital should intimate the arrival of above from (inland/ outland) in a particular form, and hen only the hospital can to use the unit (or) source after confirmation. 5. In the case of radioactive source used (or) decayed, hospital should get NOC from AERB for re-export to supplier outside country (it is internationally accepted norms).This will also be valid for 1 year only. 6. The AERB conducts random checks of the department on routine basis.

52

Imaging reports

Patient investigation in concerned imaging section In case of X-Ray, wet films are given to S1 patient, in case of all other modalities provisional report given except color Doppler Digital image reviewed by consultant In case of CT & MRI, consultants report by Dictaphone, in all other modalities, hand written reports sent to typing pool via Runner (10-6 duty) Draft copy is typed and sent by typing pool to consultants, in case of X- rays final report is typed Report rechecked by consultant and sent back to typing pool Final report typed and sent to consultant for signing Final signed report sent back to typing pool, wherein name is verified and then reports are sent to dispatch counter in imaging department Dispatch attendant (3-11duty) delivers reports to floors in west block same day, unable to deliver to S1 the same day due to case load in imaging department and time taken to deliver to S1 Reports delivered to S1 by 10.30 am next day by Runner

53

CSSD
Introduction:

The department is located on the 5th floor close to the O.T. The used material (linen, equipment etc.) and sterilized material from and to the O.T. are conveyed through two separate decided elevators. Department send their use articles while, from wards CSSD personnel collect the used articles every night. During the day the used articles from the wards are sent to CSSD by their personnel. The layout of the department and flow of materials ensures that there is no possibility of mix up of un sterilized materials. The department is divided into 3 parts- dirty area, clean area and sterile area. OT instruments are collected by CSSD in OT instruments wash/area and are send to CSSD through unsterile dump elevator. In night, sundries and holidays the instruments are sent to CSSD through unsterile dump waiter by theatre nurse. Ward instruments are collected early in the morning by CSSD. Departments like cathlab, AKD, Radiology, casualty OPD send their used sets themselves All sterilizers are cleaned once a week. The inside of the sterilizer is cleaned ever morning with a disinfectant solution. Micro biology department checks the air count weekly and issues a report of sterile area. In case of unsatisfactory levels, microbiology department intimates the CSSD within its report.

Objectives of the department Central sterile supply department is responsible to sterile material for use in the O.T and wards in order to control the incidence of nosocomial infection. The department is also responsible for maintaining sufficient stock level of all surgical instruments, drapes and other accessories required for surgical procedures in good condition. The following types of items are sterilized: i. Surgical instruments 54

ii. iii. iv. v. vi.

Catheters (rubber) Linen Dressing materials Laparoscopic instruments PVC Tubing etc.

Staffing plan

Category Asst. Mgr. Supervisors Sr.charge technician charge technician Sr. technician Technician-II Assistant-II Store keeper Attendants

No. 1 1 1 6 10 5 1 1 23

Organogram

Director Medical Co-ordination Assistant Manager

Supervisor

Clerk

Store keeper

55 Technician

Charge Technician

Attendant

HOUSE KEEPING
Introduction Housekeeping services play a vital role in the management of complex facilities in a hospital. On one hand the management of bio medical waste as per the regulation is of prime importance to comply with legal norms and on other side, handling of patients on wheel chair, beds, stretchers require an alert hosekeeping staff for safe transport of patients in hospital focused to deliver safety across the hospital. Staffing: S.No 01 02 03 04 05 Designation Asstt. Manager Sr. Officer & Officer Sr. Supervisor & Supervisors Team Leaders Healthcare workers Total Manpower Nos. 01 03 04 04 309 321

Range of activities Maintaining the aesthetic and cleanliness of all the hospital properties which include inpatient and outpatient areas and S1 building . Planning and controlling of all inventories to ensure clean, hygienic and safe environment. Systematic collections and disposal of hospital waste. Quality sanitary procedure in every area including the sanitary needs of the patient.

56

Issuing and controlling replacement of furniture to other departments as per their requirement. Accurate and timely meal services for patient and their relatives. Safe transportation of patients. Pest control management.

CLINCAL ADMINISTRATIVE SERVICES

57

AMBULANCE SERVICES
Introduction Ambulance Services under the purview of the Accident & Emergency department. Hospital offers round the clock ambulance services, geared to meet any emergency surgical or medical. There are two types of Ambulance services. - Cardiac ambulance (Advance care ambulance) - Non Cardiac ambulance - The cardiac ambulance serves all critical patients coming in from - Nursing homes - Office - House - Accident Site RTA - All critical patients who requires medical intervention immediately The Non cardiac ambulance serves patients who are - Discharged. - Planned admissions. - For appointments to Hinduja clinic. Air Ambulance Air ambulance is a blessing when the critical patient is in a remote area and urgently needs to be transferred to a tertiary care centre like Hinduja hospital for specialist treatment. Hinduja hospital, in its continuous endeavor to provide quality health care for all now offers air ambulance services for seamless transfer of national and international patients.

58

NURSING DEPARTMENT
Introduction Hinduja Hospital has a very efficient nursing department. This department is divided into two categories, Clinical and Administrative. It also has Special Nurses who are trained in a particular area and work only in that area. Clinical: The division deals with administration of clinical services to the patients. The Hierarchy in Clinical Nursing division is-

Director- Nursing

Asst. Dir. Nursing NURSING INCHARGE (Head Nurse, Senior Officer, officer, Assistant manager, Executive.)

Senior Staff Nurse

Junior Staff Nurse

Nursing Aids

59

Administrative: The Administrative Nursing Division comprises of staff development. It deals with providing continuous training with formal structural programs and informal training. Induction Training and On-job training are also a part of staff development. Once a week, mainly on Thursdays, in-house training is given to the nurses. Special nurses The special nurses are trained in a particular area, and are assigned to work in that area only. There are 8 special nurses1. Diabetic Nurse educator 2. Onchology Nurse 3. Infection Control Nurse 4. Breast Clinic Nurse 5. Stoma Care Nurse 6. Pain Management Nurse 7. Diabetic Foot Care Nurse 8. Home Care Nurse The patient to nurse ratio in the hospital varies from 4:1 to 6:1 The nurses work in The OPD, IPD, Radiology, S1. In the IPD building, at each floor nursing stations are present in each wing. The nurses operate from these areas.

Education and training facility for nurses In line with its continued commitment towards education and training in the field of healthcare, particularly the preparation of highly competent nursing professionals dedicated to patient care, the Board of Management has upgraded its School of Nursing to a fully fledged College of Nursing. Prior to this, the hospital successfully conducted over two decades, a recognized three and half year diploma in General Nursing & Midwifery (GNM) for female candidates. Its students over the years excelled in academics, co-curricular, extracurricular activities and clinical practice.

60

LAUNDRY SERVICES
The importance of a clean, hygienic, un-stained and defect free linen for optimal patient care has been stressed upon since the very inception of hospitals. Clean linen delivery in a timely manner to healthcare areas is important. The quality of any health care system. Laundry service is responsible for providing an adequate, clean and constant supply of linen to all users. The laundry facilitates is designed, equipped and ventilated to reduce the dissemination of microorganisms on to finished textiles. The basic tasks include: sorting, washing, extracting, drying, ironing, folding, mending and delivery. Cleaning of soiled linen collected from patient care areas. Storage and distribution of clean, unstained and defect free linen to various areas of hospitals like floors (for patients), CSSD (for sterile linen supply to operation theaters), housekeeping and food service department (for conference and other functions). Cleaning, storage and distribution of uniform to all employees and consultants. Specific procedure for handling, including labeling of materials contaminated with hazardous materials or body fluids. Policies and procedures for cleaning of contaminated materials. Storage and distribution of curtains across the hospital facilities.

MORTUARY SERVICES
Mortuary at Hinduja hospital is managed by A & E department and security and maintained by Housekeeping department. It currently has capacity to keep 6 bodies. Only inpatient bodies are allowed to keep at Mortuary. Mortuary is also used to keep Amputated body parts.

61

ADMINISTRATIVE SERVICES

62

MEDICAL RECORDS DEPARTMENT

Introduction A medical record, health record, or medical chart is a systematic documentation of a patient's medical history and care. The term 'Medical record' is used both for the physical folder for each individual patient and for the body of information which comprises the total of each patient's health history. MR is intensely personal documents and there are many ethical and legal issues surrounding them such as the degree of third-party access and appropriate storage and disposal. MR are traditionally compiled, stored and maintained by MRD of the P.D.Hinduja hospital from 1987. Terminal Digit System of file is most secure and safe system as far as the identification of the file is concern. New Registration forms are kept at various station i.e.OPD, Casualty, Admission counters etc. Patient or next of kin fill up the form for all demographic details and puts the signature, and then the entry is done by the receptionist at counter in the system. The patient is given a ID card which has 6 digit HH no, and name, sex ,age etc.The file has 6 digit number where last 3 digits are color coded. The filing system is dependent on the last 3 digits; hence total confidentiality of the patients file is maintained. The information contained in the medical record allows health care providers to provide continuity of care to individual patients. The medical record also serves as a basis for planning patient care, documenting communication between the health care provider and any other health professional contributing to the patient's care, assisting in protecting the legal interest of the patient and the health care providers responsible for the patient's care, and documenting the care and services provided to the patient. In addition, the medical record may serve as a document to educate medical students/resident physicians, to provide data for internal hospital auditing and quality assurance, and to provide data for medical research. Personal health records combine many of the above features with portability, thus allowing a patient to share medical records across providers and health care systems. The most basic rules governing access to a medical record dictate that only the patient and the health care providers directly involved in delivering care have the right to view the 63

record. The patient, however, may grant consent for any person or entity to evaluate the record. Research, auditing, and evaluation Individuals involved in medical research, financial or management audits, or program evaluation have access to the medical record. They are not allowed access to any identifying information, however the patients or their representatives the right to a copy of their record, except where information breaches confidentiality (e.g. information from another family member or where a patient has asked for information not to be disclosed to third parties) or would be harmful to the patient's well-being (eg some psychiatric assessments). Objectives 1. To aid in the diagnosis and treatment of patient 2. To provide written documentation of directed medical care and to show services were medically necessary 3. To assist in the research of disease and injuries so other patients may benefit from previous patient care 4. To substantiate procedure and diagnostic code selections for research purposes 5. To comply with legal requirement 6. To legally defend the physician in the event of lawsuits 7. To provide records of communicable diseases as per government requirement Location & layout The MRD is located on the 1st floor, 3rd wing of the OPD. It is spread over 1500 sq. ft. with additional area of allocated for the storage of records. The department has over 80,000 active files in the OPD, while are being maintained in archived form for legal/ research purposes.

