Post on 26-Oct-2014
Summer Training
[April 11th ndash April 30th 2011]
In
Shija Hospitals and Research Institute
[May 4th ndashJune 4th 2011]
In
A Report
By
Anisha Khundongbam
Post-graduate Diploma in Hospital and Health Management
(2010-12)
Institute of Health Management Research Jaipur
2010
PREFACE
Summer training is an integral part of the course curriculum of PGDHM As part of the
course students of first year are required to undergo summer placement at any reputed
organization to get in depth exposure of various departments in the organization
During the period of summer training I completed three projects which were carried out
at two different Healthcare setups
The first study titled ldquoA Study on Discharge Procedure with Special Emphasis on In-
Patient Feedback was carried out at Shija Hospitals and Research Institute Manipur
The aim of the study was to understand the existing discharge procedure at the hospital
and to analyze the probable reasons for low in-patient feedback ( which was a part of
discharge procedure)
The second study titled ldquoMedical Records Management and Protocol
Implementationrdquo was undertaken at Fortis Malar Hospital Chennai to understand the
structure process outcome of the Medical Records Department at the Hospital
The third study titled ldquoEmployee Joining Kitrdquo was also pursued at the Fortis Malar
Hospital Chennai This was a special project assigned by the HR department of the
Hospital The designing and preparation of the employee joining kit took many HR
aspects into consideration as it had to be a comprehensive manual to be presented to the
new employees at the time of joining
The Objectives of summer training were
To learn the daily operational management of the Organization and its various
departments areas
To study the salient and critical features about the functioning of these
departments areas
To identify issues problems associated with some specific departments areas
To undertake the projects special tasks assigned to us
TABLE OF CONTENTS
A Profile of Shija Hospitals And Research Institute(Shri) Manipurhelliphellip 1
a) Introductionhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip3b) Services available(Departments)helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip3c) Organization charthelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip5d) Front officehelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip6e) IPD departmenthelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip8f) Operation Theatre and ICUhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip10g) Human Resource Departmenthelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip14h) Stores helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip15i) Hospital management information systemhelliphelliphelliphelliphelliphelliphelliphelliphellip16j) Medical records departmenthelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip17k) Clinical nutrition and dietetics departmenthelliphelliphelliphelliphelliphelliphelliphelliphellip18l) Security and Safetyhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip19m) Housekeepinghelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip19n) Laundry helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip20
B PROJECT 1- A Study on Discharge Procedure with Special Emphasis on In-Patient
Feedbackhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip22
C Profile of Fortis Malar Hospital Chennaihelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip32
D PROJECT STUDY 2- Medical Records Management and Protocol
Implementationhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip36
E PROJECT STUDY 3- Employee Joining Kithelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip46
C ANNEXURES
a) Discharge checklistb) Feedback formc) Final Summary sheetd) Forms verification checkliste) Hospital statistics Recordf) Employee joining kit
ABBREVIATIONS
ALOS - Average Length of Stay
BOR ndash Bed Occupancy Ratio
CCTV - Closed Circuit Television
CSSD - Central Sterile and Supply Department
DOR - Discharge on Request
ECG - Electro Cardiogram
ENT - Ear Nose Throat
HIS - Hospital Information System
HRD - Human Resource Development
ICD - International Classification of Diseases
ICU - Intensive care Unit
IPD - In Patient department
IT - Information Technology
MLC - Medico Legal case
MRD - Medical Records department
OPD - Out patient Department
OT - Operation Theatre
RMO - Resident medical Officer
Shija Hospitals and Research Institute
[April 11th ndash April 30th 2011]
1
ACKNOWLEDGEMENT
I am extremely indebted to all the professionals at Shija Hospitals and Research
Institute(SHRI) Manipur for sharing generously their knowledge and precious time
which inspired me to do best during summer training
I owe a great debt to DrKHPalin Managing Director and Chairman Shija Hospitals
and Research Institute Manipur for allowing me to do my summer training at the
hospital
I would also like to thank Dr Jugindra S Medical Superintendant and Ms Gayatri S
Head - Human Resource for their valuable guidance and at whose behest I received
tremendous assistance from other departments and their respective heads without which
the project would not have been completed
I would like to extend my special thanks to Ms Leema and Ms Arti Operations
Executives for sparing their valuable time and sharing with me the nuances of Hospital
operations and to all Executives of HR and Operations department for their support
and guidance throughout the summer training
Most importantly I would like to thank my mentor DrNeetu Purohit for her
unconditional support and motivation throughout the study period and
DrTanjul Saxena for her guidance on the report preparation and compilation of the
same
2
3
INTRODUCTION
Shija Hospitals is a pioneer ISO 90012008 certified private health institute in Manipur providing advanced healthcare technology with humane touch With the recognition by its customer for their holistic approach personal touch and technological advancement Shija Hospitals has been successful to a great extent in bringing highly needed medical technology in the region
Shija Hospitals located at environment friendly Langol Manipur is 200 bedded fully computerized institute having five modern operation theatres and 18 bedded fully functional ICU with all the latest life supporting equipments The hospital currently has 500 trained and dedicated staff
Shija Hospitals has becomes the only centre in Eastern India having under one-roof the total lsquostate of the artrsquo solution for treatment of stones at different locations of the body viz Lap-Chole Lap-CBD Exploration ERCP ESWL PCNL URS CLT and Lap-Urosurgery In Manipur it is the only private hospital having a consolidated Neuroscience centre under one roof has all the requisite resource in its Neurosurgery and Neurology unit Also SHRI is today a premier institute in India for minimally invasive surgery (MIS) viz Laparoscopic Surgery Arthroscopy Thoracoscopy Functional Endoscopic Sinus Surgery (FESS) and Upper and Lower GI Endoscopic procedures
To mention the recognition the hospital has been awarded Guinness World record for removing the largest neck tumor in the world from a 12 days old baby the tumor weighed 40 of the body weight
Facilities
Shija Hospitals Langol has the following departments ndash
Emergency and Trauma Care Pathology Radiology and imaging General Surgery Paediatric Dental ENT Obstetrics amp Gynaecology Ophthalmology Orthopaedics
4
Cardiology Anaesthesiology Medicine and Psychiatry Physiotherapy Surgical Gastroenterology Plastic Surgery Neurosurgery Neurology Urology
Vision 2015
To be a premium amp leading brand in healthcare services in the South East Asia recognized by our customers for our holistic approach personal touch and technological advancement
Mission
1048766 Customer needs 1048766 Research and development1048766 Quality system 1048766 Networking1048766 People development
Core Values -
Integrity Agility Passion for Excellence
5
FRONT OFFICE
In Patient Out PatientI) MAIN RECEPTION
Patient entry
Main reception area
Registered If Not Registered Registration done (At Main Reception)
OPD Billing
OPD Nursing Station
Consultation with Doctor
Advised Medication Advised Investigation Advised Admission
6
CMDMSConsultantsDuty DoctorsNursingMRDPharmacyOP PharmacyIP PharmacyCEOMaterials amp CRSFinanceAccountsCredit CellHRHR AdminRecruitment amp TrainingIR Appraisals Quality AssuranceEducationOperationsEngineering Maintenance amp ProjectsSecurity amp TransportITDHouse KeepingOut Patient ServicesIn Patient ServicesMarketingGR amp PRLiaison Advertising amp MediaSales Promotion amp CampsOrganization Chart
OPD Pharmacy Counter Sample collection Diagnostics Admission amp
Billing Counter
EXIT Report Collection
Registration Procedure
OPD requisition form to be filled
Submitted at the front office
A unique hospital ID is assigned
Cash Memo is issued
Mode of paymentCash payment was accepted Debit Credit card payment were under process
Waiting areaThere were three different OPD complexes
General OPD Eye OPD Obstetrics amp Gynecology
The General OPD waiting area would accommodate 150-200 people whereas the other OPDs had a capacity of 100 with no sub waiting area
In case of empanelled organizations
o The client has to produce an authorisation lettero Compendium of orders by Central Government Health Scheme is strictly
followedo Same charges and rates according to states are followedo In Manipur Delhi rates followed for all examinations and procedures
Payment method for clients from empanelled organizations
7
o IP payments are always due and payments have to be drawn from the empanelled organization
o OP payments have to be collected in cash from the patients which they can refund it on their own
o IP patients can give cheques
SHIJA MASTER HEALTH CHECK
Patient enters hospital
Registration done at Main reception
Billing done at IPD Counter
Sample collection done in Master Health Check Sample Collection Room
Sample sent to Lab
IN PATIENT DEPARTMENT
Categories of wards o Male General Ward
o Female General Ward
o Intensive Care Unit
o Neuro ICU
o Special rooms
o Cabins Twin sharing
o Deluxe Suites
8
In Patient Flow
Patient can come from
OPD ICU EMERGENCY POST -OPERATIVE
WARD
Admission counter - Nursing staff of ward changes the patient status in HIS by
Assistant gives a call doing ldquoCHECK-INrdquo of the patient received
to nursing station to - ICU EMERGENCY POST-OPERATIVE WARDS (from where
confirm for bed the patient is coming) changes the patient status in their
availability HIS by doing ldquoCHECK-OUTrdquo of the patient
Nursing staff prepares the roombed
Entry done in HIS Register White Board
Nurse informs the concerned Doctor
Doctor comes amp prescribes medication and investigation (if any)
Nurse writes the prescribed drugs on Indoor Drug Requisition Form
Ward boy goes and collects the drugs from Pharmacy
Nurse starts medication + prepares the patient for investigation (if any)
9
OPERATION THEATRE
Doctor sends request for OT Availability
OT Incharge confirms OT availability
Entry into OT Booking Register regarding
Scheduled surgeryrsquos Date Time Doctor Patient
A day before surgery verification of
Surgery Set Drugs
10
Instrument Verification
Verification of CSSD amp other consumables
In Non Usable condition
Discarded
Entry into Instrument
Replacement Register
Respective HOD informed
Request send to stores
Request sent
In usable condition
Suitable for use in surgery
Expiry check
Unused amp not
expired
Suitable for use
in surgery
Used
Depleted stock for surgery use
Requisition sent to Pharmacy through Drug Requisition Form
Pharmacy replenishes request
Sufficient stock Inventory
Linen amp Instrument
check
Dirty Linen list formed amp
sent to Laundry amp received
later
Entry made
Surgical set amp consumables prepared
Before start of surgery Inspection of
Before start of surgery Inspection of
Patientrsquos Records
Medical Gas
Pressure Leakage
Sterilization
Daily OT cleaning
records duly filled
Mopping of OT floor with
Bacillocid
Disinfection of OT items
listed on form with 2 Trigene
Instrument checklist
form
Completion of ldquoopened
byrdquo amp ldquocross checkedrdquo columns
Electrical points in
OT
Equipments
Transfer of equipment specific for
surgery into OT
OT Preparation done
Reception of Patient in Pre Operation area 20 minutes before surgery
Patient shifted to OT
11
In Non Usable condition
Discarded
Entry into Instrument
Replacement Register
Respective HOD informed
Request send to stores
Request sent
Depleted stock for surgery use
Requisition sent to Pharmacy through Drug Requisition Form
Pharmacy replenishes request
Linen amp Instrument
check
Dirty Linen list formed amp
sent to Laundry amp received
later
Entry made
Expired
Separated
Entry made into RE-
AUTOCLAVE register
Send to CSSD
Not expired
Suitable for surgery
Patientrsquos Identification done amp verified
Surgery performed
Recording of all consumable used is recorded
Surgery completed
Surgery completed
Collection of OT Waste
Disposal by housekeeping
staff as per rules
Count of instruments
ldquoPostrdquo Column of Instrument
check list form completed
Transfer of patient to Recovery
room
Patient shifted to Ward SICU
Updation of records
Operation notes amp patientrsquos
record completed
Operation Daily charge bill formed
OT Drug inventory checked
Requisition send to
Pharmacy
OT Inventory replenished
OT Prepared for next surgery
Operation Theatre
Layout 1st flooor No of OTrsquos 6
General OTrsquos ndash 3 Eye OT- 1 Minor OT - 2
12
No of beds in Pre operative ward 7 No of beds in post operative wards 8 Utility room 1 Doctorrsquos Lounge 1 Nurse and Technician Lounge 1 Pantry 1 Sterile room 1 Changing rooms 4
Doctor (male) changing room 1 Doctor (female) changing room 1 Nurse (female) changing room 1 Technician + Nurse (male) changing room 1
Patient admission procedure in ICU
Physician
(Desiring admission of a patient in ICU)
contacts
Admission Office
Contacts for Bed Availability with
ICU
(Nurse ndash Ward Supervisor)
Beds Available No ICU Bed available
Admission done Admission office contacts
Nursing Administrator
Nursing Administrator starts
ICU patients ldquostatus evaluationrdquo
13
Any patient can be shifted None can be shifted
to Wards
Patient shifted to ICU after one patient Patient is stabilizedis shifted to Wards
Nursing Supervisor contacts
Administrator on-call
He authorize transfer of
patient to other hospital
HUMAN RESOURCE DEPARTMENT
Layout -Administrative Block Ground Floor
Total Staff 4
Organogram
Head Manager
HR Executives (3)
Trainee
Jobs amp Responsibilities
Manpower Planning
Internal Job Posting Process
CV Selection
Confirmation and Appraisal
Staff Queries
Follow up with selected candidates
Issuing of appointment letters
Disciplinary Policy
Leaves sanctioning
14
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Payroll
Budgeting for departments
Doctors payout
Duty roster
Issuing of Experience letters
STORES
Layout -New Stores Block
Staff 4
Hierarchy
Stores Manager
Store Supervisor
Bio medical Engineer GDA
Records Maintained
Goods Receipt Note Quotations Purchase Requests Capital Sanctioned Record
WORK FLOW
Department in need of material
Through HIS Indentation
or Requisition slip
Store15
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Issue Note Return File Purchase Receipt Purchase Orders
Store checks for the required material and the quantity
YES NO
Material issued and recorded in Issue Register Entry into Shortage Register
Record of the material entered HIS ldquoPurchase Requestrdquo is filled in HIS
Duties of Store In charge
Forecasting requirement Budgetary requirement Inventory control Stock verification Communicate the purchase
department about requirement Minimize pilferage
INFORMATION TECHNOLOGY (IT) DEPARTMENT
Layout -Ground Floor Main Building
Staff 3
Functions and responsibilities
To keep the servers alive
To keep the network alive
To keep internet connection alive
To take care of all the desktops amp laptops in the organization
To track the records of all the desktops
To keep an eye on the employees desktops
To resolve the complaints of the employees
Training of the other staff for the HIS
Major Work Areas General Administration amp HIS
16
Bin card maintained At a time 2800 items maintained in
the stores Random sample check to ensure the
genuinity and authenticity of product Disposal of surplus obsolete
Material Distribution
I) General Administration
Servers
Anti virus server Database server Application server Archive server
II) HIS (Hospital Information System)
Application by Avanttec
Billing Ward management Laboratory services Discharges + Medical Records Housekeeping Pharmacy Payroll Medical equipment
Access to Information
o User specific access according to their roles
HIS Backup
Done once a day Centralized database Internal backups
MEDICAL RECORD DEPARTMENT
Layout -MRD Block
Staff 3
Infrastructure
Desktop 1
Printer 1
Organogram Medical Records Officer Statistician
Medical Records Technician
17
Functions of MRD
To ensure that the Shija Hospital has complete amp accurate medical record for every
patient
Public dealings with respect to Bill verification MLC cases and dealing with
Summons to the doctors hospital
To maintain high level of confidentiality as far as patientrsquos records are concerned
To ensure that the records are Identified and stored safely to prevent unauthorized
changes and easily retrieved whenever required
Issuing Emergency Medical Birth amp Death certificates
To generate Bed Occupancy reports ALOS and other hospital statistics (daily amp
monthly)
Record Retention Periods
IP Record 05 years
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patient
CLINICAL NUTRITION amp DIETICS DEPARTMENT
Layout -Ground floor OPD Block
Head Dietician Ms Bimota
Functions
Catering to Inpatients Diet counseling Education Smooth provision of laid out diets to the patients To check the patient food for quality preparation presentation and packing Coordinating closely with the Nursing shift in charges for changes in the patientrsquos