64

Nature of activity 1. Allocation of H.H. No. 2. Collection of computerized list of Discharged / death cases. 3. Collection of health record charts from wards / casualty. 4. Assembling in standard order. 5. Deficiency check. 6. Medical coding. 7. Indexing. 8. Filing of various reports. 9. Operation procedure. 10. Retrieval and issuance of files. 11. Receiving and storing of files. 12. Medical certificates, Injury Certificate, correspondence of L.I.C. claims and legal matters etc. 13. Third Party Administration queries. And any other Insurance companies queries pertaining to the patient illness and its duration.

65

INFORMATION TECHNOLOGY
Introduction Primary purpose of Information Technology department is to: i. Cater to any needs of computerization within the organization. ii. Maintenance of existing hardware and software. iii. iv. Provide guidance to the user in terms of operation procedure. Develop a user friendly and automated software system.

Today, I T department is the backbone of Hospital Operation which facilitate in achieving the quality service, performance and maximum results. The department is responsible for providing highly automated user friendly and zero defect computer based solutions as per the requirements of the Hospital. This department works under the direction and supervision of the Dy. Director (Information Technology). Scope of Services I.T department has three sections: i. Software Section ii. Hardware Section iii. Telecom Section i. Software Section is responsible for system operation & control, software

maintenance, controlling database backups & their libraries and to provide ongoing assistance to the application users. It is also responsible for system recovery in case of failure and for recording and monitoring down time of the system for optimal & smooth performance of the organization. ii. Hardware Section responsible for hardware functions of the system with zero

downtime and high availability. It also fulfill the hardware related requirements from 66

users and supports there systems. This section introduces the technology which is use full for users in there day to day working.

iii.

Telecom section is responsible for implementation of new technology and

maintenance of telecommunication operations of the hospital. Telecom section also looks after the maintenance of wireless system and paging system.

ENGINEERING DEPARTMENT
Introduction Engineering & Maintenance Department is manned for 24 hours for keeping round the clock vigil on the proper functioning of plant engineering equipment coming under the purview of the department. This covers maintenance of major supplies to the hospital such as power, water, medical gases, air- conditioning and related equipment supporting the same, which form the life line to the hospitals activities. The responsibilities of the department are: 1. Operation and maintenance of plant equipment installed in the basement of main building and various other areas to support the normal functioning of the hospital. 2. Repair work of equipment related to the departments responsibility. The policy of the department is: 1. Serve well with safety and in time 2. Continuous improvement, cost saving 3. Optimum utilization of manpower and equipment 4. Optimum utilization of inventory. 5. Teamwork Objective: To ensure uninterrupted support and supply of engineering services to end users by adopting correct process and practices leading to successful maintenance of all engineering systems in fully Operational condition, at all the times. 67

Scope of Engineering Services: The major engineering services involved are as follows: Electrical Power Supply Normal & Emergency. Air conditioning, Ventilation & Refrigeration. Steam & Hot water Supply. Water Stations & Cold water supplies Filtration systems. Medical gases supplies. Fire detection, Alarm & fighting systems. Internal & external plumbing systems. Civil works Masonry, Carpentry, Glasswork, Upholstery, Painting etc. PNG & LPG Supply. Safety assessment of facilities

THE KNOWLEDGE CORE

Introduction Research is an important activity of Hinduja Hospital. It is recognized as a Research Organization by the Department of Scientific & Industrial Research, Ministry of Science & Technology, and Government of India. Various clinical research projects are carried out with the objective of improving medical practices. A Research Advisory Committee with eminent scientists and researchers from all parts of the country guide & give direction to the research programme. The hospital is recognized by the Bombay University for M.Sc. and PhD in Applied Biology. The faculty members are recognized guides for M.Sc. and PhD, Bombay University. The hospital is approved by the Diplomate National Board for specialization in the following DNB RECOGNIZED SPECIALITIES 68

MATERIAL MANAGEMENT DEPARTMENT

The materials management department aims at maintaining uninterrupted supply chain without affecting cost, quality and service parameters. The materials management department can be classified majorly under 2 heads i.e. purchase department and stores.

Materials management department

PURCHASE

STORES

1. Local and engineering purchase 2. Capital import purchase 3. Lab. Purchase 4. Medical and consignment 5. Pharmacy purchase 6. Provision Purchase 7. Scrap and surplus sales

1. General stores 2. Provision stores 3. Pharmacy stores 4. Engineering stores 5. Diagnostic stores 6. Medical stores

OT stores Cath lab stores

69

Organogram:

Director Materials

ManagerPurchase(CAPEX,

Assistant manager purchase (local, Scrap)

ManagerStores

Assistant Manager - Pharmacy Senior supervisor

ExecutiveStores Executive imports and CAP Officer Senior officer Senior Clerk attendant Senior Supervisor Purchase assistant

Supervisor Pharmacist

Officer

Senior Supervisor Management Trainee

Senior Clerk Senior Clerk

Attendants
1. OFFICER- medical and

Multi Skill

Pharmacist

cath lab Sr. Clerk, clerk Attendant

2. Sr. Supervisor General

Sr. clerk, clerk Attendant

3. Sr. clerk Provision Clerk

attendant
4. Sr. officer OT Supervisor

Sr. Clerk, Clerk attendant

Categories of staff :

5. Supervisor engineering Sr. clerk 70

Type Director Manager Executive Sr. Officers Officers Executive secretary Sr. Supervisors Supervisors Management trainee Pharmacists Senior clerk Clerks Purchase assistant Attendants Multi skill Piece rate Casual Temporary attendant Total

Nos. 1 3 2 2 3 1 5 3 1 15 10 3 1 18 2 1 5 1 77

71

Process flow Purchase Section START

Stockable/ Nonstockable purchase Is the material available in main store New item purchase (free format) Consignment item

Consignment Process Items value less than rs. 5000/and nonregularized Capital items (CAP) value is more than rs. 5000/Consignment materials

NO

YES

Online indent is raised to purchas e

Material s issued to user dept.

PR is raised by user dept. and approved by DDM

CAP Procedure

STOP

Purchase order is generated

STOP

Identify the existing vendors and if required then call for more quotations

Purchase of capital equipment

STOP
Materials are accepted from suppliers with DC Distribution to user dept. Call suppliers for negotiations

Once the supplier is identified P.O. is generated

Follow up with supplier for delivery

72

Pharmacy
Hinduja Hospital runs a inpatient pharmacy which works 24/7 throughout the year and consists of Dispensing area and store. It is located on the 5th floor of the new building. The Pharmacy also has a formulary with around 3000 items mentioned in it and also a DTC ( Drug and therapeutic committee), with senior doctors, nurses and pharmacists as its members. In the pharmacy no cash transactions take place and no relative has to go there, the nurses enter the medications required into the system from the floors, and then a Floor Wise Consolidated Report is taken and all the items are sent together in 7 rounds to the nursing station at each floor by the pharmacy attendants. The patient is billed from the pharmacy on his HH No. and the information is sent to billing department directly. The Pharmacy keeps only 1 brand of the drugs, which is generally the research molecule. They also have a provision for narcotic drugs, which they store in a lock according to the narcotic drugs and psychotropic substances act. The narcotic prescriptions are kept in a record. The hospital formulary is updated periodically. A pharmacy news bulletin is also prepared and is given to the doctors. The inventory control methods used are: 1. ABC- Always better control 2. HML-High Medium low 3. VED- Vital essential Desirable
4. XYZ

5. GOLF-Government Open Local Foreign Product 6. SDE-Scarce Difficult easy 7. FSN- Fast, Slow and Non- Moving.

73

SECTION B

PROJECT REPORTS

CUMULATIVE PROJECTS

74

PROJECT REPORT ON PATIENT DISCHARGE PROCESS

PHASE 1 STUDY ON: Patient discharge process DEPARTMENT: NURSING STUDY PERIOD: 29-04-2010 to 06-05-2010 AIM: To determine the difference in discahrge time between predicted discharges and nonpredicted discharges. OBJECTIVE: To determine the following time lag for predicted and non- predicted discharges: Average time from verbal intimation to physical discharge of patient Average time from verbal intimation to initiation of discharge process Average time from written order to physical discharge of patient Average time from written order to initiation of discharge process Average time from receival of Discharge clearance slip to physical discharge of patient.

METHOD AND SAMPLING: SAMPLING: The patients discharged were observed for the average discharge time on random basis during the period of 29th April 10 to 6th may 10. The sampling process adopted in this study is Simple random sampling. SAMPLE SIZE: 102 patients (12 predicted discharges and 90 non predicted discharges)

75

METHODOLOGY: The patients discharge process was tracked as followed: Firstly the date and time of verbal intimation to the patient by the doctor was noted. Following it, the date and time when a written order is given to the nurse by the doctor was noted. Then the time lag between these two activities was calculated. Then the actual discharge date was noted down along with time of initiation of discharge process, i.e. when the financial folder of the patient is sent to the billing department. Then the time when the nurse receives discharge slip from the patients relative and the time of physical discharge of patient i.e. when the patient leaves the floor were noted down and the time lag between the 2 activities was calculated. In this study a sample of 102 patients was observed. The patients were classified according to predicted and non- predicted discharge and the various time lags were calculated and averaged for both the classes RESULTS/ FINDINGS: Following is the summary of observations (for detailed observation refer annex-I and annex II). ADMISSION NO. NAME CLASS LOCATION

discharge order

actual dischar ge date

time

time

time lag (minutes)

verbal intimati on (patient ) date

verbal intimati on (patient ) time

writt en order (nurs e) date

writt en order (nurs e) time

time lag (mi n)

finan ce folde r sent to billin g

nurse recieve s dischar ge slip

physi cal disch arge of patie nt

from verbal intimation to physical discharge

from verbal intimati on to initiatio n of dischar ge process

from written order to physica l dischar ge

from writte n order to finan ce folde r sent to billin g

from reciev al of disch arge slip to physi cal disch arge

76

It was observed that the average time from verbal intimation to physical discharge of patient, verbal intimation to initiation of discharge process, written order to physical discharge of patient, written order to initiation of discharge process, receival of Discharge clearance slip to physical discharge of patient were more in case of predicted discharge over non- predicted discharge. This difference is because the intimation of discharge is given 1-2 days before the actual discharge date.

NON- PREDICTED DISCHARGE

Average time (verbal intimation to physical discharge of patient): 2.76 hrs (166 minutes) Average time (verbal intimation to initiation of discharge process): 1.2 hrs (72 minutes) Average time (written order to physical discharge of patient): 2.76 hrs (167 minutes) Average time (written order to initiation of discharge process): 0.96 hrs (58 minutes) Average time (from receival of Discharge clearance slip to physical discharge of patient): 0.43 hrs (25.94 minutes)

PREDICTED DISCHARGE Average time (written order to physical discharge of patient): 13.57 hrs (814.25 min) Average time (written order to initiation of discharge process): 11.81 hrs (708.75 min) Average time (verbal intimation to physical discharge of patient): 25.02 hrs (1501.36 min) Average time (verbal intimation to initiation of discharge process): 19.08 hrs (1144.55 min) Average time (from receival of Discharge clearance slip to physical discharge of patient): 0.hrs (37.5 minutes)

CONCLUSION: It was observed that the average time for the discharge process is more in case of predicted discharge over non- predicted discharge. This is because the intimation of discharge is given 1-2 days before the actual discharge date. The process thus takes more time since the time lag from intimation to physical discharge of patient increases. RECOMMENDATIONS:

77

In order to get an accurate result for predicted discharge, the average time from initiation of process on the actual day of discharge to the physical discharge should be calculated. Since the time difference between verbal intimation to physical discharge and written order to physical discharge is being considered, the resulting time lags are higher in case of predicted discharges over non- predicted discharges.

PATIENT DISCHARGE PROCESS

PHASE 2 STUDY ON: Patient discharge process DEPARTMENT: NURSING STUDY PERIOD: 29-04-2010 to 06-05-2010 AIM: To determine the difference in Discharge time between Median class patients and the patients of special, deluxe and suite class so as to find out the role of customer care. OBJECTIVES: To determine the following time lag for different classes of patients: Average time from receival of Discharge clearance slip to physical discharge of patient Average time from written order to physical discharge of patient Average time from verbal intimation to physical discharge of patient

METHOD AND SAMPLING:

SAMPLING: The patients discharged were observed for the average discharge time on random basis during the period of 29th April 10 to 6th may 10. The sampling process adopted in this study is Simple random sampling. SAMPLE SIZE: 102 patients (18 patients- special, deluxe and suite class and 84 patients- median, median A and median B class.)

78

METHODOLOGY: The patients discharge process was tracked as followed: Firstly the date and time of verbal intimation to the patient by the doctor was noted. Following it, the date and time when a written order is given to the nurse by the doctor was noted. Then the time lag between these two activities was calculated. Then the actual discharge date was noted down along with time of initiation of discharge process, i.e. when the financial folder of the patient is sent to the billing department. Then the time when the nurse receives discharge slip from the patients relative and the time of physical discharge of patient i.e. the time when the patient leaves the floor were noted down and the time lag between the 2 activities was calculated. In this study a sample of 102 patients was observed. The patients were classified according to the class into 2 groups. The first group comprised of median, median-A and median-B class and the second group consist of special, deluxe and suite class and the average time were calculated for both the classes: Average time from receival of Discharge clearance slip to physical discharge of patient Average time from written order to physical discharge of patient Average time from verbal intimation to physical discharge of patient

RESULTS/ FINDINGS: Following is the summary of observations (for detailed observation refer annex-I and annex II): ADMISSION NO. NAME CLASS LOCATION

Discharge order Verbal intimation(pat ient) date Verbal intimati on (patient ) time Writt en order (nurs e) date Writt en order (nurs e) time Time lag ( minu tes)

Actual dischar ge date

Time Finan ce folder sent to billin g Nurse receives dischar ge slip

Time Physic al dischar ge of patient From verbal intimati on to physica l dischar ge

Time lag (minutes) From verbal intimati on to initiatio n of dischar ge From written order to physic al dischar ge From writt en order to finan ce folde From recieva l of dischar ge slip to physic al

79

process

r sent to billin g

dischar ge

The average time for deluxe, special and suite class: Average time (from receival of Discharge clearance slip to physical discharge of patient): 0.53 hrs (31.94 minutes) Average time (written order to physical discharge of patient): 3.81 hrs (228.61 minutes) Average time (verbal intimation to physical discharge of patient): 5.01 hrs (300.833 minutes)

The average time for median, median-A and median-B class: Average time (from receival of Discharge clearance slip to physical discharge of patient): 2.31 hrs (138.80 minutes) Average time (written order to physical discharge of patient): 3.78 hrs (227.45 minutes) Average time (verbal intimation to physical discharge of patient): 4.56 hrs (274.1 minutes)

CONCLUSION: It was observed that the average time lag between the receival of discharge slip to the physical discharge of patient was less in case of special, deluxe and suite class. This is because of the assistance they receive from customer care executives. However the time lags for the other two activities were almost similar. Hence, it can be concluded that the assistance from customer care speeds up the process of discharge.

RECOMMENDATIONS: The median class patients should also be provided assistance from customer care department, to speed up their discharge process. The guidance from customer care department can reduce the time lag between receival of discharge slip by the nurse and the physical discharge of patients.

80

PROJECT REPORT ON REPORT ON MEDICINE AUDIT

AIM: To find out Areas which are more prone & requires proactive approach to prevent Incidence of Medication error. OBJECTIVE: To ensure that There is Zero error in copying medicines from physicians order sheet to medication administration record. Documentation for medicines administered is done according to protocol. There is no discrepancy in putting online request for prescribed medicines. METHODOLOGY: Retrospective Analysis: A Tool was designed for various inpatient areas of hospital to audit Medication Administration records. A small team of auditors was identified to audit various inpatient areas of the hospital. AUDIT AREAS: All IPD areas were audited & they were classified as: ICUs Floors SAMPLING TECHNIQUE:

81

Systematic Random Sampling: Alternate patients (Even numbered beds were audited on each floor by the team) Sample Size: 100 Patients Out of the total 100 patients medication administration record Audited, total 494 medicine samples were covered.

Following are the details of area wise sample size:

a) ICU : 32 patients & 159 Medicines b) Floors : 68 patients & 335 Medicines

TOOL USED FOR DATA COLLECTION:

82

P.D. Hinduja National Hospital & MRC

Date: Sample 1 S.No. Activity Admission No. No. Of Medicine Prescribed To Patient 1 2 3 4 5 6 7 8 9 10 Medicine Copied to Medication Administration Record Medicine Entered in System Medicine Received From Pharmacy Medicine Administered (From Records) Route Of administration (From Records) Dose of Drug (From Records) Time Of Administration (From Records) Medicine Administered To (From Records) Technique of Administration (From Records) Drug Omission (From Records) Sample 2

Sample 3

Sample 4

Sample 5

Sample 6

Name Of The Auditor Signature Of Auditor

: :

Floor/ Dept :

DRUG OMITTED: It means drug is not recorded after administration or Drug is not administered. DRUG RECEIVED FROM PHARMACY: In this incorrect Incidence means drug was not available or wrong drug was received from pharmacy. DRUG ADMINISTERED: 83

In this incorrect entry means either drug is not documented after administration or it is not given to patient. RESULTS: The data collected for medicine audit is confidential, therefore as per the hospital policy the results cannot be revealed.

PROJECT REPORT ON TAT OF APPOINTMENT UNREGISTERED OPD PATIENTS

DEPARTMENT: OPD STUDY PERIOD: 10th and 11th May 2010

84

AIM: To find out the Turn Around Time of appointment unregistered OPD patients.

OBJECTIVE: To measure the time taken for each process of Appointment Unregistered OPD patients.

METHODOLOGY: A team was formed who interviewed different patients and explained them the study so as to take their consent. The patients (unregistered appointment) were selected on a random basis. With the consent of the patient certain set of activities were tracked i.e. from the queue in time to the voucher given to the nurse time. The above timings were noted down by the team members and then the form was handed over to the patient to enter the clinic-in time and clinic-out time. Lastly they were requested to drop the form in a white colored suggestion box, kept on the help desk at ground floor of OPD wing.