diet or new admissions etc
Records Maintained
Diet order sheet Meal count register Store register Diet Sheets
18
Counseling Register
Type of Diet Diet Card Color
Normal White
Diabetes Mellitus Yellow
Chronic Renal Failure Blue
Liquid Diet Pink
Flowchart of Dietician and Inpatient Interaction
The Dietician takes details of new patients such as name UHID doctorrsquos name diagnosis and diet prescribed Then Dietician takes a detailed round wherein she meets every patient and determines patientsrsquo actual intake Dietician then provides nutritional counseling and education ensures patientsrsquo compliance to recommended diet She also recognizes personal eating and food preferences
Afterwards the dietician does nutritional screening in order to know about patientsrsquo clinical condition appetite and tolerance to food and acceptance to hospital diet personal preferences disliking and food allergies if any
After the rounds detailed food summary sheets are planned and prepared for every patient keeping in mind medical history and preferences of patient as well
SECURITY
Own security force not outsourced since 2009
Area of Operation (Present)
To deal with 3 ldquoMrdquo- Man Material amp Machinery
Visitorrsquos check Entry restriction at ICU gate Security for doctors and nurse quarter Surveillance of hospital through CCTVrsquos Theft Burglary Violence Material movements in amp out of the hospital Handling visitorrsquos pass In case of patientrsquos death handling emotional chaos of attendants Parking management and traffic control
19
HOUSEKEEPING
Status Own
Department Manager Mr Arju
FUNCTIONS
bull Clean Floor Wall Ceiling
bull Discharge Cleaning
bull Remove Garbage
bull Replace Supplies In Utility Rooms
bull Clean Housekeeping Equipments
bull Clean Room Wards Reception OT ICU Etc
bull Infection Control
bull Pest amp Rodent Control
bull Odour Control
LAUNDRY- Own
Department in charge- MsUmajini
Functions
Segregation of soiled and clean linen Traffic flow of linen before 8am Carrying the linen around the hospital Registered linen and purpose System of collection
o Colored bins
Infected linen handled separately- soaked in sodium hyperchloride Register maintained ndash separate for infected and un-infected linen Floor wise collection Different registers for each type of linen Separate people for ironing and drying from those who collect and wash
20
bull Environment Hygiene
bull Sanitation Hygiene
bull Checking Cleanliness Of All Areas
bull Control amp Reporting Of All
Maintenance Works
bull Hospital Waste Disposal
bull In-Service Training
bull Cooperation with Other Depts
Shared responsibility with nurses in charge Report- washing record submitted to HR dept Due list of linen- expected on Monday
GAPS IDENTIFIED IN STORES MANAGEMENT
No forecasting of requirement done ie Reorder Levels not defined
No analysis like ABC VED done for inventory control
Codification of items still in progress
HIS for Stores still not completely streamlined
AMC amp CMC not maintained for all
Some departments go beyond the indent allowance
Repair and Maintenance of equipments There are instruments which are not used at all
o Non-functionalo Repair requiredo Condemned
For Quality assurance o Quality calibration o Annual Maintenance Contracto Complete Maintenance Contract
Instruments go for regular servicing or they are serviced and examined regularly- Some machines are serviced in the hospital- eg computers printers patient
monitor BP instrument Alternative arrangements are available during that period of time- Patient
monitors from other wards are managedo No back up stock available
Shortage during repair period Patient monitor ndash completely mobile thus record maintenance difficult-
communication gap between the material managers 3 total staff
GAPS IDENTIFIED IN HMIS
Avanttec is a Chennai Based HIS system hence immediate access to providers not available
Strong foundation but HIS is still not fully streamlined Personnel shortage in the department No staff at night
21
GAPS IDENTIFIED IN LAUNDRY DEPARTMENT
6 Set rule per patient not followed Presently only 2 sets per patient No weighing scale No sewing machine for repair No supervision over measured use of detergent and other chemicals
PROJECT ndash 1
A Study on Discharge Procedure with Special Emphasis
on In-Patient Feedback
22
INTRODUCTION
The study was carried out in Shija Hospitals and Research Institute which is a 180 bedded hospital located in Manipur The Hospital is well known for its high end technology and services in the region The Hospital looks forward to continually develop its services and improve the facilities available in order to become a well known health service provider in the South East Asian region in the future The operations management had identified the discharge procedure as an area where there was a scope for improvement Hence the hospital had assigned the project to study the discharge procedure
Discharging a patient is an activity common to every hospital - small large community inner-city teaching or non-teaching The discharge process can have an impact on numerous factors such as patient satisfaction bed availability timely tests and procedures needed for discharge transportation and nursing home arrangements No matter what type of patient is being discharged (maternity medicine orthopedic neurologic) numerous activities must be completed for each before the patient can be released This work toward discharge day should begin upon admission
As part of a progress towards NABH accreditation at Shija Hospital the discharge process is one of the many process improvement projects The discharge process at this hospital also incorporates obtaining feedback from the in-patient regarding the services at the time of discharge Due to inappropriate management the hospital was facing an acute shortage in the feedback response from the patients
The management at the hospital realizes the need and importance of patient satisfaction and a need of a measurable index through feedback analysis In all service industries customer retention is a vital issue Hence the management wanted to do all that they could to obtain feedback from the patients at the time of discharge and make the discharge procedure as smooth as it can get
The objective of this study was to study the process of discharge and find out the probable reasons for the failure to attain feedback from the patients at the time of discharge
23
STUDY METHODOLOGY
AIM
To study the discharge procedure practiced at Shija Hospitals with special emphasis on
analyzing the reasons for the short-fall of In-Patient Feedback
OBJECTIVE
1 To find the steps followed during discharge of an in-patient2 To find the total time taken for a discharge of a single patient3 To find the contributing reasons for the short fall of in-patient feedback
received in the wards
RATIONALE
The discharge of a patient is a very important component of in-patient service and needs to be smooth and efficient On the other hand in-patient feedback is equally important as it provides the performance standards of the hospital which needs to be continually enhanced
METHODOLOGY
Study design-
Area- Shija Hospitals and Research Institute Manipur
Duration- From 11-04-2011 to 30-04-2011
Type of study- Observational and Survey study
Sample size-120 in-patients and the following hospital staff
Nurse Superintendant
RMOs on duty
Staff nurse
Front office executives
Service entry staff
Sampling Method-Convenience sampling
Study tool Questionnaire and personal interviews
24
Type of Data collected -
Interviewer guided questionnaires collected from patients by visiting the different wards
Personal interview of various hospital staff and officials involved in discharge procedure
DISCHARGE PROCESS
25
Doctor prescribes the discharge
Nurse informs the patient about the time of discharge
26
Staff nurse starts discharge formalities by
Asking the Resident Medical Officer Concerned Physician to
make discharge summary
Informing Dietician to make discharge diet report for patient
Counseling of the patient by the dietician and physiotherapist (if
physiotherapy is going on for patient)
Asking the service entry assistants to enter all the details regarding the
patients starting from the no of consultant visits to medicines
consumed
Sending to Pharmacy Daily Billing Activity Sheet
Daily Pharmacy BillsDischarge medication detailsMedicines left unconsumed
In Pharmacy Summary of Pharmacy Bill is prepared
Daily Billing Activity Sheet
Summarized Pharmacy Bill
Giving the feedback form to the patient attendants
Fig1 Communication channels during the discharge procedure
27
Billing department finalizes the bill
Payment taken by billing department from attendants
IPD Billing informs at the nursing station about the clearance of bill
Discharge Summary completion by Medical Transcriptionist
Nurse informs the patient amp patient changes clothes
Nurse checks the checklist given for discharge of patient
All medications + Investigations reports + Patientrsquos file given to the patient
Patient given amp explained about how to take the medications + any special instruction + follow up schedule
Patient Discharged
Collects the filled up feedback form from the patient attendants
There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays
Fig 2 A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital
020406080
100120
82
28 39
102
Compliance to discharge procedure
No
of p
atien
ts
Table1 Duration of various parameters related to discharge
28
DoctorNurseService ward boysBillingofficePatient
Various other departments of the hospital
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
PREFACE
Summer training is an integral part of the course curriculum of PGDHM As part of the
course students of first year are required to undergo summer placement at any reputed
organization to get in depth exposure of various departments in the organization
During the period of summer training I completed three projects which were carried out
at two different Healthcare setups
The first study titled ldquoA Study on Discharge Procedure with Special Emphasis on In-
Patient Feedback was carried out at Shija Hospitals and Research Institute Manipur
The aim of the study was to understand the existing discharge procedure at the hospital
and to analyze the probable reasons for low in-patient feedback ( which was a part of
discharge procedure)
The second study titled ldquoMedical Records Management and Protocol
Implementationrdquo was undertaken at Fortis Malar Hospital Chennai to understand the
structure process outcome of the Medical Records Department at the Hospital
The third study titled ldquoEmployee Joining Kitrdquo was also pursued at the Fortis Malar
Hospital Chennai This was a special project assigned by the HR department of the
Hospital The designing and preparation of the employee joining kit took many HR
aspects into consideration as it had to be a comprehensive manual to be presented to the
new employees at the time of joining
The Objectives of summer training were
To learn the daily operational management of the Organization and its various
departments areas
To study the salient and critical features about the functioning of these
departments areas
To identify issues problems associated with some specific departments areas
To undertake the projects special tasks assigned to us
TABLE OF CONTENTS
A Profile of Shija Hospitals And Research Institute(Shri) Manipurhelliphellip 1
a) Introductionhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip3b) Services available(Departments)helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip3c) Organization charthelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip5d) Front officehelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip6e) IPD departmenthelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip8f) Operation Theatre and ICUhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip10g) Human Resource Departmenthelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip14h) Stores helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip15i) Hospital management information systemhelliphelliphelliphelliphelliphelliphelliphelliphellip16j) Medical records departmenthelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip17k) Clinical nutrition and dietetics departmenthelliphelliphelliphelliphelliphelliphelliphelliphellip18l) Security and Safetyhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip19m) Housekeepinghelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip19n) Laundry helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip20
B PROJECT 1- A Study on Discharge Procedure with Special Emphasis on In-Patient
Feedbackhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip22
C Profile of Fortis Malar Hospital Chennaihelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip32
D PROJECT STUDY 2- Medical Records Management and Protocol
Implementationhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip36
E PROJECT STUDY 3- Employee Joining Kithelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip46
C ANNEXURES
a) Discharge checklistb) Feedback formc) Final Summary sheetd) Forms verification checkliste) Hospital statistics Recordf) Employee joining kit
ABBREVIATIONS
ALOS - Average Length of Stay
BOR ndash Bed Occupancy Ratio
CCTV - Closed Circuit Television
CSSD - Central Sterile and Supply Department
DOR - Discharge on Request
ECG - Electro Cardiogram
ENT - Ear Nose Throat
HIS - Hospital Information System
HRD - Human Resource Development
ICD - International Classification of Diseases
ICU - Intensive care Unit
IPD - In Patient department
IT - Information Technology
MLC - Medico Legal case
MRD - Medical Records department
OPD - Out patient Department
OT - Operation Theatre
RMO - Resident medical Officer
Shija Hospitals and Research Institute
[April 11th ndash April 30th 2011]
1
ACKNOWLEDGEMENT
I am extremely indebted to all the professionals at Shija Hospitals and Research
Institute(SHRI) Manipur for sharing generously their knowledge and precious time
which inspired me to do best during summer training
I owe a great debt to DrKHPalin Managing Director and Chairman Shija Hospitals
and Research Institute Manipur for allowing me to do my summer training at the
hospital
I would also like to thank Dr Jugindra S Medical Superintendant and Ms Gayatri S
Head - Human Resource for their valuable guidance and at whose behest I received
tremendous assistance from other departments and their respective heads without which
the project would not have been completed
I would like to extend my special thanks to Ms Leema and Ms Arti Operations
Executives for sparing their valuable time and sharing with me the nuances of Hospital
operations and to all Executives of HR and Operations department for their support
and guidance throughout the summer training
Most importantly I would like to thank my mentor DrNeetu Purohit for her
unconditional support and motivation throughout the study period and
DrTanjul Saxena for her guidance on the report preparation and compilation of the
same
2
3
INTRODUCTION
Shija Hospitals is a pioneer ISO 90012008 certified private health institute in Manipur providing advanced healthcare technology with humane touch With the recognition by its customer for their holistic approach personal touch and technological advancement Shija Hospitals has been successful to a great extent in bringing highly needed medical technology in the region
Shija Hospitals located at environment friendly Langol Manipur is 200 bedded fully computerized institute having five modern operation theatres and 18 bedded fully functional ICU with all the latest life supporting equipments The hospital currently has 500 trained and dedicated staff
Shija Hospitals has becomes the only centre in Eastern India having under one-roof the total lsquostate of the artrsquo solution for treatment of stones at different locations of the body viz Lap-Chole Lap-CBD Exploration ERCP ESWL PCNL URS CLT and Lap-Urosurgery In Manipur it is the only private hospital having a consolidated Neuroscience centre under one roof has all the requisite resource in its Neurosurgery and Neurology unit Also SHRI is today a premier institute in India for minimally invasive surgery (MIS) viz Laparoscopic Surgery Arthroscopy Thoracoscopy Functional Endoscopic Sinus Surgery (FESS) and Upper and Lower GI Endoscopic procedures
To mention the recognition the hospital has been awarded Guinness World record for removing the largest neck tumor in the world from a 12 days old baby the tumor weighed 40 of the body weight
Facilities
Shija Hospitals Langol has the following departments ndash
Emergency and Trauma Care Pathology Radiology and imaging General Surgery Paediatric Dental ENT Obstetrics amp Gynaecology Ophthalmology Orthopaedics
4
Cardiology Anaesthesiology Medicine and Psychiatry Physiotherapy Surgical Gastroenterology Plastic Surgery Neurosurgery Neurology Urology
Vision 2015
To be a premium amp leading brand in healthcare services in the South East Asia recognized by our customers for our holistic approach personal touch and technological advancement
Mission
1048766 Customer needs 1048766 Research and development1048766 Quality system 1048766 Networking1048766 People development
Core Values -
Integrity Agility Passion for Excellence
5
FRONT OFFICE
In Patient Out PatientI) MAIN RECEPTION
Patient entry
Main reception area
Registered If Not Registered Registration done (At Main Reception)
OPD Billing
OPD Nursing Station
Consultation with Doctor
Advised Medication Advised Investigation Advised Admission
6
CMDMSConsultantsDuty DoctorsNursingMRDPharmacyOP PharmacyIP PharmacyCEOMaterials amp CRSFinanceAccountsCredit CellHRHR AdminRecruitment amp TrainingIR Appraisals Quality AssuranceEducationOperationsEngineering Maintenance amp ProjectsSecurity amp TransportITDHouse KeepingOut Patient ServicesIn Patient ServicesMarketingGR amp PRLiaison Advertising amp MediaSales Promotion amp CampsOrganization Chart
OPD Pharmacy Counter Sample collection Diagnostics Admission amp
Billing Counter
EXIT Report Collection
Registration Procedure
OPD requisition form to be filled
Submitted at the front office
A unique hospital ID is assigned
Cash Memo is issued
Mode of paymentCash payment was accepted Debit Credit card payment were under process
Waiting areaThere were three different OPD complexes
General OPD Eye OPD Obstetrics amp Gynecology
The General OPD waiting area would accommodate 150-200 people whereas the other OPDs had a capacity of 100 with no sub waiting area
In case of empanelled organizations
o The client has to produce an authorisation lettero Compendium of orders by Central Government Health Scheme is strictly
followedo Same charges and rates according to states are followedo In Manipur Delhi rates followed for all examinations and procedures
Payment method for clients from empanelled organizations
7
o IP payments are always due and payments have to be drawn from the empanelled organization
o OP payments have to be collected in cash from the patients which they can refund it on their own
o IP patients can give cheques
SHIJA MASTER HEALTH CHECK
Patient enters hospital
Registration done at Main reception
Billing done at IPD Counter
Sample collection done in Master Health Check Sample Collection Room
Sample sent to Lab
IN PATIENT DEPARTMENT
Categories of wards o Male General Ward
o Female General Ward
o Intensive Care Unit
o Neuro ICU
o Special rooms
o Cabins Twin sharing
o Deluxe Suites
8
In Patient Flow
Patient can come from
OPD ICU EMERGENCY POST -OPERATIVE
WARD
Admission counter - Nursing staff of ward changes the patient status in HIS by
Assistant gives a call doing ldquoCHECK-INrdquo of the patient received
to nursing station to - ICU EMERGENCY POST-OPERATIVE WARDS (from where
confirm for bed the patient is coming) changes the patient status in their
availability HIS by doing ldquoCHECK-OUTrdquo of the patient
Nursing staff prepares the roombed
Entry done in HIS Register White Board
Nurse informs the concerned Doctor
Doctor comes amp prescribes medication and investigation (if any)
Nurse writes the prescribed drugs on Indoor Drug Requisition Form
Ward boy goes and collects the drugs from Pharmacy
Nurse starts medication + prepares the patient for investigation (if any)
9
OPERATION THEATRE
Doctor sends request for OT Availability
OT Incharge confirms OT availability
Entry into OT Booking Register regarding
Scheduled surgeryrsquos Date Time Doctor Patient
A day before surgery verification of
Surgery Set Drugs
10
Instrument Verification
Verification of CSSD amp other consumables
In Non Usable condition
Discarded
Entry into Instrument
Replacement Register
Respective HOD informed
Request send to stores
Request sent
In usable condition
Suitable for use in surgery
Expiry check
Unused amp not
expired
Suitable for use
in surgery
Used
Depleted stock for surgery use
Requisition sent to Pharmacy through Drug Requisition Form
Pharmacy replenishes request
Sufficient stock Inventory
Linen amp Instrument
check
Dirty Linen list formed amp
sent to Laundry amp received
later
Entry made
Surgical set amp consumables prepared
Before start of surgery Inspection of
Before start of surgery Inspection of
Patientrsquos Records
Medical Gas
Pressure Leakage
Sterilization
Daily OT cleaning
records duly filled
Mopping of OT floor with
Bacillocid
Disinfection of OT items
listed on form with 2 Trigene
Instrument checklist
form
Completion of ldquoopened
byrdquo amp ldquocross checkedrdquo columns
Electrical points in
OT
Equipments
Transfer of equipment specific for
surgery into OT
OT Preparation done
Reception of Patient in Pre Operation area 20 minutes before surgery
Patient shifted to OT
11
In Non Usable condition
Discarded
Entry into Instrument
Replacement Register
Respective HOD informed
Request send to stores
Request sent
Depleted stock for surgery use
Requisition sent to Pharmacy through Drug Requisition Form
Pharmacy replenishes request
Linen amp Instrument
check
Dirty Linen list formed amp
sent to Laundry amp received
later
Entry made
Expired
Separated
Entry made into RE-
AUTOCLAVE register
Send to CSSD
Not expired
Suitable for surgery
Patientrsquos Identification done amp verified
Surgery performed
Recording of all consumable used is recorded
Surgery completed
Surgery completed
Collection of OT Waste
Disposal by housekeeping
staff as per rules
Count of instruments
ldquoPostrdquo Column of Instrument
check list form completed
Transfer of patient to Recovery
room
Patient shifted to Ward SICU
Updation of records
Operation notes amp patientrsquos
record completed
Operation Daily charge bill formed
OT Drug inventory checked
Requisition send to
Pharmacy
OT Inventory replenished
OT Prepared for next surgery
Operation Theatre
Layout 1st flooor No of OTrsquos 6
General OTrsquos ndash 3 Eye OT- 1 Minor OT - 2
12
No of beds in Pre operative ward 7 No of beds in post operative wards 8 Utility room 1 Doctorrsquos Lounge 1 Nurse and Technician Lounge 1 Pantry 1 Sterile room 1 Changing rooms 4
Doctor (male) changing room 1 Doctor (female) changing room 1 Nurse (female) changing room 1 Technician + Nurse (male) changing room 1
Patient admission procedure in ICU
Physician
(Desiring admission of a patient in ICU)
contacts
Admission Office
Contacts for Bed Availability with
ICU
(Nurse ndash Ward Supervisor)
Beds Available No ICU Bed available
Admission done Admission office contacts
Nursing Administrator
Nursing Administrator starts
ICU patients ldquostatus evaluationrdquo
13
Any patient can be shifted None can be shifted
to Wards
Patient shifted to ICU after one patient Patient is stabilizedis shifted to Wards
Nursing Supervisor contacts
Administrator on-call
He authorize transfer of
patient to other hospital
HUMAN RESOURCE DEPARTMENT
Layout -Administrative Block Ground Floor
Total Staff 4
Organogram
Head Manager
HR Executives (3)
Trainee
Jobs amp Responsibilities
Manpower Planning
Internal Job Posting Process
CV Selection
Confirmation and Appraisal
Staff Queries
Follow up with selected candidates
Issuing of appointment letters
Disciplinary Policy
Leaves sanctioning
14
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Payroll
Budgeting for departments
Doctors payout
Duty roster
Issuing of Experience letters
STORES
Layout -New Stores Block
Staff 4
Hierarchy
Stores Manager
Store Supervisor
Bio medical Engineer GDA
Records Maintained
Goods Receipt Note Quotations Purchase Requests Capital Sanctioned Record
WORK FLOW
Department in need of material
Through HIS Indentation
or Requisition slip
Store15
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Issue Note Return File Purchase Receipt Purchase Orders
Store checks for the required material and the quantity
YES NO
Material issued and recorded in Issue Register Entry into Shortage Register
Record of the material entered HIS ldquoPurchase Requestrdquo is filled in HIS
Duties of Store In charge
Forecasting requirement Budgetary requirement Inventory control Stock verification Communicate the purchase
department about requirement Minimize pilferage
INFORMATION TECHNOLOGY (IT) DEPARTMENT
Layout -Ground Floor Main Building
Staff 3
Functions and responsibilities
To keep the servers alive
To keep the network alive
To keep internet connection alive
To take care of all the desktops amp laptops in the organization
To track the records of all the desktops
To keep an eye on the employees desktops
To resolve the complaints of the employees
Training of the other staff for the HIS
Major Work Areas General Administration amp HIS
16
Bin card maintained At a time 2800 items maintained in
the stores Random sample check to ensure the
genuinity and authenticity of product Disposal of surplus obsolete
Material Distribution
I) General Administration
Servers
Anti virus server Database server Application server Archive server
II) HIS (Hospital Information System)
Application by Avanttec
Billing Ward management Laboratory services Discharges + Medical Records Housekeeping Pharmacy Payroll Medical equipment
Access to Information
o User specific access according to their roles
HIS Backup
Done once a day Centralized database Internal backups
MEDICAL RECORD DEPARTMENT
Layout -MRD Block
Staff 3
Infrastructure
Desktop 1
Printer 1
Organogram Medical Records Officer Statistician
Medical Records Technician
17
Functions of MRD
To ensure that the Shija Hospital has complete amp accurate medical record for every
patient
Public dealings with respect to Bill verification MLC cases and dealing with
Summons to the doctors hospital
To maintain high level of confidentiality as far as patientrsquos records are concerned
To ensure that the records are Identified and stored safely to prevent unauthorized
changes and easily retrieved whenever required
Issuing Emergency Medical Birth amp Death certificates
To generate Bed Occupancy reports ALOS and other hospital statistics (daily amp
monthly)
Record Retention Periods
IP Record 05 years
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patient
CLINICAL NUTRITION amp DIETICS DEPARTMENT
Layout -Ground floor OPD Block
Head Dietician Ms Bimota
Functions
Catering to Inpatients Diet counseling Education Smooth provision of laid out diets to the patients To check the patient food for quality preparation presentation and packing Coordinating closely with the Nursing shift in charges for changes in the patientrsquos
diet or new admissions etc
Records Maintained
Diet order sheet Meal count register Store register Diet Sheets
18
Counseling Register
Type of Diet Diet Card Color
Normal White
Diabetes Mellitus Yellow
Chronic Renal Failure Blue
Liquid Diet Pink
Flowchart of Dietician and Inpatient Interaction
The Dietician takes details of new patients such as name UHID doctorrsquos name diagnosis and diet prescribed Then Dietician takes a detailed round wherein she meets every patient and determines patientsrsquo actual intake Dietician then provides nutritional counseling and education ensures patientsrsquo compliance to recommended diet She also recognizes personal eating and food preferences
Afterwards the dietician does nutritional screening in order to know about patientsrsquo clinical condition appetite and tolerance to food and acceptance to hospital diet personal preferences disliking and food allergies if any
After the rounds detailed food summary sheets are planned and prepared for every patient keeping in mind medical history and preferences of patient as well
SECURITY
Own security force not outsourced since 2009
Area of Operation (Present)
To deal with 3 ldquoMrdquo- Man Material amp Machinery
Visitorrsquos check Entry restriction at ICU gate Security for doctors and nurse quarter Surveillance of hospital through CCTVrsquos Theft Burglary Violence Material movements in amp out of the hospital Handling visitorrsquos pass In case of patientrsquos death handling emotional chaos of attendants Parking management and traffic control
19
HOUSEKEEPING
Status Own
Department Manager Mr Arju
FUNCTIONS
bull Clean Floor Wall Ceiling
bull Discharge Cleaning
bull Remove Garbage
bull Replace Supplies In Utility Rooms
bull Clean Housekeeping Equipments
bull Clean Room Wards Reception OT ICU Etc
bull Infection Control
bull Pest amp Rodent Control
bull Odour Control
LAUNDRY- Own
Department in charge- MsUmajini
Functions
Segregation of soiled and clean linen Traffic flow of linen before 8am Carrying the linen around the hospital Registered linen and purpose System of collection
o Colored bins
Infected linen handled separately- soaked in sodium hyperchloride Register maintained ndash separate for infected and un-infected linen Floor wise collection Different registers for each type of linen Separate people for ironing and drying from those who collect and wash
20
bull Environment Hygiene
bull Sanitation Hygiene
bull Checking Cleanliness Of All Areas
bull Control amp Reporting Of All
Maintenance Works
bull Hospital Waste Disposal
bull In-Service Training
bull Cooperation with Other Depts
Shared responsibility with nurses in charge Report- washing record submitted to HR dept Due list of linen- expected on Monday
GAPS IDENTIFIED IN STORES MANAGEMENT
No forecasting of requirement done ie Reorder Levels not defined
No analysis like ABC VED done for inventory control
Codification of items still in progress
HIS for Stores still not completely streamlined
AMC amp CMC not maintained for all
Some departments go beyond the indent allowance
Repair and Maintenance of equipments There are instruments which are not used at all
o Non-functionalo Repair requiredo Condemned
For Quality assurance o Quality calibration o Annual Maintenance Contracto Complete Maintenance Contract
Instruments go for regular servicing or they are serviced and examined regularly- Some machines are serviced in the hospital- eg computers printers patient
monitor BP instrument Alternative arrangements are available during that period of time- Patient
monitors from other wards are managedo No back up stock available
Shortage during repair period Patient monitor ndash completely mobile thus record maintenance difficult-
communication gap between the material managers 3 total staff
GAPS IDENTIFIED IN HMIS
Avanttec is a Chennai Based HIS system hence immediate access to providers not available
Strong foundation but HIS is still not fully streamlined Personnel shortage in the department No staff at night
21
GAPS IDENTIFIED IN LAUNDRY DEPARTMENT
6 Set rule per patient not followed Presently only 2 sets per patient No weighing scale No sewing machine for repair No supervision over measured use of detergent and other chemicals
PROJECT ndash 1
A Study on Discharge Procedure with Special Emphasis
on In-Patient Feedback
22
INTRODUCTION
The study was carried out in Shija Hospitals and Research Institute which is a 180 bedded hospital located in Manipur The Hospital is well known for its high end technology and services in the region The Hospital looks forward to continually develop its services and improve the facilities available in order to become a well known health service provider in the South East Asian region in the future The operations management had identified the discharge procedure as an area where there was a scope for improvement Hence the hospital had assigned the project to study the discharge procedure
Discharging a patient is an activity common to every hospital - small large community inner-city teaching or non-teaching The discharge process can have an impact on numerous factors such as patient satisfaction bed availability timely tests and procedures needed for discharge transportation and nursing home arrangements No matter what type of patient is being discharged (maternity medicine orthopedic neurologic) numerous activities must be completed for each before the patient can be released This work toward discharge day should begin upon admission
As part of a progress towards NABH accreditation at Shija Hospital the discharge process is one of the many process improvement projects The discharge process at this hospital also incorporates obtaining feedback from the in-patient regarding the services at the time of discharge Due to inappropriate management the hospital was facing an acute shortage in the feedback response from the patients
The management at the hospital realizes the need and importance of patient satisfaction and a need of a measurable index through feedback analysis In all service industries customer retention is a vital issue Hence the management wanted to do all that they could to obtain feedback from the patients at the time of discharge and make the discharge procedure as smooth as it can get
The objective of this study was to study the process of discharge and find out the probable reasons for the failure to attain feedback from the patients at the time of discharge
23
STUDY METHODOLOGY
AIM
To study the discharge procedure practiced at Shija Hospitals with special emphasis on
analyzing the reasons for the short-fall of In-Patient Feedback
OBJECTIVE
1 To find the steps followed during discharge of an in-patient2 To find the total time taken for a discharge of a single patient3 To find the contributing reasons for the short fall of in-patient feedback
received in the wards
RATIONALE
The discharge of a patient is a very important component of in-patient service and needs to be smooth and efficient On the other hand in-patient feedback is equally important as it provides the performance standards of the hospital which needs to be continually enhanced
METHODOLOGY
Study design-
Area- Shija Hospitals and Research Institute Manipur
Duration- From 11-04-2011 to 30-04-2011
Type of study- Observational and Survey study
Sample size-120 in-patients and the following hospital staff
Nurse Superintendant
RMOs on duty
Staff nurse
Front office executives
Service entry staff
Sampling Method-Convenience sampling
Study tool Questionnaire and personal interviews
24
Type of Data collected -
Interviewer guided questionnaires collected from patients by visiting the different wards
Personal interview of various hospital staff and officials involved in discharge procedure
DISCHARGE PROCESS
25
Doctor prescribes the discharge
Nurse informs the patient about the time of discharge
26
Staff nurse starts discharge formalities by
Asking the Resident Medical Officer Concerned Physician to
make discharge summary
Informing Dietician to make discharge diet report for patient
Counseling of the patient by the dietician and physiotherapist (if
physiotherapy is going on for patient)
Asking the service entry assistants to enter all the details regarding the
patients starting from the no of consultant visits to medicines
consumed
Sending to Pharmacy Daily Billing Activity Sheet