SAMPLE SIZE: 16 (The actual sample was 50 but the response rate was 32%)

TOOL USED: Patient Tracking Sheet Form NO. Date Appt. Time Floor Queue in time Voucher start time Vouch er end time Voucher given to nurse time Clinic in time Clinic out time Specialty

RESULTS AND FINDINGS: On the basis of the tracking sheet the following time laps were calculated

Total Queue Time

Total Vouchering

Total Total Travel Waiting Time Time

Total Consultation Time

Total Process Time

85

Average Time (min)

45

18

90

LIMITATION OF THE STUDY: The response rate of the patients was 32%.

PROJECT REPORT ON COMPARATIVE ANALYSIS OF REPORT TURN AROUND TIME

86

DEPARTMENT: OPD

STUDY PERIOD: 24/05/2010 to 26/05/2010

AIM: To compare the Report Turn Around Time of P.D Hinduja National Hospital with other hospitals at par in Mumbai. OBJECTIVES: To compare the Report Turn Around Time of CNP (Cardiology, Neurology, Pulmonology) reports with different hospitals, and identify the grey areas that needs improvement. METHODOLOGY: 1. 2. 3. 4. 5. 6. For the purpose of carrying out a comparative analysis, in order to identify the areas of improvement, 5 hospitals and 1 diagnostic centre were selected, which are at par with Hinduja Hospital. The selected hospitals and diagnostic centre are as follows :LILAVATI HOSPITAL HIRANANDANI HOSPITAL BREACH CANDY HOSPITAL KOKILABEN DHIRUBHAI AMBANI HOSPITAL FORTIS, MULUND PIRAMAL DIAGNOSTIC CENTRE.

The tests included were as follows:

1) CARDIOLOGY-

a. b. c. d.

ECG ECHO STRESS TEST HOLTER TEST

2) NEUROLOGYa. EEG b. EMG 87

c. VEEG d. EP STUDIES- BERA, SSEP, ERG, VEP 3) PULMONOLOGY a. Complete PFT b. Spirometry

TOOL USED: The data was collected by making mock calls to the above stated Hospitals/Diagnostic center and enquiring about the expected day of report delivery. SAMPLE SIZE: Not Applicable

SAMPLING TECHNIQUE: Not Applicable

RESULTS AND FINDINGS: NEUROLOGY:

For EEG and EMG test the report Turn Around Time (TAT) after comparing showed a time difference of 1 day (approx.) For VEEG test, the report Turn Around Time is 10 days, which is higher as compared to the other hospitals. While collecting the data it was found out that the tests included in the EP studies were different for different hospitals. However there was time difference of 1 day (approx.)

CARDIOLOGY: For ECG most hospitals like Lilavati, Breach Candy and L.H Hiranandani deliver the reports within 1 hour. For ECHO and Stress almost all the hospitals are delivering the reports within 1 day. Report TAT for Holter test is almost similar for all hospitals i.e. 3 days. 88

PULMONOLOGY: For Spirometry and Complete PFT report TAT for all hospitals is almost similar.

CONCLUSION: It was observed that the Report TAT of P.D Hinduja National Hospital was higher for Cardiology & Neurology reports as compared to the other hospitals.

RECOMMENDATION:
The report Turn Around Time for Cardiology and Neurology tests needs attention.

Specific measures should be taken to speed up the process and eliminate all the possible reasons for delay.

89

PROJECT REPORT ON BIOMEDICAL WASTE MANAGEMENT

Aim Objective Introduction Bio-Medical Waste (Management and Handling) Rules, 1998 Protocols PDHNH Protocols for BMW Management Process Flow Observation & Gap Analysis Non Compliance with BMW (M & H) Rules Results & Findings Recommendations

90

AIM: To identity that the waste generated in the hospital is managed and disposed off in an environment friendly manner, in conformance with the Bio Medical Waste (Management & Handling) Rules, 1998. SPECIFIC OBJECTIVES: 1. To understand the complete process flow of Bio-Medical waste management in the hospital. 2. To conduct gap analysis in order to identify the bottlenecks associated with the process of Bio Medical Waste Management in the hospital. INTRODUCTION: Healthcare activities protect and restore health and save lives. At the same time they generate large quantities of waste and by-products that need to be managed safely and disposed of properly. Provided that the waste is properly segregated and separated, most of the waste can be managed in the same way as municipal waste. Proper disposal of Hospital waste is of paramount importance because of its infectious and hazardous characteristics. The Govt, of India promulgated the Bio-medical Waste (Management & Handling) Rules, 1998 and it became mandatory for Hinduja Hospital also to comply with the rules and the standards laid down under statutory regulations. Medical waste is broadly defined as any solid or liquid waste that is generated in the diagnosis, treatment of immunization of human beings or animals in research pertaining thereto, or in the production or testing of biological material. According to World Health Organisation (WHO) estimates 85% of hospital waste is actually non-hazardous and around 10% is infectious while the remaining 5% is non-infectious but consists of hazardous chemicals like methylchloride and formaldehyde. Here., the main concern of infectious hospital waste is the transmission of HIV and Hepatitis B or C viruses. In this context, syringes and needles have the highest disease transmission potential. Hospital waste, till recently was not being managed but it was simply disposed off. The disposal of hospital waste can be very hazardous particularly when it gets mixed with municipal solid waste and is dumped in uncontrolled or illegal landfills such as vacant lots in neighboring residential areas and slums. This can lead to a higher degree of environmental pollution, apart from posing serious public health risks such as AIDS, Hepatitis, plague, cholera, etc. PERCENTAGE CONSTITUENT OF HOSPITAL WASTE: Constituents Pathological Waste Infectious Material General Non-Infectious Kitchen Waste Recyclable materials (papers, plastic, metal) Approx. % 5 10 50 30 4.5

91

Above statistics are as per the World Health Organization (WHO) estimates. BIO MEDICAL WASTE: Bio-medical waste is defined as waste that is generated during the diagnosis, treatment or immunization of human beings and are contaminated with patients body fluids (such as syringes, needles, ampoules, organs and body parts, placenta, dressings, disposables plastics and microbiological wastes).

BIO-MEDICAL WASTE (MANAGEMENT AND HANDLING) RULES, 1998 PROTOCOLS

COLOR CODING AND TYPES OF WASTES Color-coding Yellow Type of container Plastic bags Waster categories Cat 1 Human anatomical waste Cat 2 animal waste Cat 3 microbiology waste Cat 6 soiled waste Cat 3 microbiological Cat 6 soiled waste Cat 7 solid waste Cat 4 waste sharps Cat 7 plastic disposable tubings Cat 5 discarded medicine Cat 9 incineration ash Cat 10 chemical wastes

Red Blue/White Black

Disinfected Container Plastic bags Plastic bag/puncture Proof containers Plastic bag/ puncture proof containers

TREATMENT & DISPOSAL OF WASTES Category 1 2 3 4 5 6 7 Waste Type Human anatomical Animal waste Microbiology & biotech Waste sharps Discarded Med & Cyto Drugs Soiled Solid Container (Yellow) (Yellow) (Yellow ,Red) (Blue, White) (Blue) (Yellow) (Red, Blue, Treatment & Disposal Incineration/Deep burial Incineration/Deep burial Autoclaving/ Microwaving/Incineration Disinfection(Chem)/Auto/Micro/Shredding Incineration/Destruction/Secured Landfill Incineration/Autoclave/Microwaving Disinfection(Chem)/Auto/Micro 92

8 9 10

Liquid Incineration Ash Chemical

White) (Black) (Black) (Black)

Chem Disinfec & Discharge into drains Muncipal Landfill Chem Treatment Drains /Landfill

PDHNH PROTOCOLS FOR BMW MANAGEMENT

PURPOSE: To ensure proper segregation, storage, transport and disposal of waste generated in the
hospital.

To ensure that the waste generated in the hospital is managed and disposed off in an
environment friendly manner, in conformance with the prevailing state/ national regulations.

FOUR COLOR CODES: 1. BLACK BAG: General Waste. It includes: a. Office papers b. Paper Cups c. Tissue Papers d. Kitchen waste. e. post autoclave shredded waste. These are sent to BMC for final disposal. 2. YELLOW BAG: Infectious waste. It includes: a. Human Tissue Organs and body parts b. Cytotoxic drugsc. Ampoules and vials d. Expired or discarded drugs 3. RED BAG: Infectious waste. It includes: a. I.V. Tubings b. Rubber - Catheters c. Infected Intravenous sets + cannulas d. Ryles Tubes+ Gloves + Plastic syringes e. Cotton Gauze Pieces 93

This waste is disinfected using sodium hypochlorite, then it is autoclaved and transferred to black bag and collected by BMC. 4. GREEN BAGS: Recyclable plastic waste handed to assigned contractors as scraps for recycling. It includes: a. Packing materials b. Non- infected plastic bottles c. Oil tins d. Cardboard boxes SHARPS (PUNCTURE PROOF CONTAINERS): The puncture proof can consist of 5 ml of 1% sodium hypochlorite solution. These are sent to BMC for final disposal. It includes: 1. Needles 2. Syringes 3. Scalpels 4. Blades 5. Infected glass waste These are disposed by autoclaving and shredding and GTB Sewri hospital. GLASS WASTE (CARDBOARD BOX): Non- infected Glass Waste includes: 1. Broken glasses 2. Glass I.V. Bottles 3. Glass petridishes 4. Non- infected glass bottles 5. Ampoules 6. Glass Slides

SPILL MANGEMENT A. MERCURY SPILL: collected using a pipette, wearing double latex gloves and handed over to infection control nurse B. Blood and Body fluid spill: treated with an absorbent material & 1% sodium hypochlorite, then collected using a scoop and discarded in RED bag. PREVENTION OF NEEDLE STICK INJURY 1. Health care workers are instructed never to recap the needles after use. 2. All sharps are disposed off in disposable BD container available on dressing trolley sand puncture proof container in nursing stations. These are pre- filled with 1% sod. Hypochlorite solution upto one-third level.