Daily Pharmacy BillsDischarge medication detailsMedicines left unconsumed
In Pharmacy Summary of Pharmacy Bill is prepared
Daily Billing Activity Sheet
Summarized Pharmacy Bill
Giving the feedback form to the patient attendants
Fig1 Communication channels during the discharge procedure
27
Billing department finalizes the bill
Payment taken by billing department from attendants
IPD Billing informs at the nursing station about the clearance of bill
Discharge Summary completion by Medical Transcriptionist
Nurse informs the patient amp patient changes clothes
Nurse checks the checklist given for discharge of patient
All medications + Investigations reports + Patientrsquos file given to the patient
Patient given amp explained about how to take the medications + any special instruction + follow up schedule
Patient Discharged
Collects the filled up feedback form from the patient attendants
There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays
Fig 2 A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital
020406080
100120
82
28 39
102
Compliance to discharge procedure
No
of p
atien
ts
Table1 Duration of various parameters related to discharge
28
DoctorNurseService ward boysBillingofficePatient
Various other departments of the hospital
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
TABLE OF CONTENTS
A Profile of Shija Hospitals And Research Institute(Shri) Manipurhelliphellip 1
a) Introductionhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip3b) Services available(Departments)helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip3c) Organization charthelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip5d) Front officehelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip6e) IPD departmenthelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip8f) Operation Theatre and ICUhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip10g) Human Resource Departmenthelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip14h) Stores helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip15i) Hospital management information systemhelliphelliphelliphelliphelliphelliphelliphelliphellip16j) Medical records departmenthelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip17k) Clinical nutrition and dietetics departmenthelliphelliphelliphelliphelliphelliphelliphelliphellip18l) Security and Safetyhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip19m) Housekeepinghelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip19n) Laundry helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip20
B PROJECT 1- A Study on Discharge Procedure with Special Emphasis on In-Patient
Feedbackhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip22
C Profile of Fortis Malar Hospital Chennaihelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip32
D PROJECT STUDY 2- Medical Records Management and Protocol
Implementationhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip36
E PROJECT STUDY 3- Employee Joining Kithelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip46
C ANNEXURES
a) Discharge checklistb) Feedback formc) Final Summary sheetd) Forms verification checkliste) Hospital statistics Recordf) Employee joining kit
ABBREVIATIONS
ALOS - Average Length of Stay
BOR ndash Bed Occupancy Ratio
CCTV - Closed Circuit Television
CSSD - Central Sterile and Supply Department
DOR - Discharge on Request
ECG - Electro Cardiogram
ENT - Ear Nose Throat
HIS - Hospital Information System
HRD - Human Resource Development
ICD - International Classification of Diseases
ICU - Intensive care Unit
IPD - In Patient department
IT - Information Technology
MLC - Medico Legal case
MRD - Medical Records department
OPD - Out patient Department
OT - Operation Theatre
RMO - Resident medical Officer
Shija Hospitals and Research Institute
[April 11th ndash April 30th 2011]
1
ACKNOWLEDGEMENT
I am extremely indebted to all the professionals at Shija Hospitals and Research
Institute(SHRI) Manipur for sharing generously their knowledge and precious time
which inspired me to do best during summer training
I owe a great debt to DrKHPalin Managing Director and Chairman Shija Hospitals
and Research Institute Manipur for allowing me to do my summer training at the
hospital
I would also like to thank Dr Jugindra S Medical Superintendant and Ms Gayatri S
Head - Human Resource for their valuable guidance and at whose behest I received
tremendous assistance from other departments and their respective heads without which
the project would not have been completed
I would like to extend my special thanks to Ms Leema and Ms Arti Operations
Executives for sparing their valuable time and sharing with me the nuances of Hospital
operations and to all Executives of HR and Operations department for their support
and guidance throughout the summer training
Most importantly I would like to thank my mentor DrNeetu Purohit for her
unconditional support and motivation throughout the study period and
DrTanjul Saxena for her guidance on the report preparation and compilation of the
same
2
3
INTRODUCTION
Shija Hospitals is a pioneer ISO 90012008 certified private health institute in Manipur providing advanced healthcare technology with humane touch With the recognition by its customer for their holistic approach personal touch and technological advancement Shija Hospitals has been successful to a great extent in bringing highly needed medical technology in the region
Shija Hospitals located at environment friendly Langol Manipur is 200 bedded fully computerized institute having five modern operation theatres and 18 bedded fully functional ICU with all the latest life supporting equipments The hospital currently has 500 trained and dedicated staff
Shija Hospitals has becomes the only centre in Eastern India having under one-roof the total lsquostate of the artrsquo solution for treatment of stones at different locations of the body viz Lap-Chole Lap-CBD Exploration ERCP ESWL PCNL URS CLT and Lap-Urosurgery In Manipur it is the only private hospital having a consolidated Neuroscience centre under one roof has all the requisite resource in its Neurosurgery and Neurology unit Also SHRI is today a premier institute in India for minimally invasive surgery (MIS) viz Laparoscopic Surgery Arthroscopy Thoracoscopy Functional Endoscopic Sinus Surgery (FESS) and Upper and Lower GI Endoscopic procedures
To mention the recognition the hospital has been awarded Guinness World record for removing the largest neck tumor in the world from a 12 days old baby the tumor weighed 40 of the body weight
Facilities
Shija Hospitals Langol has the following departments ndash
Emergency and Trauma Care Pathology Radiology and imaging General Surgery Paediatric Dental ENT Obstetrics amp Gynaecology Ophthalmology Orthopaedics
4
Cardiology Anaesthesiology Medicine and Psychiatry Physiotherapy Surgical Gastroenterology Plastic Surgery Neurosurgery Neurology Urology
Vision 2015
To be a premium amp leading brand in healthcare services in the South East Asia recognized by our customers for our holistic approach personal touch and technological advancement
Mission
1048766 Customer needs 1048766 Research and development1048766 Quality system 1048766 Networking1048766 People development
Core Values -
Integrity Agility Passion for Excellence
5
FRONT OFFICE
In Patient Out PatientI) MAIN RECEPTION
Patient entry
Main reception area
Registered If Not Registered Registration done (At Main Reception)
OPD Billing
OPD Nursing Station
Consultation with Doctor
Advised Medication Advised Investigation Advised Admission
6
CMDMSConsultantsDuty DoctorsNursingMRDPharmacyOP PharmacyIP PharmacyCEOMaterials amp CRSFinanceAccountsCredit CellHRHR AdminRecruitment amp TrainingIR Appraisals Quality AssuranceEducationOperationsEngineering Maintenance amp ProjectsSecurity amp TransportITDHouse KeepingOut Patient ServicesIn Patient ServicesMarketingGR amp PRLiaison Advertising amp MediaSales Promotion amp CampsOrganization Chart
OPD Pharmacy Counter Sample collection Diagnostics Admission amp
Billing Counter
EXIT Report Collection
Registration Procedure
OPD requisition form to be filled
Submitted at the front office
A unique hospital ID is assigned
Cash Memo is issued
Mode of paymentCash payment was accepted Debit Credit card payment were under process
Waiting areaThere were three different OPD complexes
General OPD Eye OPD Obstetrics amp Gynecology
The General OPD waiting area would accommodate 150-200 people whereas the other OPDs had a capacity of 100 with no sub waiting area
In case of empanelled organizations
o The client has to produce an authorisation lettero Compendium of orders by Central Government Health Scheme is strictly
followedo Same charges and rates according to states are followedo In Manipur Delhi rates followed for all examinations and procedures
Payment method for clients from empanelled organizations
7
o IP payments are always due and payments have to be drawn from the empanelled organization
o OP payments have to be collected in cash from the patients which they can refund it on their own
o IP patients can give cheques
SHIJA MASTER HEALTH CHECK
Patient enters hospital
Registration done at Main reception
Billing done at IPD Counter
Sample collection done in Master Health Check Sample Collection Room
Sample sent to Lab
IN PATIENT DEPARTMENT
Categories of wards o Male General Ward
o Female General Ward
o Intensive Care Unit
o Neuro ICU
o Special rooms
o Cabins Twin sharing
o Deluxe Suites
8
In Patient Flow
Patient can come from
OPD ICU EMERGENCY POST -OPERATIVE
WARD
Admission counter - Nursing staff of ward changes the patient status in HIS by
Assistant gives a call doing ldquoCHECK-INrdquo of the patient received
to nursing station to - ICU EMERGENCY POST-OPERATIVE WARDS (from where
confirm for bed the patient is coming) changes the patient status in their
availability HIS by doing ldquoCHECK-OUTrdquo of the patient
Nursing staff prepares the roombed
Entry done in HIS Register White Board
Nurse informs the concerned Doctor
Doctor comes amp prescribes medication and investigation (if any)
Nurse writes the prescribed drugs on Indoor Drug Requisition Form
Ward boy goes and collects the drugs from Pharmacy
Nurse starts medication + prepares the patient for investigation (if any)
9
OPERATION THEATRE
Doctor sends request for OT Availability
OT Incharge confirms OT availability
Entry into OT Booking Register regarding
Scheduled surgeryrsquos Date Time Doctor Patient
A day before surgery verification of
Surgery Set Drugs
10
Instrument Verification
Verification of CSSD amp other consumables
In Non Usable condition
Discarded
Entry into Instrument
Replacement Register
Respective HOD informed
Request send to stores
Request sent
In usable condition
Suitable for use in surgery
Expiry check
Unused amp not
expired
Suitable for use
in surgery
Used
Depleted stock for surgery use
Requisition sent to Pharmacy through Drug Requisition Form
Pharmacy replenishes request
Sufficient stock Inventory
Linen amp Instrument
check
Dirty Linen list formed amp
sent to Laundry amp received
later
Entry made
Surgical set amp consumables prepared
Before start of surgery Inspection of
Before start of surgery Inspection of
Patientrsquos Records
Medical Gas
Pressure Leakage
Sterilization
Daily OT cleaning
records duly filled
Mopping of OT floor with
Bacillocid
Disinfection of OT items
listed on form with 2 Trigene
Instrument checklist
form
Completion of ldquoopened
byrdquo amp ldquocross checkedrdquo columns
Electrical points in
OT
Equipments
Transfer of equipment specific for
surgery into OT
OT Preparation done
Reception of Patient in Pre Operation area 20 minutes before surgery
Patient shifted to OT
11
In Non Usable condition
Discarded
Entry into Instrument
Replacement Register
Respective HOD informed
Request send to stores
Request sent
Depleted stock for surgery use
Requisition sent to Pharmacy through Drug Requisition Form
Pharmacy replenishes request
Linen amp Instrument
check
Dirty Linen list formed amp
sent to Laundry amp received
later
Entry made
Expired
Separated
Entry made into RE-
AUTOCLAVE register
Send to CSSD
Not expired
Suitable for surgery
Patientrsquos Identification done amp verified
Surgery performed
Recording of all consumable used is recorded
Surgery completed
Surgery completed
Collection of OT Waste
Disposal by housekeeping
staff as per rules
Count of instruments
ldquoPostrdquo Column of Instrument
check list form completed
Transfer of patient to Recovery
room
Patient shifted to Ward SICU
Updation of records
Operation notes amp patientrsquos
record completed
Operation Daily charge bill formed
OT Drug inventory checked
Requisition send to
Pharmacy
OT Inventory replenished
OT Prepared for next surgery
Operation Theatre
Layout 1st flooor No of OTrsquos 6
General OTrsquos ndash 3 Eye OT- 1 Minor OT - 2
12
No of beds in Pre operative ward 7 No of beds in post operative wards 8 Utility room 1 Doctorrsquos Lounge 1 Nurse and Technician Lounge 1 Pantry 1 Sterile room 1 Changing rooms 4
Doctor (male) changing room 1 Doctor (female) changing room 1 Nurse (female) changing room 1 Technician + Nurse (male) changing room 1
Patient admission procedure in ICU
Physician
(Desiring admission of a patient in ICU)
contacts
Admission Office
Contacts for Bed Availability with
ICU
(Nurse ndash Ward Supervisor)
Beds Available No ICU Bed available
Admission done Admission office contacts
Nursing Administrator
Nursing Administrator starts
ICU patients ldquostatus evaluationrdquo
13
Any patient can be shifted None can be shifted
to Wards
Patient shifted to ICU after one patient Patient is stabilizedis shifted to Wards
Nursing Supervisor contacts
Administrator on-call
He authorize transfer of
patient to other hospital
HUMAN RESOURCE DEPARTMENT
Layout -Administrative Block Ground Floor
Total Staff 4
Organogram
Head Manager
HR Executives (3)
Trainee
Jobs amp Responsibilities
Manpower Planning
Internal Job Posting Process
CV Selection
Confirmation and Appraisal
Staff Queries
Follow up with selected candidates
Issuing of appointment letters
Disciplinary Policy
Leaves sanctioning
14
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Payroll
Budgeting for departments
Doctors payout
Duty roster
Issuing of Experience letters
STORES
Layout -New Stores Block
Staff 4
Hierarchy
Stores Manager
Store Supervisor
Bio medical Engineer GDA
Records Maintained
Goods Receipt Note Quotations Purchase Requests Capital Sanctioned Record
WORK FLOW
Department in need of material
Through HIS Indentation
or Requisition slip
Store15
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Issue Note Return File Purchase Receipt Purchase Orders
Store checks for the required material and the quantity
YES NO
Material issued and recorded in Issue Register Entry into Shortage Register
Record of the material entered HIS ldquoPurchase Requestrdquo is filled in HIS
Duties of Store In charge
Forecasting requirement Budgetary requirement Inventory control Stock verification Communicate the purchase
department about requirement Minimize pilferage
INFORMATION TECHNOLOGY (IT) DEPARTMENT
Layout -Ground Floor Main Building
Staff 3
Functions and responsibilities
To keep the servers alive
To keep the network alive
To keep internet connection alive
To take care of all the desktops amp laptops in the organization
To track the records of all the desktops
To keep an eye on the employees desktops
To resolve the complaints of the employees
Training of the other staff for the HIS
Major Work Areas General Administration amp HIS
16
Bin card maintained At a time 2800 items maintained in
the stores Random sample check to ensure the
genuinity and authenticity of product Disposal of surplus obsolete
Material Distribution
I) General Administration
Servers
Anti virus server Database server Application server Archive server
II) HIS (Hospital Information System)
Application by Avanttec
Billing Ward management Laboratory services Discharges + Medical Records Housekeeping Pharmacy Payroll Medical equipment
Access to Information
o User specific access according to their roles
HIS Backup
Done once a day Centralized database Internal backups
MEDICAL RECORD DEPARTMENT
Layout -MRD Block
Staff 3
Infrastructure
Desktop 1
Printer 1
Organogram Medical Records Officer Statistician
Medical Records Technician
17
Functions of MRD
To ensure that the Shija Hospital has complete amp accurate medical record for every
patient
Public dealings with respect to Bill verification MLC cases and dealing with
Summons to the doctors hospital
To maintain high level of confidentiality as far as patientrsquos records are concerned
To ensure that the records are Identified and stored safely to prevent unauthorized
changes and easily retrieved whenever required
Issuing Emergency Medical Birth amp Death certificates
To generate Bed Occupancy reports ALOS and other hospital statistics (daily amp
monthly)
Record Retention Periods
IP Record 05 years
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patient
CLINICAL NUTRITION amp DIETICS DEPARTMENT
Layout -Ground floor OPD Block
Head Dietician Ms Bimota
Functions
Catering to Inpatients Diet counseling Education Smooth provision of laid out diets to the patients To check the patient food for quality preparation presentation and packing Coordinating closely with the Nursing shift in charges for changes in the patientrsquos
diet or new admissions etc
Records Maintained
Diet order sheet Meal count register Store register Diet Sheets
18
Counseling Register
Type of Diet Diet Card Color
Normal White
Diabetes Mellitus Yellow
Chronic Renal Failure Blue
Liquid Diet Pink
Flowchart of Dietician and Inpatient Interaction
The Dietician takes details of new patients such as name UHID doctorrsquos name diagnosis and diet prescribed Then Dietician takes a detailed round wherein she meets every patient and determines patientsrsquo actual intake Dietician then provides nutritional counseling and education ensures patientsrsquo compliance to recommended diet She also recognizes personal eating and food preferences
Afterwards the dietician does nutritional screening in order to know about patientsrsquo clinical condition appetite and tolerance to food and acceptance to hospital diet personal preferences disliking and food allergies if any
After the rounds detailed food summary sheets are planned and prepared for every patient keeping in mind medical history and preferences of patient as well
SECURITY
Own security force not outsourced since 2009
Area of Operation (Present)
To deal with 3 ldquoMrdquo- Man Material amp Machinery
Visitorrsquos check Entry restriction at ICU gate Security for doctors and nurse quarter Surveillance of hospital through CCTVrsquos Theft Burglary Violence Material movements in amp out of the hospital Handling visitorrsquos pass In case of patientrsquos death handling emotional chaos of attendants Parking management and traffic control
19
HOUSEKEEPING
Status Own
Department Manager Mr Arju
FUNCTIONS
bull Clean Floor Wall Ceiling
bull Discharge Cleaning
bull Remove Garbage
bull Replace Supplies In Utility Rooms
bull Clean Housekeeping Equipments
bull Clean Room Wards Reception OT ICU Etc
bull Infection Control
bull Pest amp Rodent Control
bull Odour Control
LAUNDRY- Own
Department in charge- MsUmajini
Functions
Segregation of soiled and clean linen Traffic flow of linen before 8am Carrying the linen around the hospital Registered linen and purpose System of collection
o Colored bins
Infected linen handled separately- soaked in sodium hyperchloride Register maintained ndash separate for infected and un-infected linen Floor wise collection Different registers for each type of linen Separate people for ironing and drying from those who collect and wash
20
bull Environment Hygiene
bull Sanitation Hygiene
bull Checking Cleanliness Of All Areas
bull Control amp Reporting Of All
Maintenance Works
bull Hospital Waste Disposal
bull In-Service Training
bull Cooperation with Other Depts
Shared responsibility with nurses in charge Report- washing record submitted to HR dept Due list of linen- expected on Monday
GAPS IDENTIFIED IN STORES MANAGEMENT
No forecasting of requirement done ie Reorder Levels not defined
No analysis like ABC VED done for inventory control
Codification of items still in progress
HIS for Stores still not completely streamlined
AMC amp CMC not maintained for all
Some departments go beyond the indent allowance
Repair and Maintenance of equipments There are instruments which are not used at all
o Non-functionalo Repair requiredo Condemned
For Quality assurance o Quality calibration o Annual Maintenance Contracto Complete Maintenance Contract
Instruments go for regular servicing or they are serviced and examined regularly- Some machines are serviced in the hospital- eg computers printers patient
monitor BP instrument Alternative arrangements are available during that period of time- Patient
monitors from other wards are managedo No back up stock available
Shortage during repair period Patient monitor ndash completely mobile thus record maintenance difficult-
communication gap between the material managers 3 total staff
GAPS IDENTIFIED IN HMIS
Avanttec is a Chennai Based HIS system hence immediate access to providers not available
Strong foundation but HIS is still not fully streamlined Personnel shortage in the department No staff at night
21
GAPS IDENTIFIED IN LAUNDRY DEPARTMENT
6 Set rule per patient not followed Presently only 2 sets per patient No weighing scale No sewing machine for repair No supervision over measured use of detergent and other chemicals
PROJECT ndash 1
A Study on Discharge Procedure with Special Emphasis
on In-Patient Feedback
22
INTRODUCTION
The study was carried out in Shija Hospitals and Research Institute which is a 180 bedded hospital located in Manipur The Hospital is well known for its high end technology and services in the region The Hospital looks forward to continually develop its services and improve the facilities available in order to become a well known health service provider in the South East Asian region in the future The operations management had identified the discharge procedure as an area where there was a scope for improvement Hence the hospital had assigned the project to study the discharge procedure
Discharging a patient is an activity common to every hospital - small large community inner-city teaching or non-teaching The discharge process can have an impact on numerous factors such as patient satisfaction bed availability timely tests and procedures needed for discharge transportation and nursing home arrangements No matter what type of patient is being discharged (maternity medicine orthopedic neurologic) numerous activities must be completed for each before the patient can be released This work toward discharge day should begin upon admission
As part of a progress towards NABH accreditation at Shija Hospital the discharge process is one of the many process improvement projects The discharge process at this hospital also incorporates obtaining feedback from the in-patient regarding the services at the time of discharge Due to inappropriate management the hospital was facing an acute shortage in the feedback response from the patients
The management at the hospital realizes the need and importance of patient satisfaction and a need of a measurable index through feedback analysis In all service industries customer retention is a vital issue Hence the management wanted to do all that they could to obtain feedback from the patients at the time of discharge and make the discharge procedure as smooth as it can get
The objective of this study was to study the process of discharge and find out the probable reasons for the failure to attain feedback from the patients at the time of discharge
23
STUDY METHODOLOGY
AIM
To study the discharge procedure practiced at Shija Hospitals with special emphasis on
analyzing the reasons for the short-fall of In-Patient Feedback
OBJECTIVE
1 To find the steps followed during discharge of an in-patient2 To find the total time taken for a discharge of a single patient3 To find the contributing reasons for the short fall of in-patient feedback
received in the wards
RATIONALE
The discharge of a patient is a very important component of in-patient service and needs to be smooth and efficient On the other hand in-patient feedback is equally important as it provides the performance standards of the hospital which needs to be continually enhanced
METHODOLOGY
Study design-
Area- Shija Hospitals and Research Institute Manipur
Duration- From 11-04-2011 to 30-04-2011
Type of study- Observational and Survey study
Sample size-120 in-patients and the following hospital staff
Nurse Superintendant
RMOs on duty
Staff nurse
Front office executives
Service entry staff
Sampling Method-Convenience sampling
Study tool Questionnaire and personal interviews
24
Type of Data collected -
Interviewer guided questionnaires collected from patients by visiting the different wards
Personal interview of various hospital staff and officials involved in discharge procedure
DISCHARGE PROCESS
25
Doctor prescribes the discharge
Nurse informs the patient about the time of discharge
26
Staff nurse starts discharge formalities by
Asking the Resident Medical Officer Concerned Physician to
make discharge summary
Informing Dietician to make discharge diet report for patient
Counseling of the patient by the dietician and physiotherapist (if
physiotherapy is going on for patient)
Asking the service entry assistants to enter all the details regarding the
patients starting from the no of consultant visits to medicines
consumed
Sending to Pharmacy Daily Billing Activity Sheet
Daily Pharmacy BillsDischarge medication detailsMedicines left unconsumed
In Pharmacy Summary of Pharmacy Bill is prepared
Daily Billing Activity Sheet
Summarized Pharmacy Bill
Giving the feedback form to the patient attendants
Fig1 Communication channels during the discharge procedure
27
Billing department finalizes the bill
Payment taken by billing department from attendants
IPD Billing informs at the nursing station about the clearance of bill
Discharge Summary completion by Medical Transcriptionist
Nurse informs the patient amp patient changes clothes
Nurse checks the checklist given for discharge of patient
All medications + Investigations reports + Patientrsquos file given to the patient
Patient given amp explained about how to take the medications + any special instruction + follow up schedule
Patient Discharged
Collects the filled up feedback form from the patient attendants
There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays
Fig 2 A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital
020406080
100120
82
28 39
102
Compliance to discharge procedure
No
of p
atien
ts
Table1 Duration of various parameters related to discharge
28
DoctorNurseService ward boysBillingofficePatient
Various other departments of the hospital
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
ABBREVIATIONS
ALOS - Average Length of Stay
BOR ndash Bed Occupancy Ratio
CCTV - Closed Circuit Television
CSSD - Central Sterile and Supply Department
DOR - Discharge on Request
ECG - Electro Cardiogram
ENT - Ear Nose Throat
HIS - Hospital Information System
HRD - Human Resource Development
ICD - International Classification of Diseases
ICU - Intensive care Unit
IPD - In Patient department
IT - Information Technology
MLC - Medico Legal case
MRD - Medical Records department
OPD - Out patient Department
OT - Operation Theatre
RMO - Resident medical Officer
Shija Hospitals and Research Institute
[April 11th ndash April 30th 2011]
1
ACKNOWLEDGEMENT
I am extremely indebted to all the professionals at Shija Hospitals and Research
Institute(SHRI) Manipur for sharing generously their knowledge and precious time
which inspired me to do best during summer training
I owe a great debt to DrKHPalin Managing Director and Chairman Shija Hospitals
and Research Institute Manipur for allowing me to do my summer training at the
hospital
I would also like to thank Dr Jugindra S Medical Superintendant and Ms Gayatri S
Head - Human Resource for their valuable guidance and at whose behest I received
tremendous assistance from other departments and their respective heads without which
the project would not have been completed
I would like to extend my special thanks to Ms Leema and Ms Arti Operations
Executives for sparing their valuable time and sharing with me the nuances of Hospital
operations and to all Executives of HR and Operations department for their support
and guidance throughout the summer training
Most importantly I would like to thank my mentor DrNeetu Purohit for her
unconditional support and motivation throughout the study period and
DrTanjul Saxena for her guidance on the report preparation and compilation of the
same
2
3
INTRODUCTION
Shija Hospitals is a pioneer ISO 90012008 certified private health institute in Manipur providing advanced healthcare technology with humane touch With the recognition by its customer for their holistic approach personal touch and technological advancement Shija Hospitals has been successful to a great extent in bringing highly needed medical technology in the region
Shija Hospitals located at environment friendly Langol Manipur is 200 bedded fully computerized institute having five modern operation theatres and 18 bedded fully functional ICU with all the latest life supporting equipments The hospital currently has 500 trained and dedicated staff
Shija Hospitals has becomes the only centre in Eastern India having under one-roof the total lsquostate of the artrsquo solution for treatment of stones at different locations of the body viz Lap-Chole Lap-CBD Exploration ERCP ESWL PCNL URS CLT and Lap-Urosurgery In Manipur it is the only private hospital having a consolidated Neuroscience centre under one roof has all the requisite resource in its Neurosurgery and Neurology unit Also SHRI is today a premier institute in India for minimally invasive surgery (MIS) viz Laparoscopic Surgery Arthroscopy Thoracoscopy Functional Endoscopic Sinus Surgery (FESS) and Upper and Lower GI Endoscopic procedures
To mention the recognition the hospital has been awarded Guinness World record for removing the largest neck tumor in the world from a 12 days old baby the tumor weighed 40 of the body weight
Facilities
Shija Hospitals Langol has the following departments ndash
Emergency and Trauma Care Pathology Radiology and imaging General Surgery Paediatric Dental ENT Obstetrics amp Gynaecology Ophthalmology Orthopaedics
4
Cardiology Anaesthesiology Medicine and Psychiatry Physiotherapy Surgical Gastroenterology Plastic Surgery Neurosurgery Neurology Urology
Vision 2015
To be a premium amp leading brand in healthcare services in the South East Asia recognized by our customers for our holistic approach personal touch and technological advancement
Mission
1048766 Customer needs 1048766 Research and development1048766 Quality system 1048766 Networking1048766 People development
Core Values -
Integrity Agility Passion for Excellence
5
FRONT OFFICE
In Patient Out PatientI) MAIN RECEPTION
Patient entry
Main reception area
Registered If Not Registered Registration done (At Main Reception)
OPD Billing
OPD Nursing Station
Consultation with Doctor
Advised Medication Advised Investigation Advised Admission
6
CMDMSConsultantsDuty DoctorsNursingMRDPharmacyOP PharmacyIP PharmacyCEOMaterials amp CRSFinanceAccountsCredit CellHRHR AdminRecruitment amp TrainingIR Appraisals Quality AssuranceEducationOperationsEngineering Maintenance amp ProjectsSecurity amp TransportITDHouse KeepingOut Patient ServicesIn Patient ServicesMarketingGR amp PRLiaison Advertising amp MediaSales Promotion amp CampsOrganization Chart
OPD Pharmacy Counter Sample collection Diagnostics Admission amp
Billing Counter
EXIT Report Collection
Registration Procedure
OPD requisition form to be filled
Submitted at the front office
A unique hospital ID is assigned
Cash Memo is issued
Mode of paymentCash payment was accepted Debit Credit card payment were under process
Waiting areaThere were three different OPD complexes
General OPD Eye OPD Obstetrics amp Gynecology
The General OPD waiting area would accommodate 150-200 people whereas the other OPDs had a capacity of 100 with no sub waiting area
In case of empanelled organizations
o The client has to produce an authorisation lettero Compendium of orders by Central Government Health Scheme is strictly
followedo Same charges and rates according to states are followedo In Manipur Delhi rates followed for all examinations and procedures
Payment method for clients from empanelled organizations
7
o IP payments are always due and payments have to be drawn from the empanelled organization
o OP payments have to be collected in cash from the patients which they can refund it on their own
o IP patients can give cheques
SHIJA MASTER HEALTH CHECK
Patient enters hospital
Registration done at Main reception
Billing done at IPD Counter
Sample collection done in Master Health Check Sample Collection Room
Sample sent to Lab
IN PATIENT DEPARTMENT
Categories of wards o Male General Ward
o Female General Ward
o Intensive Care Unit
o Neuro ICU
o Special rooms
o Cabins Twin sharing
o Deluxe Suites
8
In Patient Flow
Patient can come from
OPD ICU EMERGENCY POST -OPERATIVE
WARD
Admission counter - Nursing staff of ward changes the patient status in HIS by
Assistant gives a call doing ldquoCHECK-INrdquo of the patient received
to nursing station to - ICU EMERGENCY POST-OPERATIVE WARDS (from where
confirm for bed the patient is coming) changes the patient status in their
availability HIS by doing ldquoCHECK-OUTrdquo of the patient
Nursing staff prepares the roombed
Entry done in HIS Register White Board
Nurse informs the concerned Doctor
Doctor comes amp prescribes medication and investigation (if any)
Nurse writes the prescribed drugs on Indoor Drug Requisition Form
Ward boy goes and collects the drugs from Pharmacy
Nurse starts medication + prepares the patient for investigation (if any)
9
OPERATION THEATRE
Doctor sends request for OT Availability
OT Incharge confirms OT availability
Entry into OT Booking Register regarding
Scheduled surgeryrsquos Date Time Doctor Patient
A day before surgery verification of
Surgery Set Drugs
10
Instrument Verification
Verification of CSSD amp other consumables
In Non Usable condition
Discarded
Entry into Instrument
Replacement Register
Respective HOD informed
Request send to stores
Request sent
In usable condition
Suitable for use in surgery
Expiry check
Unused amp not
expired
Suitable for use
in surgery
Used
Depleted stock for surgery use
Requisition sent to Pharmacy through Drug Requisition Form
Pharmacy replenishes request
Sufficient stock Inventory
Linen amp Instrument
check
Dirty Linen list formed amp
sent to Laundry amp received
later
Entry made
Surgical set amp consumables prepared
Before start of surgery Inspection of
Before start of surgery Inspection of
Patientrsquos Records
Medical Gas
Pressure Leakage
Sterilization
Daily OT cleaning
records duly filled
Mopping of OT floor with
Bacillocid
Disinfection of OT items
listed on form with 2 Trigene
Instrument checklist
form
Completion of ldquoopened
byrdquo amp ldquocross checkedrdquo columns
Electrical points in
OT
Equipments
Transfer of equipment specific for
surgery into OT
OT Preparation done
Reception of Patient in Pre Operation area 20 minutes before surgery
Patient shifted to OT
11
In Non Usable condition
Discarded
Entry into Instrument
Replacement Register
Respective HOD informed
Request send to stores
Request sent
Depleted stock for surgery use
Requisition sent to Pharmacy through Drug Requisition Form
Pharmacy replenishes request
Linen amp Instrument
check
Dirty Linen list formed amp
sent to Laundry amp received
later