94

Biomedical Waste Management

Segregation

Transportation

Disposal

SEGREGATION:

95

TRANSPORTATION

Phase I: To service lift

96

Phase II: To BMW Room

97

DISPOSAL

98

OBSERVATIONS: At the Nursing Station of every floor stationary of Bio Medical Waste is kept such as Plastic bags (Red, Black, Yellow and Green). At each patient bed a black and Red bag is kept for normal and infectious waste respectively. At every Nursing Station poster of hand wash is pinned up. Once the bags are filled they are taken by the Healthcare Worker to the service lift area (Black bags are dumped in the Blue Container and Red & Yellow bags in Red Container) While taking the waste to the service lift area the Healthcare Worker uses PPE (Personal Protective Equipment) such as Gloves and mask. From the nursing station to the service lift the bio-medical waste is carried with bare hands (trolleys are not used). From the service lift area another Healthcare Worker takes the wastes to the Biomedical Room (backyard of IP Building) through trolley. Autoclaving of the infectious waste is done at the 5th floor (IP Building). Training is provided to the staff regarding PPE and procedures twice a week (Wed. & Fri.) In the wards of S1 Building, near every patient bed one dustbin with black bag was observed whereas the other three bags (Red, Yellow & Green) were common for all the beds and was kept at the nursing station of every floor. Outside every floor of S1 Building, there were two Big containers (Red and Blue) to keep the waste in them. RESULTS & FINDINGS: From the BMW floor wise data of our hospital between 1st May 2010 to 23rd May 2010, it was found out that:

Infectious Waste generated in 20 Days 99

Categories of Infectious Waste Total Red Bags Total Yellow Bags Total Sharp container

Number 455 46 65

Hence, Requirement of bags per day

Categories of Infectious Waste Total Red Bags Total Yellow Bags Total Sharp container

Average 22 2 3

Infectious Waste generated in 20 Days

Categories of Infectious Waste Total Red Bags Total Yellow Bags Total Sharp Containers Total Infectious Waste generated Hence, Infectious Waste generated per day

Weight (kg) 1677 57 119 1853

Categories of Infectious Waste Total Red Bags Total Yellow Bags Total Sharp Containers

Average Weight (kg) 80 3 6 100

Total Infectious Waste generated

89

Now we can calculate the proportion of each type of infectious waste from the total infectious waste by using below mentioned formula:

Avg. weight of each category of infectious waste (kg)*100 Total infectious waste generated per day

Red bag Yellow bag Sharp container

Proportion of different categories of infectious waste 90 3 7

GAP ANALYSIS: 101

 Absence of Bio Hazard logo at the door of Bio Medical Waste room at the backyard of the building. Green bags are mixed with the general scrap and are not tied properly. Some of the green bags were found outside the scrap room at the pavement and were in contact with spilled water. The fresh cans for storage of sharps were stored outside the Bio Medical Room, which in a way were in contact with the infectious waste. While carrying the waste bags the Healthcare workers were not wearing proper closed shoes. At the dumping area of the OPD Building all the segregated waste bags were kept together which were converting non infectious waste also into infectious waste. In the dumping area of S1 Building there was no proper room to keep Bio Medical Waste so all the waste was in open contact with external environment and was mixed with the construction materials over there.

RECOMMENDATIONS: The general waste should be transported in black colored trolleys and the bio-medical waste in red colored covered trolleys marked with bio-hazard symbol The workers should be checked for respiratory disorders at least once in six months. A log book of waste generated floor wise shall be maintained so as to get a clear picture of Hospital waste generated.

102

PROJECT REPORT INDIVIDUAL PROJECT

103

104

PROJECT REPORT ON PATIENT SATISFACTION SURVEY FOR MRI AND CT PATIENTS

AIM:

To identify the problem areas leading to patient dissatisfaction in Imaging Department. Patient satisfaction should be more than 90%, less than that signifies the problem areas

OBJECTIVES:

To ensure defined patient satisfaction level in all the functional areas of the imaging department. There should be more than 90% patient satisfaction at CT Scan and MRI in every functional area.

METHODS AND SAMPLING: Sample size: The patients who had completed the following investigations of CT Scan and MRI Department were given the feedback forms during the period of 19th April 2010 to 6th May 2010 CT scan = 50 MRI = 50 Methodology: The feedback forms were filled by the patients who had undergone the investigations. Filled Up forms were then analysed for the patient satisfaction level. The parameters of assessments of satisfaction are Poor (P), Satisfactory (S), Good (G), and Very Good (VG). The S, G & VG have been clubbed together and if it is more than 90% for any parameter then it is acceptable else it signifies the problem area. 105

RESULTS/ FINDINGS: Following is the Summary of the Observations: (for detail observation refer Annex-I)

Satisfaction level of the patient in Imaging CT Patients Apr 2009 Sample studied 15 CT Patients Aug 2009 28 CT Patients Apr 2010 50 MRI Patients Arp 2010 50

Appointment (Telephonic)

93.22%

92.45%

100%

99.43%

Vouchering/ Appointment (At Counter)

97.12% 95.75% 100% 99.43%

Nursing Care

97.78%

100.00%

100%

100%

General Comfort of the Department

92.59%

95.12%

98.74%

97.74%

Investigation Processes

82.00%

96.30%

100%

97.74%

Report Availability

91.67%

94.44%

96.36%

93.18%

106

100% Overall Experience 94.12% 100% 100%

As illustrated in the above table it can be seen that the patient satisfaction is excellent and scored 100% for both the departments for overall experience. Interestingly, in these departments the Scores of all the parameters have gone up magnificently in a years time. For e.g. In the department of CT Scan Scores on Report Availability has been elevated from 91.67% (Apr 2010) to 96.36 % (Apr 2010).

DISCUSSION/ ANALYSIS: CT-Scan

The same study was conducted in the month of April 09, and that time the satisfaction level investigation process in CT Scan department was 82%.

After the corrective measures taken the satisfaction level in CT Scan department has been improved gradually

MRI

As this study is conducted for the first time there, there is no comparative data available.

LIMITATION:

107

As the survey was conducted simultaneously for two departments i.e. CT Scan & MRI, many patients were not covered due to following reasons: Both the departments were on different floors Procedure timings were different for both the procedures Less response rate from patient side to fill up the Questionnaire.

CONCLUSION: As the operational processes involved in investigation for MRI and CT Scan is excellent as per the patients. There is no such root cause study required, Just sustaining on the quality parameters (time, efficiency and patient-centered approach) will continuous enhance the quality of care provided to patients. Nevertheless to say more satisfied patient are less likely to file medical malpractice lawsuits. RECOMMENDATIONS: As the procedure of CT Scan takes 20-30 minutes (approx.) the patients and their relatives sitting in the waiting area can be provided with knowledge materials or media. a. The inpatients waiting time can be reduced by better coordination with the nursing staffs at the floors. b. Incorporation of more sitting chairs is required in the waiting area of MRI department.

CORRECTIVE ACTION PLAN: As for both the departments (CT-Scan & MRI) scores on all the parameters has gone up magnificently. So there is no such corrective action plan required.

108

109

SECTION C

ANNEXURES:

Annexure-I: Data sheet of Patient Discharge Process Annexure-II: Data sheet of OPD Turn Around Time for appointment unregistered patients Annexure-III: Data sheet of Report Turn Around Time Annexure-IV: Data Sheet of Bio Medical Waste floor wise Annexure-V: Patient Satisfaction Survey for MRI and C.T Patients Sample Feeedback form

110

ANNEXURE-I DATA SHEET OF PATIENT DISCHARGE PROCESS PREDICTED DISCHARGE

ADM No.

NAME

LOC

CLAS S

DISCHARGE ORDER

ACTUA L DISCH ARGE DATE WRIT TEN ORDE R (NUR SE) TIME 10:20 AM 10:00 AM 30-0410 30-0410

TIME FINA NCE FOLD ER SENT TO BILLI NG 10:40 AM 10:20 AM

TIME

VERBAL INTIMATION( PATIENT) DATE Merc hant Sarla Sawa nE Vivek Shivaj i Rao Badri nath Patil Shivaj i Shaik h Sabin a Loke Vidya Rame sh Shah Hites h Jaswa ntlal Shind e Aditi Umes h Shah Amita Shau nak Shah Mona Nime sh 16 W 18 16W 15