Entry made
Expired
Separated
Entry made into RE-
AUTOCLAVE register
Send to CSSD
Not expired
Suitable for surgery
Patientrsquos Identification done amp verified
Surgery performed
Recording of all consumable used is recorded
Surgery completed
Surgery completed
Collection of OT Waste
Disposal by housekeeping
staff as per rules
Count of instruments
ldquoPostrdquo Column of Instrument
check list form completed
Transfer of patient to Recovery
room
Patient shifted to Ward SICU
Updation of records
Operation notes amp patientrsquos
record completed
Operation Daily charge bill formed
OT Drug inventory checked
Requisition send to
Pharmacy
OT Inventory replenished
OT Prepared for next surgery
Operation Theatre
Layout 1st flooor No of OTrsquos 6
General OTrsquos ndash 3 Eye OT- 1 Minor OT - 2
12
No of beds in Pre operative ward 7 No of beds in post operative wards 8 Utility room 1 Doctorrsquos Lounge 1 Nurse and Technician Lounge 1 Pantry 1 Sterile room 1 Changing rooms 4
Doctor (male) changing room 1 Doctor (female) changing room 1 Nurse (female) changing room 1 Technician + Nurse (male) changing room 1
Patient admission procedure in ICU
Physician
(Desiring admission of a patient in ICU)
contacts
Admission Office
Contacts for Bed Availability with
ICU
(Nurse ndash Ward Supervisor)
Beds Available No ICU Bed available
Admission done Admission office contacts
Nursing Administrator
Nursing Administrator starts
ICU patients ldquostatus evaluationrdquo
13
Any patient can be shifted None can be shifted
to Wards
Patient shifted to ICU after one patient Patient is stabilizedis shifted to Wards
Nursing Supervisor contacts
Administrator on-call
He authorize transfer of
patient to other hospital
HUMAN RESOURCE DEPARTMENT
Layout -Administrative Block Ground Floor
Total Staff 4
Organogram
Head Manager
HR Executives (3)
Trainee
Jobs amp Responsibilities
Manpower Planning
Internal Job Posting Process
CV Selection
Confirmation and Appraisal
Staff Queries
Follow up with selected candidates
Issuing of appointment letters
Disciplinary Policy
Leaves sanctioning
14
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Payroll
Budgeting for departments
Doctors payout
Duty roster
Issuing of Experience letters
STORES
Layout -New Stores Block
Staff 4
Hierarchy
Stores Manager
Store Supervisor
Bio medical Engineer GDA
Records Maintained
Goods Receipt Note Quotations Purchase Requests Capital Sanctioned Record
WORK FLOW
Department in need of material
Through HIS Indentation
or Requisition slip
Store15
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Issue Note Return File Purchase Receipt Purchase Orders
Store checks for the required material and the quantity
YES NO
Material issued and recorded in Issue Register Entry into Shortage Register
Record of the material entered HIS ldquoPurchase Requestrdquo is filled in HIS
Duties of Store In charge
Forecasting requirement Budgetary requirement Inventory control Stock verification Communicate the purchase
department about requirement Minimize pilferage
INFORMATION TECHNOLOGY (IT) DEPARTMENT
Layout -Ground Floor Main Building
Staff 3
Functions and responsibilities
To keep the servers alive
To keep the network alive
To keep internet connection alive
To take care of all the desktops amp laptops in the organization
To track the records of all the desktops
To keep an eye on the employees desktops
To resolve the complaints of the employees
Training of the other staff for the HIS
Major Work Areas General Administration amp HIS
16
Bin card maintained At a time 2800 items maintained in
the stores Random sample check to ensure the
genuinity and authenticity of product Disposal of surplus obsolete
Material Distribution
I) General Administration
Servers
Anti virus server Database server Application server Archive server
II) HIS (Hospital Information System)
Application by Avanttec
Billing Ward management Laboratory services Discharges + Medical Records Housekeeping Pharmacy Payroll Medical equipment
Access to Information
o User specific access according to their roles
HIS Backup
Done once a day Centralized database Internal backups
MEDICAL RECORD DEPARTMENT
Layout -MRD Block
Staff 3
Infrastructure
Desktop 1
Printer 1
Organogram Medical Records Officer Statistician
Medical Records Technician
17
Functions of MRD
To ensure that the Shija Hospital has complete amp accurate medical record for every
patient
Public dealings with respect to Bill verification MLC cases and dealing with
Summons to the doctors hospital
To maintain high level of confidentiality as far as patientrsquos records are concerned
To ensure that the records are Identified and stored safely to prevent unauthorized
changes and easily retrieved whenever required
Issuing Emergency Medical Birth amp Death certificates
To generate Bed Occupancy reports ALOS and other hospital statistics (daily amp
monthly)
Record Retention Periods
IP Record 05 years
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patient
CLINICAL NUTRITION amp DIETICS DEPARTMENT
Layout -Ground floor OPD Block
Head Dietician Ms Bimota
Functions
Catering to Inpatients Diet counseling Education Smooth provision of laid out diets to the patients To check the patient food for quality preparation presentation and packing Coordinating closely with the Nursing shift in charges for changes in the patientrsquos
diet or new admissions etc
Records Maintained
Diet order sheet Meal count register Store register Diet Sheets
18
Counseling Register
Type of Diet Diet Card Color
Normal White
Diabetes Mellitus Yellow
Chronic Renal Failure Blue
Liquid Diet Pink
Flowchart of Dietician and Inpatient Interaction
The Dietician takes details of new patients such as name UHID doctorrsquos name diagnosis and diet prescribed Then Dietician takes a detailed round wherein she meets every patient and determines patientsrsquo actual intake Dietician then provides nutritional counseling and education ensures patientsrsquo compliance to recommended diet She also recognizes personal eating and food preferences
Afterwards the dietician does nutritional screening in order to know about patientsrsquo clinical condition appetite and tolerance to food and acceptance to hospital diet personal preferences disliking and food allergies if any
After the rounds detailed food summary sheets are planned and prepared for every patient keeping in mind medical history and preferences of patient as well
SECURITY
Own security force not outsourced since 2009
Area of Operation (Present)
To deal with 3 ldquoMrdquo- Man Material amp Machinery
Visitorrsquos check Entry restriction at ICU gate Security for doctors and nurse quarter Surveillance of hospital through CCTVrsquos Theft Burglary Violence Material movements in amp out of the hospital Handling visitorrsquos pass In case of patientrsquos death handling emotional chaos of attendants Parking management and traffic control
19
HOUSEKEEPING
Status Own
Department Manager Mr Arju
FUNCTIONS
bull Clean Floor Wall Ceiling
bull Discharge Cleaning
bull Remove Garbage
bull Replace Supplies In Utility Rooms
bull Clean Housekeeping Equipments
bull Clean Room Wards Reception OT ICU Etc
bull Infection Control
bull Pest amp Rodent Control
bull Odour Control
LAUNDRY- Own
Department in charge- MsUmajini
Functions
Segregation of soiled and clean linen Traffic flow of linen before 8am Carrying the linen around the hospital Registered linen and purpose System of collection
o Colored bins
Infected linen handled separately- soaked in sodium hyperchloride Register maintained ndash separate for infected and un-infected linen Floor wise collection Different registers for each type of linen Separate people for ironing and drying from those who collect and wash
20
bull Environment Hygiene
bull Sanitation Hygiene
bull Checking Cleanliness Of All Areas
bull Control amp Reporting Of All
Maintenance Works
bull Hospital Waste Disposal
bull In-Service Training
bull Cooperation with Other Depts
Shared responsibility with nurses in charge Report- washing record submitted to HR dept Due list of linen- expected on Monday
GAPS IDENTIFIED IN STORES MANAGEMENT
No forecasting of requirement done ie Reorder Levels not defined
No analysis like ABC VED done for inventory control
Codification of items still in progress
HIS for Stores still not completely streamlined
AMC amp CMC not maintained for all
Some departments go beyond the indent allowance
Repair and Maintenance of equipments There are instruments which are not used at all
o Non-functionalo Repair requiredo Condemned
For Quality assurance o Quality calibration o Annual Maintenance Contracto Complete Maintenance Contract
Instruments go for regular servicing or they are serviced and examined regularly- Some machines are serviced in the hospital- eg computers printers patient
monitor BP instrument Alternative arrangements are available during that period of time- Patient
monitors from other wards are managedo No back up stock available
Shortage during repair period Patient monitor ndash completely mobile thus record maintenance difficult-
communication gap between the material managers 3 total staff
GAPS IDENTIFIED IN HMIS
Avanttec is a Chennai Based HIS system hence immediate access to providers not available
Strong foundation but HIS is still not fully streamlined Personnel shortage in the department No staff at night
21
GAPS IDENTIFIED IN LAUNDRY DEPARTMENT
6 Set rule per patient not followed Presently only 2 sets per patient No weighing scale No sewing machine for repair No supervision over measured use of detergent and other chemicals
PROJECT ndash 1
A Study on Discharge Procedure with Special Emphasis
on In-Patient Feedback
22
INTRODUCTION
The study was carried out in Shija Hospitals and Research Institute which is a 180 bedded hospital located in Manipur The Hospital is well known for its high end technology and services in the region The Hospital looks forward to continually develop its services and improve the facilities available in order to become a well known health service provider in the South East Asian region in the future The operations management had identified the discharge procedure as an area where there was a scope for improvement Hence the hospital had assigned the project to study the discharge procedure
Discharging a patient is an activity common to every hospital - small large community inner-city teaching or non-teaching The discharge process can have an impact on numerous factors such as patient satisfaction bed availability timely tests and procedures needed for discharge transportation and nursing home arrangements No matter what type of patient is being discharged (maternity medicine orthopedic neurologic) numerous activities must be completed for each before the patient can be released This work toward discharge day should begin upon admission
As part of a progress towards NABH accreditation at Shija Hospital the discharge process is one of the many process improvement projects The discharge process at this hospital also incorporates obtaining feedback from the in-patient regarding the services at the time of discharge Due to inappropriate management the hospital was facing an acute shortage in the feedback response from the patients
The management at the hospital realizes the need and importance of patient satisfaction and a need of a measurable index through feedback analysis In all service industries customer retention is a vital issue Hence the management wanted to do all that they could to obtain feedback from the patients at the time of discharge and make the discharge procedure as smooth as it can get
The objective of this study was to study the process of discharge and find out the probable reasons for the failure to attain feedback from the patients at the time of discharge
23
STUDY METHODOLOGY
AIM
To study the discharge procedure practiced at Shija Hospitals with special emphasis on
analyzing the reasons for the short-fall of In-Patient Feedback
OBJECTIVE
1 To find the steps followed during discharge of an in-patient2 To find the total time taken for a discharge of a single patient3 To find the contributing reasons for the short fall of in-patient feedback
received in the wards
RATIONALE
The discharge of a patient is a very important component of in-patient service and needs to be smooth and efficient On the other hand in-patient feedback is equally important as it provides the performance standards of the hospital which needs to be continually enhanced
METHODOLOGY
Study design-
Area- Shija Hospitals and Research Institute Manipur
Duration- From 11-04-2011 to 30-04-2011
Type of study- Observational and Survey study
Sample size-120 in-patients and the following hospital staff
Nurse Superintendant
RMOs on duty
Staff nurse
Front office executives
Service entry staff
Sampling Method-Convenience sampling
Study tool Questionnaire and personal interviews
24
Type of Data collected -
Interviewer guided questionnaires collected from patients by visiting the different wards
Personal interview of various hospital staff and officials involved in discharge procedure
DISCHARGE PROCESS
25
Doctor prescribes the discharge
Nurse informs the patient about the time of discharge
26
Staff nurse starts discharge formalities by
Asking the Resident Medical Officer Concerned Physician to
make discharge summary
Informing Dietician to make discharge diet report for patient
Counseling of the patient by the dietician and physiotherapist (if
physiotherapy is going on for patient)
Asking the service entry assistants to enter all the details regarding the
patients starting from the no of consultant visits to medicines
consumed
Sending to Pharmacy Daily Billing Activity Sheet
Daily Pharmacy BillsDischarge medication detailsMedicines left unconsumed
In Pharmacy Summary of Pharmacy Bill is prepared
Daily Billing Activity Sheet
Summarized Pharmacy Bill
Giving the feedback form to the patient attendants
Fig1 Communication channels during the discharge procedure
27
Billing department finalizes the bill
Payment taken by billing department from attendants
IPD Billing informs at the nursing station about the clearance of bill
Discharge Summary completion by Medical Transcriptionist
Nurse informs the patient amp patient changes clothes
Nurse checks the checklist given for discharge of patient
All medications + Investigations reports + Patientrsquos file given to the patient
Patient given amp explained about how to take the medications + any special instruction + follow up schedule
Patient Discharged
Collects the filled up feedback form from the patient attendants
There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays
Fig 2 A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital
020406080
100120
82
28 39
102
Compliance to discharge procedure
No
of p
atien
ts
Table1 Duration of various parameters related to discharge
28
DoctorNurseService ward boysBillingofficePatient
Various other departments of the hospital
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
Shija Hospitals and Research Institute
[April 11th ndash April 30th 2011]
1
ACKNOWLEDGEMENT
I am extremely indebted to all the professionals at Shija Hospitals and Research
Institute(SHRI) Manipur for sharing generously their knowledge and precious time
which inspired me to do best during summer training
I owe a great debt to DrKHPalin Managing Director and Chairman Shija Hospitals
and Research Institute Manipur for allowing me to do my summer training at the
hospital
I would also like to thank Dr Jugindra S Medical Superintendant and Ms Gayatri S
Head - Human Resource for their valuable guidance and at whose behest I received
tremendous assistance from other departments and their respective heads without which
the project would not have been completed
I would like to extend my special thanks to Ms Leema and Ms Arti Operations
Executives for sparing their valuable time and sharing with me the nuances of Hospital
operations and to all Executives of HR and Operations department for their support
and guidance throughout the summer training
Most importantly I would like to thank my mentor DrNeetu Purohit for her
unconditional support and motivation throughout the study period and
DrTanjul Saxena for her guidance on the report preparation and compilation of the
same
2
3
INTRODUCTION
Shija Hospitals is a pioneer ISO 90012008 certified private health institute in Manipur providing advanced healthcare technology with humane touch With the recognition by its customer for their holistic approach personal touch and technological advancement Shija Hospitals has been successful to a great extent in bringing highly needed medical technology in the region
Shija Hospitals located at environment friendly Langol Manipur is 200 bedded fully computerized institute having five modern operation theatres and 18 bedded fully functional ICU with all the latest life supporting equipments The hospital currently has 500 trained and dedicated staff
Shija Hospitals has becomes the only centre in Eastern India having under one-roof the total lsquostate of the artrsquo solution for treatment of stones at different locations of the body viz Lap-Chole Lap-CBD Exploration ERCP ESWL PCNL URS CLT and Lap-Urosurgery In Manipur it is the only private hospital having a consolidated Neuroscience centre under one roof has all the requisite resource in its Neurosurgery and Neurology unit Also SHRI is today a premier institute in India for minimally invasive surgery (MIS) viz Laparoscopic Surgery Arthroscopy Thoracoscopy Functional Endoscopic Sinus Surgery (FESS) and Upper and Lower GI Endoscopic procedures
To mention the recognition the hospital has been awarded Guinness World record for removing the largest neck tumor in the world from a 12 days old baby the tumor weighed 40 of the body weight
Facilities
Shija Hospitals Langol has the following departments ndash
Emergency and Trauma Care Pathology Radiology and imaging General Surgery Paediatric Dental ENT Obstetrics amp Gynaecology Ophthalmology Orthopaedics