VERBA L INTIMA TION (PATIE NT ) TIME 2:00 PM 10:00 AM

WRITT EN ORDE R (NURS E) DATE 30-0410 30-0410

NURSE RECIE VES DISCH ARGE SLIP 11:45 AM 11:00 AM

PHYSI CAL DISCH ARGE OF PATIEN T 12:00 PM 11:15 AM

1123 994 1123 049

MEDI AN A MEDI AN

29-04-10

29-04-10

1123 741

8E 40

MEDI AN

29-04-10

9:00 AM

29-0410

10:00 AM

30-0410

10:30 AM

12:00 PM

12:35 PM

1124 162 1124 037

9E 47 9N 34

MEDI AN MEDI AN

29/04/10

5:30 PM 7:00 PM

01-0510 30-0410

10:50 AM 7:20 PM

01-0510 01-0510

10:55 AM 10:40 AM

11:50 AM 11:40 AM

1:05 PM 11:55 AM

30/04/2010

1124 305

8E 43

MEDI AN

30/04/10

12:00 AM

30/04/ 2010

12:00 AM

01-0510

10:00 AM

10:30 AM

11:00 AM

1124 388

7E 42

MEDI AN

30/04/ 2010

5:00 PM

01-0510

10:10 AM

11:15 AM

11:40 AM

1124 060 1124 237

15N 7 14 E 40

Delux

28-4-10

11:00a m 1:00 PM

28-410 04-0510

12:30 pm 8:40 AM

29-410 04-0510

8:00a m 10:00 AM

10:00 AM 11:00 AM

10:30 AM 11:40 AM

Speci al

03-05-10

111

NON-PREDICTED DISCHARGE

1124097 1124067 1124238 1124049 112358 1124322 1124059 1124177 1124160 1124230 1124214 1124303 1124324 1123987 1124062 1124232 1123833 11240812 1123324 1124406 1124330 1124020 11242595 1123530 1123274 1124387 1124413 1123772 1123796 1123676 1124312 1123891 1124204 1124142 1123680 1124220 1123915 1123985 1123690 1123965 1123825 1123879 1124153 1124244 1123988 1123607 1123718 1124381 1123867 1123074 1123916 1124044 1124385 1123986 1124152 1124227

Sen Ram Kumar Biswas tapati Goncalves Monica Nanda kananbala Patuck Dr. Dina Muzamabar Suvarna Ravi Kapoor Nirmala Mahadev Karan Abhijit Asim Sashitendra Borkar Sulbha Nagesh Koli Anusaya Shantaram Dediya Bharti C. Sarkar Pinki Shah Geeta Subhash Mehta maganlal Lahori Renu Kishin Ramane Sunanda Desai Esha Vijaya Panfung E Suresh Rajninath Chavan Mangala Mody Jayshree Patel Nathlal Sundaram Bhanumati Sateesh kumar Bhandari Yojana Mohan Doshi Bharajlal Goud Prathamesh D'Silva Rostan Agaria Laxman Bhana Singh Atul Kumar Dalvi Chinmay H. Amdekar Rajendra Ms. Fauziya M Kumar Madan Agarwal Geeta Jadhav Vidhi Pange Jayashree Janardan Joy Cicily Solanki Prakash Sudheer Jaiswal Sakpal Shankar Tukaram Pitre Padamaja Dinkar Gavry Rahul Rajkumar D'costa Marlin Judith Dhurandhar Narendra P Koley Nishika Agarwal Prakash C Jayesh Samant More Nandkumar Gurav Yashwant Nadar Anthony Shah Ambalal Jivaji Bavisi Pankajkumar Kartha Radhakrishnan Dubash Meher Phiroz Bhatia Mahesh Techchand

16 E 38 16N32 16 E 41 16N31 15 E 12 15 E 13 13N27 8 E 39 8 E 43 9 E 43 9S7 9S5 9W17 12 E 44 12S6 12W16 9W23 13W18 16 W 16 16 E 40 16 E 39 14 S 6 14 E 37 14 E 39 13 E 40 13 E 37 9 W 22 8 W 18 8 W 20 8 N 30 7S6 7S8 16S1 8E43 9E42 9N31 9S4 9W22 8E38 8S9 8W19 13N32 13N30 13E37 12E38 7E42 12W15 16S1 16S7 16W14 16N25 14N25 14S3 13W16 11W14 8N34

MEDIAN A MEDIAN A MEDIAN MEDIAN DELUXE DELUXE SPECIAL MEDIAN MEDIAN MEDIAN MEDIAN MEDIAN MEDIAN MEDIAN MEDIAN MEDIAN MEDIAN MEDIAN MEDIAN A MEDIAN A MEDIAN A MEDIAN A MEDIAN A MEDIAN A MEDIAN A MEDIAN A MEDIAN MEDIAN MEDIAN MEDIAN MEDIAN A MEDIAN A Med. A Med. A Med.B Med.B Med.B Med.B Med.B Med.B Med.B Med.B Med.B Med.B Med. A Med. A Med. A Med Med Med Med Med Spl Spl Spl

30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 01-05-2010 01-05-2010 01-05-2010 01-05-2010 01-05-2010 30/04/2010 01-05-2010 01-05-2010 01-05-2010 01-05-2010 01-05-2010 01-05-2010 01-05-2010 01-05-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 03-05-2010 03-05-2010 03-05-2010 03-05-2010 03-05-2010 03-05-2010 03-05-2010 03-05-2010 03-05-2010

8:30 9:30 10:00 9:00 12:00 10:50 11:35 11:00 9:00 10:50 9:45 8:30 9:45 10:30 10:30 10:30 10:00 17:00 8:30 8:00 8:30 10:00 9:30 18:40 10:00 8:30 9:00 8:40 9:00 9:00 8:30 9:30 10:00 9:30 10:00 8:00 10:30 9:00 10:00 13:00 10:50 13:10 13:10 11:15 10:15 10:15 8:45 10:30 16:00 10:30 8:00 14:40 10:45 13:00 14:10 9:30

30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 01-05-2010 01-05-2010 01-05-2010 01-05-2010 01-05-2010 30-04-2010 01-05-2010 01-05-2010 01-05-2010 01-05-2010 01-05-2010 01-05-2010 01-05-2010 01-05-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 03-05-2010 03-05-2010 03-05-2010 03-05-2010 03-05-2010 03-05-2010 03-05-2010 03-05-2010 03-05-2010

8:45 9:30 10:10 9:00 0:05 10:50 11:35 11:15 9:00 10:50 10:00 8:40 10:00 10:35 10:30 10:30 10:00 17:00 8:30 8:05 8:35 10:15 10:15 19:00 10:15 8:30 9:15 8:40 9:00 9:00 8:30 9:30 10:00 9:30 10:00 8:30 10:45 9:00 14:10 13:15 10:50 13:15 13:20 11:20 10:20 10:30 8:50 10:30 16:00 10:30 8:05 14:40 10:45 13:00 14:10 9:35

30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 30-04-2010 01-05-2010 01-05-2010 01-05-2010 01-05-2010 01-05-2010 30/04/2010 01-05-2010 01-05-2010 01-05-2010 01-05-2010 01-05-2010 01-05-2010 01-05-2010 11:15AM 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 29-04-2010 03-05-2010 03-05-2010 03-05-2010 03-05-2010 03-05-2010 03-05-2010 03-05-2010 03-05-2010 03-05-2010

11:45 11:10 10:30 9:10 12:20 10:55 11:55 13:55 10:30 11:25 10:40 9:40 10:40 10:40 10:40 10:50 17:15 18:00 8:55 8:45 8:45 10:30 10:50 19:15 10:30 9:00 9:40 9:20 10:45 9:50 10:20 12:10 10:35 13:30 10:55 10:00 11:00 10:30 14:20 13:25 13:25 14:00 14:00 11:40 10:30 10:30 10:30 10:50 18:30 10:45 8:50 15:15 11:10 14:20 14:15 9:45

1:15 PM 12:55 PM 12:15 PM 10:35 AM 12:35 AM 12:35 AM 1:00 PM 2:25 PM 11:30 AM 2:45 PM 11:15 AM 12:00 PM 11:15 AM 12:10 PM 11:30 AM 11:30 AM 5:55 PM 19:15 10:00 AM 9:35 AM 9:30 AM 11:15 AM 11:30 AM 8:45 PM 12:00 PM 11:15 AM 11:00 AM 12:45 PM 12:30 PM 11:40AM 12:30 PM 12:45 PM 11:15 AM 12:10 PM 12:00 PM 11:25 AM 12:15 PM 1:30 PM 2:45 PM 3:00 PM 3:10 PM 2:35 PM 2:20 PM 12:30 PM 1:15 PM 11:45 AM 9:45 AM 11:45 AM 7:10 PM 12:00 PM 10:30 AM 4:45 PM 12:10 PM 3:40 PM 4:00 PM 2:45 PM

13:45 13:15 12:35 10:45 13:30 14:00 13:15 14:40 12:20 14:50 11:30 12:15 11:30 12:30 11:45 11:35 18:10 19:30 10:15 9:40 10:00 11:30 11:45 20:50 12:10 11:35 11:20 13:00 13:00 11:45 12:45 13:00 11:30 13:30 12:50 11:35 12:20 14:00 15:00 15:20 15:25 15:00 15:55 13:00 13:30 12:30 11:30 12:00 19:30 12:30 10:40 17:00 12:15 16:00 16:55 14:50

112

SPECIAL, DELUXE, SUITE CLASS

ADM No.