4
Cardiology Anaesthesiology Medicine and Psychiatry Physiotherapy Surgical Gastroenterology Plastic Surgery Neurosurgery Neurology Urology
Vision 2015
To be a premium amp leading brand in healthcare services in the South East Asia recognized by our customers for our holistic approach personal touch and technological advancement
Mission
1048766 Customer needs 1048766 Research and development1048766 Quality system 1048766 Networking1048766 People development
Core Values -
Integrity Agility Passion for Excellence
5
FRONT OFFICE
In Patient Out PatientI) MAIN RECEPTION
Patient entry
Main reception area
Registered If Not Registered Registration done (At Main Reception)
OPD Billing
OPD Nursing Station
Consultation with Doctor
Advised Medication Advised Investigation Advised Admission
6
CMDMSConsultantsDuty DoctorsNursingMRDPharmacyOP PharmacyIP PharmacyCEOMaterials amp CRSFinanceAccountsCredit CellHRHR AdminRecruitment amp TrainingIR Appraisals Quality AssuranceEducationOperationsEngineering Maintenance amp ProjectsSecurity amp TransportITDHouse KeepingOut Patient ServicesIn Patient ServicesMarketingGR amp PRLiaison Advertising amp MediaSales Promotion amp CampsOrganization Chart
OPD Pharmacy Counter Sample collection Diagnostics Admission amp
Billing Counter
EXIT Report Collection
Registration Procedure
OPD requisition form to be filled
Submitted at the front office
A unique hospital ID is assigned
Cash Memo is issued
Mode of paymentCash payment was accepted Debit Credit card payment were under process
Waiting areaThere were three different OPD complexes
General OPD Eye OPD Obstetrics amp Gynecology
The General OPD waiting area would accommodate 150-200 people whereas the other OPDs had a capacity of 100 with no sub waiting area
In case of empanelled organizations
o The client has to produce an authorisation lettero Compendium of orders by Central Government Health Scheme is strictly
followedo Same charges and rates according to states are followedo In Manipur Delhi rates followed for all examinations and procedures
Payment method for clients from empanelled organizations
7
o IP payments are always due and payments have to be drawn from the empanelled organization
o OP payments have to be collected in cash from the patients which they can refund it on their own
o IP patients can give cheques
SHIJA MASTER HEALTH CHECK
Patient enters hospital
Registration done at Main reception
Billing done at IPD Counter
Sample collection done in Master Health Check Sample Collection Room
Sample sent to Lab
IN PATIENT DEPARTMENT
Categories of wards o Male General Ward
o Female General Ward
o Intensive Care Unit
o Neuro ICU
o Special rooms
o Cabins Twin sharing
o Deluxe Suites
8
In Patient Flow
Patient can come from
OPD ICU EMERGENCY POST -OPERATIVE
WARD
Admission counter - Nursing staff of ward changes the patient status in HIS by
Assistant gives a call doing ldquoCHECK-INrdquo of the patient received
to nursing station to - ICU EMERGENCY POST-OPERATIVE WARDS (from where
confirm for bed the patient is coming) changes the patient status in their
availability HIS by doing ldquoCHECK-OUTrdquo of the patient
Nursing staff prepares the roombed
Entry done in HIS Register White Board
Nurse informs the concerned Doctor
Doctor comes amp prescribes medication and investigation (if any)
Nurse writes the prescribed drugs on Indoor Drug Requisition Form
Ward boy goes and collects the drugs from Pharmacy
Nurse starts medication + prepares the patient for investigation (if any)
9
OPERATION THEATRE
Doctor sends request for OT Availability
OT Incharge confirms OT availability
Entry into OT Booking Register regarding
Scheduled surgeryrsquos Date Time Doctor Patient
A day before surgery verification of
Surgery Set Drugs
10
Instrument Verification
Verification of CSSD amp other consumables
In Non Usable condition
Discarded
Entry into Instrument
Replacement Register
Respective HOD informed
Request send to stores
Request sent
In usable condition
Suitable for use in surgery
Expiry check
Unused amp not
expired
Suitable for use
in surgery
Used
Depleted stock for surgery use
Requisition sent to Pharmacy through Drug Requisition Form
Pharmacy replenishes request
Sufficient stock Inventory
Linen amp Instrument
check
Dirty Linen list formed amp
sent to Laundry amp received
later
Entry made
Surgical set amp consumables prepared
Before start of surgery Inspection of
Before start of surgery Inspection of
Patientrsquos Records
Medical Gas
Pressure Leakage
Sterilization
Daily OT cleaning
records duly filled
Mopping of OT floor with
Bacillocid
Disinfection of OT items
listed on form with 2 Trigene
Instrument checklist
form
Completion of ldquoopened
byrdquo amp ldquocross checkedrdquo columns
Electrical points in
OT
Equipments
Transfer of equipment specific for
surgery into OT
OT Preparation done
Reception of Patient in Pre Operation area 20 minutes before surgery
Patient shifted to OT
11
In Non Usable condition
Discarded
Entry into Instrument
Replacement Register
Respective HOD informed
Request send to stores
Request sent
Depleted stock for surgery use
Requisition sent to Pharmacy through Drug Requisition Form
Pharmacy replenishes request
Linen amp Instrument
check
Dirty Linen list formed amp
sent to Laundry amp received
later
Entry made
Expired
Separated
Entry made into RE-
AUTOCLAVE register
Send to CSSD
Not expired
Suitable for surgery
Patientrsquos Identification done amp verified
Surgery performed
Recording of all consumable used is recorded
Surgery completed
Surgery completed
Collection of OT Waste
Disposal by housekeeping
staff as per rules
Count of instruments
ldquoPostrdquo Column of Instrument
check list form completed
Transfer of patient to Recovery
room
Patient shifted to Ward SICU
Updation of records
Operation notes amp patientrsquos
record completed
Operation Daily charge bill formed
OT Drug inventory checked
Requisition send to
Pharmacy
OT Inventory replenished
OT Prepared for next surgery
Operation Theatre
Layout 1st flooor No of OTrsquos 6
General OTrsquos ndash 3 Eye OT- 1 Minor OT - 2
12
No of beds in Pre operative ward 7 No of beds in post operative wards 8 Utility room 1 Doctorrsquos Lounge 1 Nurse and Technician Lounge 1 Pantry 1 Sterile room 1 Changing rooms 4
Doctor (male) changing room 1 Doctor (female) changing room 1 Nurse (female) changing room 1 Technician + Nurse (male) changing room 1
Patient admission procedure in ICU
Physician
(Desiring admission of a patient in ICU)
contacts
Admission Office
Contacts for Bed Availability with
ICU
(Nurse ndash Ward Supervisor)
Beds Available No ICU Bed available
Admission done Admission office contacts
Nursing Administrator
Nursing Administrator starts
ICU patients ldquostatus evaluationrdquo
13
Any patient can be shifted None can be shifted
to Wards
Patient shifted to ICU after one patient Patient is stabilizedis shifted to Wards
Nursing Supervisor contacts
Administrator on-call
He authorize transfer of
patient to other hospital
HUMAN RESOURCE DEPARTMENT
Layout -Administrative Block Ground Floor
Total Staff 4
Organogram
Head Manager
HR Executives (3)
Trainee
Jobs amp Responsibilities
Manpower Planning
Internal Job Posting Process
CV Selection
Confirmation and Appraisal
Staff Queries
Follow up with selected candidates
Issuing of appointment letters
Disciplinary Policy
Leaves sanctioning
14
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Payroll
Budgeting for departments
Doctors payout
Duty roster
Issuing of Experience letters
STORES
Layout -New Stores Block
Staff 4
Hierarchy
Stores Manager
Store Supervisor
Bio medical Engineer GDA
Records Maintained
Goods Receipt Note Quotations Purchase Requests Capital Sanctioned Record
WORK FLOW
Department in need of material
Through HIS Indentation
or Requisition slip
Store15
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Issue Note Return File Purchase Receipt Purchase Orders
Store checks for the required material and the quantity
YES NO
Material issued and recorded in Issue Register Entry into Shortage Register
Record of the material entered HIS ldquoPurchase Requestrdquo is filled in HIS
Duties of Store In charge
Forecasting requirement Budgetary requirement Inventory control Stock verification Communicate the purchase
department about requirement Minimize pilferage
INFORMATION TECHNOLOGY (IT) DEPARTMENT
Layout -Ground Floor Main Building
Staff 3
Functions and responsibilities
To keep the servers alive
To keep the network alive
To keep internet connection alive
To take care of all the desktops amp laptops in the organization
To track the records of all the desktops
To keep an eye on the employees desktops
To resolve the complaints of the employees
Training of the other staff for the HIS
Major Work Areas General Administration amp HIS
16
Bin card maintained At a time 2800 items maintained in
the stores Random sample check to ensure the
genuinity and authenticity of product Disposal of surplus obsolete
Material Distribution
I) General Administration
Servers
Anti virus server Database server Application server Archive server
II) HIS (Hospital Information System)
Application by Avanttec
Billing Ward management Laboratory services Discharges + Medical Records Housekeeping Pharmacy Payroll Medical equipment
Access to Information
o User specific access according to their roles
HIS Backup
Done once a day Centralized database Internal backups
MEDICAL RECORD DEPARTMENT
Layout -MRD Block
Staff 3
Infrastructure
Desktop 1
Printer 1
Organogram Medical Records Officer Statistician
Medical Records Technician
17
Functions of MRD
To ensure that the Shija Hospital has complete amp accurate medical record for every
patient
Public dealings with respect to Bill verification MLC cases and dealing with
Summons to the doctors hospital
To maintain high level of confidentiality as far as patientrsquos records are concerned
To ensure that the records are Identified and stored safely to prevent unauthorized
changes and easily retrieved whenever required
Issuing Emergency Medical Birth amp Death certificates
To generate Bed Occupancy reports ALOS and other hospital statistics (daily amp
monthly)
Record Retention Periods
IP Record 05 years
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patient
CLINICAL NUTRITION amp DIETICS DEPARTMENT
Layout -Ground floor OPD Block
Head Dietician Ms Bimota
Functions
Catering to Inpatients Diet counseling Education Smooth provision of laid out diets to the patients To check the patient food for quality preparation presentation and packing Coordinating closely with the Nursing shift in charges for changes in the patientrsquos
diet or new admissions etc
Records Maintained
Diet order sheet Meal count register Store register Diet Sheets
18
Counseling Register
Type of Diet Diet Card Color
Normal White
Diabetes Mellitus Yellow
Chronic Renal Failure Blue
Liquid Diet Pink
Flowchart of Dietician and Inpatient Interaction
The Dietician takes details of new patients such as name UHID doctorrsquos name diagnosis and diet prescribed Then Dietician takes a detailed round wherein she meets every patient and determines patientsrsquo actual intake Dietician then provides nutritional counseling and education ensures patientsrsquo compliance to recommended diet She also recognizes personal eating and food preferences
Afterwards the dietician does nutritional screening in order to know about patientsrsquo clinical condition appetite and tolerance to food and acceptance to hospital diet personal preferences disliking and food allergies if any
After the rounds detailed food summary sheets are planned and prepared for every patient keeping in mind medical history and preferences of patient as well
SECURITY
Own security force not outsourced since 2009
Area of Operation (Present)
To deal with 3 ldquoMrdquo- Man Material amp Machinery
Visitorrsquos check Entry restriction at ICU gate Security for doctors and nurse quarter Surveillance of hospital through CCTVrsquos Theft Burglary Violence Material movements in amp out of the hospital Handling visitorrsquos pass In case of patientrsquos death handling emotional chaos of attendants Parking management and traffic control
19
HOUSEKEEPING
Status Own
Department Manager Mr Arju
FUNCTIONS
bull Clean Floor Wall Ceiling
bull Discharge Cleaning
bull Remove Garbage
bull Replace Supplies In Utility Rooms
bull Clean Housekeeping Equipments
bull Clean Room Wards Reception OT ICU Etc
bull Infection Control
bull Pest amp Rodent Control
bull Odour Control
LAUNDRY- Own
Department in charge- MsUmajini
Functions
Segregation of soiled and clean linen Traffic flow of linen before 8am Carrying the linen around the hospital Registered linen and purpose System of collection
o Colored bins
Infected linen handled separately- soaked in sodium hyperchloride Register maintained ndash separate for infected and un-infected linen Floor wise collection Different registers for each type of linen Separate people for ironing and drying from those who collect and wash
20
bull Environment Hygiene
bull Sanitation Hygiene
bull Checking Cleanliness Of All Areas
bull Control amp Reporting Of All
Maintenance Works
bull Hospital Waste Disposal
bull In-Service Training
bull Cooperation with Other Depts
Shared responsibility with nurses in charge Report- washing record submitted to HR dept Due list of linen- expected on Monday
GAPS IDENTIFIED IN STORES MANAGEMENT
No forecasting of requirement done ie Reorder Levels not defined
No analysis like ABC VED done for inventory control
Codification of items still in progress
HIS for Stores still not completely streamlined
AMC amp CMC not maintained for all
Some departments go beyond the indent allowance
Repair and Maintenance of equipments There are instruments which are not used at all
o Non-functionalo Repair requiredo Condemned
For Quality assurance o Quality calibration o Annual Maintenance Contracto Complete Maintenance Contract
Instruments go for regular servicing or they are serviced and examined regularly- Some machines are serviced in the hospital- eg computers printers patient
monitor BP instrument Alternative arrangements are available during that period of time- Patient
monitors from other wards are managedo No back up stock available
Shortage during repair period Patient monitor ndash completely mobile thus record maintenance difficult-
communication gap between the material managers 3 total staff
GAPS IDENTIFIED IN HMIS
Avanttec is a Chennai Based HIS system hence immediate access to providers not available
Strong foundation but HIS is still not fully streamlined Personnel shortage in the department No staff at night
21
GAPS IDENTIFIED IN LAUNDRY DEPARTMENT
6 Set rule per patient not followed Presently only 2 sets per patient No weighing scale No sewing machine for repair No supervision over measured use of detergent and other chemicals
PROJECT ndash 1
A Study on Discharge Procedure with Special Emphasis
on In-Patient Feedback
22
INTRODUCTION
The study was carried out in Shija Hospitals and Research Institute which is a 180 bedded hospital located in Manipur The Hospital is well known for its high end technology and services in the region The Hospital looks forward to continually develop its services and improve the facilities available in order to become a well known health service provider in the South East Asian region in the future The operations management had identified the discharge procedure as an area where there was a scope for improvement Hence the hospital had assigned the project to study the discharge procedure
Discharging a patient is an activity common to every hospital - small large community inner-city teaching or non-teaching The discharge process can have an impact on numerous factors such as patient satisfaction bed availability timely tests and procedures needed for discharge transportation and nursing home arrangements No matter what type of patient is being discharged (maternity medicine orthopedic neurologic) numerous activities must be completed for each before the patient can be released This work toward discharge day should begin upon admission
As part of a progress towards NABH accreditation at Shija Hospital the discharge process is one of the many process improvement projects The discharge process at this hospital also incorporates obtaining feedback from the in-patient regarding the services at the time of discharge Due to inappropriate management the hospital was facing an acute shortage in the feedback response from the patients
The management at the hospital realizes the need and importance of patient satisfaction and a need of a measurable index through feedback analysis In all service industries customer retention is a vital issue Hence the management wanted to do all that they could to obtain feedback from the patients at the time of discharge and make the discharge procedure as smooth as it can get
The objective of this study was to study the process of discharge and find out the probable reasons for the failure to attain feedback from the patients at the time of discharge
23
STUDY METHODOLOGY
AIM
To study the discharge procedure practiced at Shija Hospitals with special emphasis on
analyzing the reasons for the short-fall of In-Patient Feedback
OBJECTIVE
1 To find the steps followed during discharge of an in-patient2 To find the total time taken for a discharge of a single patient3 To find the contributing reasons for the short fall of in-patient feedback
received in the wards
RATIONALE
The discharge of a patient is a very important component of in-patient service and needs to be smooth and efficient On the other hand in-patient feedback is equally important as it provides the performance standards of the hospital which needs to be continually enhanced
METHODOLOGY
Study design-
Area- Shija Hospitals and Research Institute Manipur
Duration- From 11-04-2011 to 30-04-2011
Type of study- Observational and Survey study