NAME

LOC

CLASS

DISCHARGE ORDER

ACTUA L DISCH ARGE DATE WRIT TEN ORDE R (NUR SE) TIME 12:05 PM 10:50 AM 11:35 AM 12:30p m 8:40 10:45 30-0410 30-0410 30-0410 29-4-10 04-0510 03-0510 03-0510 03-0510

TIME FINA NCE FOLD ER SENT TO BILLI NG 12:20 PM 10:55 AM 11:55 AM 8:00a m 10:00 11:10

TIME

VERBAL INTIMATIO N(PATIENT ) DATE

VERBA L INTIMA TION (PATIE NT ) TIME 12:00 PM 10:50 AM 11:35 AM 11:00am 13:00 10:45

WRIT TEN ORDE R (NUR SE) DATE 30-0410 30-0410 30-0410 28-410 04-0510 03-0510 03-0510 03-0510

NURSE RECIE VES DISCH ARGE SLIP 12:35 AM 12:35 PM 1:00 PM 10:00 AM 11:00 AM 12:10 PM

PHYSIC AL DISCH ARGE OF PATIEN T 1:30 PM 2:00 PM 1:15 PM 10:30 AM 11:40 AM 12:15

1123 58 1124 322 1124 059 1124 060 1124 237 1124 385 1123 986 1124 152

Patuck Dr. Dina Muzamabar Suvarna Ravi Kapoor Nirmala Shah Amita Shaunak Shah Mona Nimish Bavisi Pankajkuma r Kartha Radhakrishn an Dubash Meher Phiroz

15 E 12 15 E 13 13N2 7 15N7 14E4 0 14S3

DELU XE DELU XE SPECI AL Delux Spl Spl

30/04/2010 30-04-10 30-04-10 28-4-10 03-05-10 03-05-10

13W 16 11W 14

Spl

03-05-10

13:00

13:00

14:20

3:40 PM

16:00

Spl

03-05-10

14:10

14:10

14:15

4:00 PM

16:55

MEDIAN, MEDIAN-A, MEDIAN_B CLASS

113

11240 97 11240 67 11242 38 11240 49 11241 77 11241 60 11242 30 11242 14 11243 03 11243 24 11239 87 11240 62 11242 32 11238 33 1.1E+ 07 11233 24 11244 06 11243 30 11240 20 1.1E+ 07 11235 30 11232 74 11243 87 11244 13 11237 72 11237 96 11236 76 11243 12 11238 91 11242 04 11241 42 11236 80 11242 20 11239 15 11239 85 11236 90 11239 65

Sen Ram Kumar Biswas tapati

16 E 38 16N32

MEDIAN A MEDIAN A MEDIAN MEDIAN MEDIAN MEDIAN MEDIAN MEDIAN MEDIAN MEDIAN MEDIAN MEDIAN MEDIAN MEDIAN MEDIAN MEDIAN A MEDIAN A MEDIAN A MEDIAN A MEDIAN A MEDIAN A MEDIAN A MEDIAN A MEDIAN MEDIAN MEDIAN MEDIAN MEDIAN A MEDIAN A Med. A Med. A Med.B Med.B Med.B Med.B Med.B Med.B Med.B Med.B

Goncalves 16 E Monica 41 Nanda 16N31 kananbala ANNEXURE-II39 Mahadev 8E Karan Abhijit Asim 8 E 43 Sashitendra Borkar Sulbha 9 E 43 Nagesh Koli Anusaya 9S7 Shantaram Dediya Bharti 9S5 C. Sarkar Pinki Shah Geeta Subhash Mehta maganlal Lahori Renu Kishin Ramane Sunanda Desai Esha Vijaya Panfung E Suresh Rajninath Chavan Mangala Mody Jayshree Patel Nathlal Sundaram Bhanumati Sateesh kumar Bhandari Yojana Mohan Doshi Bharajlal Goud Prathamesh D'Silva Rostan Agaria Laxman Bhana Singh Atul Kumar Dalvi Chinmay H. Amdekar Rajendra Ms. Fauziya M Kumar Madan Agarwal Geeta Jadhav Vidhi Pange Jayashree Janardan Joy Cicily Solanki Prakash Sudheer Jaiswal Sakpal Shankar Tukaram Pitre Padamaja Dinkar 9W17 12 E 44 12S6 12W1 6 9W23 13W1 8 16 W 16 16 E 40 16 E 39 14 S 6 14 E 37 14 E 39 13 E 40 13 E 37 9W 22 8W 18 8W 20 8 N 30 7S6 7S8 16S1 8E43 9E42 9N31 9S4 9W22 8E38 8S9 8W19 13N32

30-042010 30-042010 30-042010 30-042010 30-042010 30-042010 30-042010 30-042010 30-042010 30-042010 30-042010 30-042010 30-042010 30-042010 30-042010 01-052010 01-052010 01-052010 01-052010 01-052010 30/04/20 10 01-052010 01-052010 01-052010 01-052010 01-052010 01-052010 01-052010 01-052010 29-4-10 29-4-10 29-4-10 29-4-10 29-4-10 29-4-10 29-4-10 29-4-10 29-4-10 29-4-10

8:30 9:30 10:00 9:00 11:00 9:00 10:50 9:45 8:30 9:45 10:30 10:30 10:30 10:00 17:00 8:30 8:00 8:30 10:00 9:30 18:40 10:00 8:30 9:00 8:40 9:00 9:00 8:30 9:30 10:00 9:30 10:00 8:00 10:30 9:00 10:00 13:00 10:50 13:10

30-042010 30-042010 30-042010 30-042010 30-042010 30-042010 30-042010 30-042010 30-042010 30-042010 30-042010 30-042010 30-042010 30-042010 30-042010 01-052010 01-052010 01-052010 01-052010 01-052010 30-042010 01-052010 01-052010 01-052010 01-052010 01-052010 01-052010 01-052010 01-052010 29-4-10 29-4-10 29-4-10 29-4-10 29-4-10 29-4-10 29-4-10 29-4-10 29-4-10 29-4-10

8:45 9:30 10:10 9:00 11:15 9:00 10:50 10:00 8:40 10:00 10:35 10:30 10:30 10:00 17:00 8:30 8:05 8:35 10:15 10:15 19:00 10:15 8:30 9:15 8:40 9:00 9:00 8:30 9:30 10:00 9:30 10:00 8:30 10:45 9:00 14:10 13:15 10:50 13:15

30-042010 30-042010 30-042010 30-042010 30-042010 30-042010 30-042010 30-042010 30-042010 30-042010 30-042010 30-042010 30-042010 30-042010 30-042010 01-052010 01-052010 01-052010 01-052010 01-052010 30/04/20 10 01-052010 01-052010 01-052010 01-052010 01-052010 01-052010 01-052010 11:15AM 29-4-10 29-4-10 29-4-10 29-4-10 29-4-10 29-4-10 29-4-10 29-4-10 29-4-10 29-4-10

11:45 11:10 10:30 9:10 13:55 10:30 11:25 10:40 9:40 10:40 10:40 10:40 10:50 17:15 18:00 8:55 8:45 8:45 10:30 10:50 19:15 10:30 9:00 9:40 9:20 10:45 9:50 10:20 12:10 10:35 13:30 10:55 10:00 11:00 10:30 14:20 13:25 13:25 14:00

1:15 PM 12:55 PM 12:15 PM 10:35 AM 2:25 PM 11:30 AM 2:45 PM 11:15 AM 12:00 PM 11:15 AM 12:10 PM 11:30 AM 11:30 AM 5:55 PM 19:15 10:00 AM 9:35 AM 9:30 AM 11:15 AM 11:30 AM 8:45 PM 12:00 PM 11:15 AM 11:00 AM 12:45 PM 12:30 PM 11:40A M 12:30 PM 12:45 PM 11:15 AM 12:10 PM 12:00 PM 11:25 AM 12:15 PM 1:30 PM 2:45 PM 3:00 PM 3:10 114 PM 2:35 PM

13:45 13:15 12:35 10:45 14:40 12:20 14:50 11:30 12:15 11:30 12:30 11:45 11:35 18:10 19:30 10:15 9:40 10:00 11:30 11:45 20:50 12:10 11:35 11:20 13:00 13:00 11:45 12:45 13:00 11:30 13:30 12:50 11:35 12:20 14:00 15:00 15:20 15:25 15:00

1E+0 6 1E+0 6 1E+0

TAT APPOINTMENT UNREGISTERD OPD PATIENTS EXCEL SHEET

Que ue Tim e 0:03 0:00 0:03 0:00 0:15 0:11 0:25 0:10 0:01 0:00 0:20 0:15 0:00 0:20 0:05 0:00 Vouc her end 3:55 PM 3:05 PM 3:50 PM 3:45 PM 11:20 AM 11:15 AM 11:15 AM 3:10 PM 11:40 AM 3:35 PM 11:10 AM 3:58 PM 3:45 PM 11:20 AM 10:50 AM 3:30 PM Vouc her given to nurse time 3:56 PM 3:17 PM 3:55 PM 3:45 PM 11:20 AM 11:17 AM 11:15 AM 3:10 PM 11:44 AM 3:35 PM 11:10 AM 4:00 PM 3:50 PM 11:20 AM 11:15 AM 3:35 PM Tra vel Tim e 0:01 0:12 0:05 0:00 0:00 0:02 0:00 0:00 0:04 0:00 0:00 0:02 0:05 0:00 0:25 0:05 Waiti ng Time Cli nic in Tim e 4:2 5 PM 5:1 0 PM 4:1 5 PM 4:0 5 PM 2:4 5 PM 11: 45 AM 11: 15 AM 3:5 9 PM 1:4 5 PM 4:2 0 PM 12: 10 PM 4:0 0 PM 5:1 5 PM 12: 25 PM 11: 45 AM 4:0 0 PM Cli nic Out Tim e 4:4 1 PM 5:2 0 PM 4:4 5 PM 4:3 0 PM 3:0 0 PM 12: 00 PM 11: 45 AM 4:4 8 PM 2:0 0 PM 4:2 6 PM 12: 15 PM 4:1 7 PM 5:3 0 PM 12: 30 PM 12: 00 PM 4:3 0 PM Consult ation Time Total Proc ess Time 0:55 2:17 1:02 0:50 4:00 1:00 1:00 1:53 2:25 0:56 1:35 0:37 1:50 1:35 1:15 1:05

Appt time

Que in

Que Out

Vouche ring

3:30 PM 3:30 PM 4:00 PM 3:45 PM 2:30 PM 10:45 AM 11:00 AM 3:30 PM 12:00 PM 3:30 PM 11:30 AM 4:00 PM 3:15 PM 11:00 AM 11:30 AM 4:00 PM

3:46 PM 3:03 PM 3:43 PM 3:40 PM 11:00 AM 11:00 AM 10:45 AM 2:55 PM 11:35 AM 3:30 PM 10:40 AM 3:40 PM 3:40 PM 10:55 AM 10:45 AM 3:25 PM

3:49 PM 3:03 PM 3:46 PM 3:40 PM 11:15 AM 11:11 AM 11:10 AM 3:05 PM 11:36 AM 3:30 PM 11:00 AM 3:55 PM 3:40 PM 11:15 AM 10:50 AM 3:25 PM

0:06 0:02 0:04 0:05 0:05 0:04 0:05 0:05 0:04 0:05 0:10 0:03 0:05 0:05 0:00 0:05

0:55 1:40 0:15 0:20 0:15 1:00 0:15 0:29 1:45 0:50 0:40 0:00 2:00 1:25 0:15 0:00

0:16 0:10 0:30 0:25 0:15 0:15 0:30 0:49 0:15 0:06 0:05 0:17 0:15 0:05 0:15 0:30

Queue Time

Vouchering

Travel Time

Waitin g Time

Consultatio n Time

Total Process

115

0:08

0:04

0:03

0:45

0:18

Time 1:30

116

ANNEXURE-III REPORT TAT EXCEL SHEET DATA

Neurology Hospitals EEG P.D. Hinduja Lilavati L.H Hiranadani 3 days 48 hour s 8 hour s 48 hour s 24 hour s 48 hour s EMG 3 days 12 hours 8 hours VEE G 10 days 48 hours 8 hours EP Studie s 3 days 48 hours 8 hours 48 hours (ERG not include d) 24 hours ECG next day 12 p.m. 1 hour On the spot ECH O 2 days 24 hours 24 hours Can exce ed 1 hour 24 hours 24 hours Stres s 2 days 1 hour 24 hours Holter 3 days 48 - 72 hours 72 hours AB P 3 day s Spirometry next day by 5 p.m. 24 hours Complete PFT next day by 5 P.M. 24 hours Cardiology Pulmonary

Breach Candy

48 hours

48 hours

1 hour

1 hour

48 hours

24 hours

24 hours

Kokilaben Fortis Mulund Diagnosti c Center Piramal

24 hours 48 hours

24 hours 48 hours

24 hours

24 hours 24 hours

24 hours

Immidiately( If before 3pm) 24 hours

Immidiately( If before 3pm) 24 hours

24 hours

48 hours

24 hour s

30 min

24 hours

24 hours

12 hours

12 hours

12 hours

On the spot

On the spot

117

ANNEXURE-IV BMW WEIGHT SHEET FLOOR WISE

BMW FLOORS DATE 5/1/2010 5/2/2010 5/3/2010 5/4/2010 5/5/2010 5/6/2010 5/7/2010 5/8/2010 5/9/2010 5/10/2010 5/11/2010 5/12/2010 5/13/2010 5/14/2010 5/15/2010 5/16/2010 5/17/2010 5/18/2010 5/19/2010 5/20/2010 5/21/2010 5/22/2010 5/23/2010 Total AVG. RED BAGS Nos. 31 19 21 28 19 30 28 25 19 22 18 22 19 16 20 22 26 18 20 25 7 455 21.66667 Kg 135 27 110 98 65 105 96 88 65 98 84 72 68 56 90 92 96 65 85 62 20 1677 79.85714 1 46 2.3 1 57 2.85 YELLOW BAGS Nos. 3 2 2 3 2 3 1 1 2 3 3 2 2 2 1 2 9 1 1 Kg. 4 3 6 5 2 2 1 1 6 3 5 2 1 1 1 2 9 1 1 1 2 65 3.421053 5 5 119 6.2631579 SHARP CONTAINERS Nos. 6 11 3 6 2 4 4 3 1 2 1 2 1 3 2 2 9 Kg 12 5 8 12 3 9 8 7 3 6 3 5 2 7 3 4 12 GREEN BAGS Nos. Kg -

118

ANNEXURE-V: PATIENT SATISFACTION SURVEY FOR MRI AND C.T PATIENTS

MRI 50 Patients
A 1 2 3 4 Appointment (Telephonic) Time taken to get through the appointment cell P 1 0 0 0 1 0.57% P 1 0 0 0 1 0.57% P 0 0 0 0 0% P 0 1 2 3 2.26% P S 4 2 4 3 13 G 24 27 23 VG 14 14 17 NA 1 1 0 0 2

Time taken to give an appointment for the service Adequacy of the information provided Courtesy shown by the staff providing the information
TOTAL PERCENTAGE

24 17 98 62 99.43% G 17 15 25 VG 20 23 17

176

B 5 6 7 8

Vouchering/ Appoinment (At Counter)

S 6 6 4 1 17

NA 0 0

Waiting time in the queue at counters for being attended Time taken by counter staff Information provided at counter Courtesy of staff providing information at the counter
TOTAL PERCENTAGE

26 17 83 77 99.43% G 23 24 VG 18 17

0 0

178

Nursing Care

S 3 6 4 13

NA 0 0 0 0

9 Behaviour and attitude of nurse 10 Help in filling up the consent form Care offered during procedure/ investigation by 11 the nurses TOTAL PERCENTAGE D 12 General Comfort of the Department

23 18 70 53 100% G 21 19 VG 23 22

136

S 1 2 1 4

NA 0 0 0 0 133

Cleanliness of the department 13 Comfort of the waiting area 14 Cleanliness of toilets

TOTAL PERCENTAGE E Investigation Processes

19 22 59 67 97.74% G VG

NA

119

Waiting time prior to the test Information provided by technician regarding the 16 preparation for the test 17 Courtesy shown by technicians
15 TOTAL PERCENTAGE F 18 Report Availability

1 1 1 3 2.26% P 3 3 6.82% P 0 0 0%

3 3 1 7

20 25

21 15

0 0 0 0 133

29 13 74 49 97.74% G VG

S 10 10

NA 7 7 44

Timely delivery of the reports

TOTAL PERCENTAGE

18 6 18 6 93.18% G VG

Overall Experience

S 3 3

NA 0 0

Overall satisfaction level on availing Imaging 19 services

TOTAL PERCENTAGE

28 13 28 13 100%

44

120

121

CT 50 Patients

A 1 2 3 4

Appointment (Telephonic) Time taken to get through the appointment cell

P 0 0 0 0 0 0% P 0 0 0 0 0 0% P 0 0 0 0 0% P 0 1 1 2 1.26% P 0

S 8 7 5 6 26

G 28 27 29

VG 20 16 19

NA 2 2 1 1 6

Time taken to give an appointment for the service Adequacy of the information provided Courtesy shown by the staff providing the information
TOTAL PERCENTAGE

28 20 112 75 100% G 24 28 31 VG 24 20 19

219

B 5 6 7 8

Vouchering/ Appoinment (At Counter)

S 8 7 4 3 22

NA 0 0 0 0 0

Waiting time in the queue at counters for being attended Time taken by counter staff Information provided at counter Courtesy of staff providing information at the counter
TOTAL PERCENTAGE

32 19 115 82 100% G 25 22 VG 25 24

219

Nursing Care

S 5 9 5 19

NA 0 0 0 0

9 Behaviour and attitude of nurse 10 Help in filling up the consent form Care offered during procedure/ investigation by 11 the nurses TOTAL PERCENTAGE D General Comfort of the Department

32 18 79 67 100% G 29 20 VG 22 23

165

S 1 9 6 16

NA 0 0 1 1 159

12 Cleanliness of the department 13 Comfort of the waiting area 14 Cleanliness of toilets TOTAL PERCENTAGE E Investigation Processes

25 21 74 66 98.74% G 29 VG 13

S 13

NA 0

15 Waiting time prior to the test

122

Information provided by technician regarding the 16 preparation for the test 17 Courtesy shown by technicians
TOTAL PERCENTAGE F 18 Report Availability

0 0 0 0% P 2 2 3.64% P 0 0 0%

8 3 24

30

17

0 0 0 165

35 17 94 47 100% G VG

S 8 8

NA 11 11 55

Timely delivery of the reports

TOTAL PERCENTAGE

27 7 27 7 96.36% G VG

Overall Experience

S 1 1

NA 2 2

Overall satisfaction level on availing Imaging 19 services

TOTAL PERCENTAGE

42 9 42 9 100%

54

123

124

SAMPLE FEEEDBACK FORM

Please evaluate your Imaging experience on a scale of 1 to 5 (by a tick mark) represented as follows: 1= Poor (P), 2=Satisfactory(S), 3=Good (G), 4=Very Good (VG), 5=Not Applicable (NA) If you think that the question is not relevant to you kindly tick the NOT APPLICABLE option. Your answers will be treated in confidence. Name: HH No/ EX No:
Sr. No A 1. 2. 3. 4. B 5. 6. 7. 8. C 9. 10. 11. D 12. 13. 14. E 15. 16. 17. Questions Appointment (Telephonic) Time taken to get through the appointment cell Time taken to give an appointment for the service Adequacy of the information provided Courtesy shown by the staff providing the information Vouchering/Appointment (At Counters) Waiting time in the queue at counters for being attended Time taken by counter staff Information provided at counter Courtesy of staff providing information at the counter Nursing Care Behaviour and attitude of nurse Help in filling up the consent form Care offered during procedure/ investigation by the nurses General Comfort of the department Cleanliness of the department Comfort of the waiting area Cleanliness of toilets Investigation Processes Waiting time prior to the test Information provided by technician regarding the preparation for the test Courtesy shown by technicians

Tel No.: Section:

1P 2S 3G 4VG 5NA

125

Sr. No

Questions

4 V G

5 N A

F 18. G 19.

Report Availability Timely delivery of the reports Overall Experience Overall satisfaction level on availing Imaging services

Thank you for your participation

126