Sample size-120 in-patients and the following hospital staff
Nurse Superintendant
RMOs on duty
Staff nurse
Front office executives
Service entry staff
Sampling Method-Convenience sampling
Study tool Questionnaire and personal interviews
24
Type of Data collected -
Interviewer guided questionnaires collected from patients by visiting the different wards
Personal interview of various hospital staff and officials involved in discharge procedure
DISCHARGE PROCESS
25
Doctor prescribes the discharge
Nurse informs the patient about the time of discharge
26
Staff nurse starts discharge formalities by
Asking the Resident Medical Officer Concerned Physician to
make discharge summary
Informing Dietician to make discharge diet report for patient
Counseling of the patient by the dietician and physiotherapist (if
physiotherapy is going on for patient)
Asking the service entry assistants to enter all the details regarding the
patients starting from the no of consultant visits to medicines
consumed
Sending to Pharmacy Daily Billing Activity Sheet
Daily Pharmacy BillsDischarge medication detailsMedicines left unconsumed
In Pharmacy Summary of Pharmacy Bill is prepared
Daily Billing Activity Sheet
Summarized Pharmacy Bill
Giving the feedback form to the patient attendants
Fig1 Communication channels during the discharge procedure
27
Billing department finalizes the bill
Payment taken by billing department from attendants
IPD Billing informs at the nursing station about the clearance of bill
Discharge Summary completion by Medical Transcriptionist
Nurse informs the patient amp patient changes clothes
Nurse checks the checklist given for discharge of patient
All medications + Investigations reports + Patientrsquos file given to the patient
Patient given amp explained about how to take the medications + any special instruction + follow up schedule
Patient Discharged
Collects the filled up feedback form from the patient attendants
There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays
Fig 2 A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital
020406080
100120
82
28 39
102
Compliance to discharge procedure
No
of p
atien
ts
Table1 Duration of various parameters related to discharge
28
DoctorNurseService ward boysBillingofficePatient
Various other departments of the hospital
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
ACKNOWLEDGEMENT
I am extremely indebted to all the professionals at Shija Hospitals and Research
Institute(SHRI) Manipur for sharing generously their knowledge and precious time
which inspired me to do best during summer training
I owe a great debt to DrKHPalin Managing Director and Chairman Shija Hospitals
and Research Institute Manipur for allowing me to do my summer training at the
hospital
I would also like to thank Dr Jugindra S Medical Superintendant and Ms Gayatri S
Head - Human Resource for their valuable guidance and at whose behest I received
tremendous assistance from other departments and their respective heads without which
the project would not have been completed
I would like to extend my special thanks to Ms Leema and Ms Arti Operations
Executives for sparing their valuable time and sharing with me the nuances of Hospital
operations and to all Executives of HR and Operations department for their support
and guidance throughout the summer training
Most importantly I would like to thank my mentor DrNeetu Purohit for her
unconditional support and motivation throughout the study period and
DrTanjul Saxena for her guidance on the report preparation and compilation of the
same
2
3
INTRODUCTION
Shija Hospitals is a pioneer ISO 90012008 certified private health institute in Manipur providing advanced healthcare technology with humane touch With the recognition by its customer for their holistic approach personal touch and technological advancement Shija Hospitals has been successful to a great extent in bringing highly needed medical technology in the region
Shija Hospitals located at environment friendly Langol Manipur is 200 bedded fully computerized institute having five modern operation theatres and 18 bedded fully functional ICU with all the latest life supporting equipments The hospital currently has 500 trained and dedicated staff
Shija Hospitals has becomes the only centre in Eastern India having under one-roof the total lsquostate of the artrsquo solution for treatment of stones at different locations of the body viz Lap-Chole Lap-CBD Exploration ERCP ESWL PCNL URS CLT and Lap-Urosurgery In Manipur it is the only private hospital having a consolidated Neuroscience centre under one roof has all the requisite resource in its Neurosurgery and Neurology unit Also SHRI is today a premier institute in India for minimally invasive surgery (MIS) viz Laparoscopic Surgery Arthroscopy Thoracoscopy Functional Endoscopic Sinus Surgery (FESS) and Upper and Lower GI Endoscopic procedures
To mention the recognition the hospital has been awarded Guinness World record for removing the largest neck tumor in the world from a 12 days old baby the tumor weighed 40 of the body weight
Facilities
Shija Hospitals Langol has the following departments ndash
Emergency and Trauma Care Pathology Radiology and imaging General Surgery Paediatric Dental ENT Obstetrics amp Gynaecology Ophthalmology Orthopaedics
4
Cardiology Anaesthesiology Medicine and Psychiatry Physiotherapy Surgical Gastroenterology Plastic Surgery Neurosurgery Neurology Urology
Vision 2015
To be a premium amp leading brand in healthcare services in the South East Asia recognized by our customers for our holistic approach personal touch and technological advancement
Mission
1048766 Customer needs 1048766 Research and development1048766 Quality system 1048766 Networking1048766 People development
Core Values -
Integrity Agility Passion for Excellence
5
FRONT OFFICE
In Patient Out PatientI) MAIN RECEPTION
Patient entry
Main reception area
Registered If Not Registered Registration done (At Main Reception)
OPD Billing
OPD Nursing Station
Consultation with Doctor
Advised Medication Advised Investigation Advised Admission
6
CMDMSConsultantsDuty DoctorsNursingMRDPharmacyOP PharmacyIP PharmacyCEOMaterials amp CRSFinanceAccountsCredit CellHRHR AdminRecruitment amp TrainingIR Appraisals Quality AssuranceEducationOperationsEngineering Maintenance amp ProjectsSecurity amp TransportITDHouse KeepingOut Patient ServicesIn Patient ServicesMarketingGR amp PRLiaison Advertising amp MediaSales Promotion amp CampsOrganization Chart
OPD Pharmacy Counter Sample collection Diagnostics Admission amp
Billing Counter
EXIT Report Collection
Registration Procedure
OPD requisition form to be filled
Submitted at the front office
A unique hospital ID is assigned
Cash Memo is issued
Mode of paymentCash payment was accepted Debit Credit card payment were under process
Waiting areaThere were three different OPD complexes
General OPD Eye OPD Obstetrics amp Gynecology
The General OPD waiting area would accommodate 150-200 people whereas the other OPDs had a capacity of 100 with no sub waiting area
In case of empanelled organizations
o The client has to produce an authorisation lettero Compendium of orders by Central Government Health Scheme is strictly
followedo Same charges and rates according to states are followedo In Manipur Delhi rates followed for all examinations and procedures
Payment method for clients from empanelled organizations
7
o IP payments are always due and payments have to be drawn from the empanelled organization
o OP payments have to be collected in cash from the patients which they can refund it on their own
o IP patients can give cheques
SHIJA MASTER HEALTH CHECK
Patient enters hospital
Registration done at Main reception
Billing done at IPD Counter
Sample collection done in Master Health Check Sample Collection Room
Sample sent to Lab
IN PATIENT DEPARTMENT
Categories of wards o Male General Ward
o Female General Ward
o Intensive Care Unit
o Neuro ICU
o Special rooms
o Cabins Twin sharing
o Deluxe Suites
8
In Patient Flow
Patient can come from
OPD ICU EMERGENCY POST -OPERATIVE
WARD
Admission counter - Nursing staff of ward changes the patient status in HIS by
Assistant gives a call doing ldquoCHECK-INrdquo of the patient received
to nursing station to - ICU EMERGENCY POST-OPERATIVE WARDS (from where
confirm for bed the patient is coming) changes the patient status in their
availability HIS by doing ldquoCHECK-OUTrdquo of the patient
Nursing staff prepares the roombed
Entry done in HIS Register White Board
Nurse informs the concerned Doctor
Doctor comes amp prescribes medication and investigation (if any)
Nurse writes the prescribed drugs on Indoor Drug Requisition Form
Ward boy goes and collects the drugs from Pharmacy
Nurse starts medication + prepares the patient for investigation (if any)
9
OPERATION THEATRE
Doctor sends request for OT Availability
OT Incharge confirms OT availability
Entry into OT Booking Register regarding
Scheduled surgeryrsquos Date Time Doctor Patient
A day before surgery verification of
Surgery Set Drugs
10
Instrument Verification
Verification of CSSD amp other consumables
In Non Usable condition
Discarded
Entry into Instrument
Replacement Register
Respective HOD informed
Request send to stores
Request sent
In usable condition
Suitable for use in surgery
Expiry check
Unused amp not
expired
Suitable for use
in surgery
Used
Depleted stock for surgery use
Requisition sent to Pharmacy through Drug Requisition Form
Pharmacy replenishes request
Sufficient stock Inventory
Linen amp Instrument
check
Dirty Linen list formed amp
sent to Laundry amp received
later
Entry made
Surgical set amp consumables prepared
Before start of surgery Inspection of
Before start of surgery Inspection of
Patientrsquos Records
Medical Gas
Pressure Leakage
Sterilization
Daily OT cleaning
records duly filled
Mopping of OT floor with
Bacillocid
Disinfection of OT items
listed on form with 2 Trigene
Instrument checklist
form
Completion of ldquoopened
byrdquo amp ldquocross checkedrdquo columns
Electrical points in
OT
Equipments
Transfer of equipment specific for
surgery into OT
OT Preparation done
Reception of Patient in Pre Operation area 20 minutes before surgery
Patient shifted to OT
11
In Non Usable condition
Discarded
Entry into Instrument
Replacement Register
Respective HOD informed
Request send to stores
Request sent
Depleted stock for surgery use
Requisition sent to Pharmacy through Drug Requisition Form
Pharmacy replenishes request
Linen amp Instrument
check
Dirty Linen list formed amp
sent to Laundry amp received
later
Entry made
Expired
Separated
Entry made into RE-
AUTOCLAVE register
Send to CSSD
Not expired
Suitable for surgery
Patientrsquos Identification done amp verified
Surgery performed
Recording of all consumable used is recorded
Surgery completed
Surgery completed
Collection of OT Waste
Disposal by housekeeping
staff as per rules
Count of instruments
ldquoPostrdquo Column of Instrument
check list form completed
Transfer of patient to Recovery
room
Patient shifted to Ward SICU
Updation of records
Operation notes amp patientrsquos
record completed
Operation Daily charge bill formed
OT Drug inventory checked
Requisition send to
Pharmacy
OT Inventory replenished
OT Prepared for next surgery
Operation Theatre
Layout 1st flooor No of OTrsquos 6
General OTrsquos ndash 3 Eye OT- 1 Minor OT - 2
12
No of beds in Pre operative ward 7 No of beds in post operative wards 8 Utility room 1 Doctorrsquos Lounge 1 Nurse and Technician Lounge 1 Pantry 1 Sterile room 1 Changing rooms 4
Doctor (male) changing room 1 Doctor (female) changing room 1 Nurse (female) changing room 1 Technician + Nurse (male) changing room 1
Patient admission procedure in ICU
Physician
(Desiring admission of a patient in ICU)
contacts
Admission Office
Contacts for Bed Availability with
ICU
(Nurse ndash Ward Supervisor)
Beds Available No ICU Bed available
Admission done Admission office contacts
Nursing Administrator
Nursing Administrator starts
ICU patients ldquostatus evaluationrdquo
13
Any patient can be shifted None can be shifted
to Wards
Patient shifted to ICU after one patient Patient is stabilizedis shifted to Wards
Nursing Supervisor contacts
Administrator on-call
He authorize transfer of
patient to other hospital
HUMAN RESOURCE DEPARTMENT
Layout -Administrative Block Ground Floor
Total Staff 4
Organogram
Head Manager
HR Executives (3)
Trainee
Jobs amp Responsibilities
Manpower Planning
Internal Job Posting Process
CV Selection
Confirmation and Appraisal
Staff Queries
Follow up with selected candidates
Issuing of appointment letters
Disciplinary Policy
Leaves sanctioning
14
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Payroll
Budgeting for departments
Doctors payout
Duty roster
Issuing of Experience letters
STORES
Layout -New Stores Block
Staff 4
Hierarchy
Stores Manager
Store Supervisor
Bio medical Engineer GDA
Records Maintained
Goods Receipt Note Quotations Purchase Requests Capital Sanctioned Record
WORK FLOW
Department in need of material
Through HIS Indentation
or Requisition slip
Store15
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Issue Note Return File Purchase Receipt Purchase Orders
Store checks for the required material and the quantity
YES NO
Material issued and recorded in Issue Register Entry into Shortage Register
Record of the material entered HIS ldquoPurchase Requestrdquo is filled in HIS
Duties of Store In charge
Forecasting requirement Budgetary requirement Inventory control Stock verification Communicate the purchase
department about requirement Minimize pilferage
INFORMATION TECHNOLOGY (IT) DEPARTMENT
Layout -Ground Floor Main Building
Staff 3
Functions and responsibilities
To keep the servers alive
To keep the network alive
To keep internet connection alive
To take care of all the desktops amp laptops in the organization
To track the records of all the desktops
To keep an eye on the employees desktops
To resolve the complaints of the employees
Training of the other staff for the HIS
Major Work Areas General Administration amp HIS
16
Bin card maintained At a time 2800 items maintained in
the stores Random sample check to ensure the
genuinity and authenticity of product Disposal of surplus obsolete
Material Distribution
I) General Administration
Servers
Anti virus server Database server Application server Archive server
II) HIS (Hospital Information System)
Application by Avanttec
Billing Ward management Laboratory services Discharges + Medical Records Housekeeping Pharmacy Payroll Medical equipment
Access to Information
o User specific access according to their roles
HIS Backup
Done once a day Centralized database Internal backups
MEDICAL RECORD DEPARTMENT
Layout -MRD Block
Staff 3
Infrastructure
Desktop 1
Printer 1
Organogram Medical Records Officer Statistician
Medical Records Technician
17
Functions of MRD
To ensure that the Shija Hospital has complete amp accurate medical record for every
patient
Public dealings with respect to Bill verification MLC cases and dealing with
Summons to the doctors hospital
To maintain high level of confidentiality as far as patientrsquos records are concerned
To ensure that the records are Identified and stored safely to prevent unauthorized
changes and easily retrieved whenever required
Issuing Emergency Medical Birth amp Death certificates
To generate Bed Occupancy reports ALOS and other hospital statistics (daily amp
monthly)
Record Retention Periods
IP Record 05 years
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patient
CLINICAL NUTRITION amp DIETICS DEPARTMENT
Layout -Ground floor OPD Block
Head Dietician Ms Bimota
Functions
Catering to Inpatients Diet counseling Education Smooth provision of laid out diets to the patients To check the patient food for quality preparation presentation and packing Coordinating closely with the Nursing shift in charges for changes in the patientrsquos
diet or new admissions etc
Records Maintained
Diet order sheet Meal count register Store register Diet Sheets
18
Counseling Register
Type of Diet Diet Card Color
Normal White
Diabetes Mellitus Yellow
Chronic Renal Failure Blue
Liquid Diet Pink
Flowchart of Dietician and Inpatient Interaction
The Dietician takes details of new patients such as name UHID doctorrsquos name diagnosis and diet prescribed Then Dietician takes a detailed round wherein she meets every patient and determines patientsrsquo actual intake Dietician then provides nutritional counseling and education ensures patientsrsquo compliance to recommended diet She also recognizes personal eating and food preferences
Afterwards the dietician does nutritional screening in order to know about patientsrsquo clinical condition appetite and tolerance to food and acceptance to hospital diet personal preferences disliking and food allergies if any
After the rounds detailed food summary sheets are planned and prepared for every patient keeping in mind medical history and preferences of patient as well
SECURITY
Own security force not outsourced since 2009
Area of Operation (Present)
To deal with 3 ldquoMrdquo- Man Material amp Machinery
Visitorrsquos check Entry restriction at ICU gate Security for doctors and nurse quarter Surveillance of hospital through CCTVrsquos Theft Burglary Violence Material movements in amp out of the hospital Handling visitorrsquos pass In case of patientrsquos death handling emotional chaos of attendants Parking management and traffic control
19
HOUSEKEEPING
Status Own
Department Manager Mr Arju
FUNCTIONS
bull Clean Floor Wall Ceiling
bull Discharge Cleaning
bull Remove Garbage
bull Replace Supplies In Utility Rooms
bull Clean Housekeeping Equipments
bull Clean Room Wards Reception OT ICU Etc
bull Infection Control
bull Pest amp Rodent Control
bull Odour Control
LAUNDRY- Own
Department in charge- MsUmajini
Functions
Segregation of soiled and clean linen Traffic flow of linen before 8am Carrying the linen around the hospital Registered linen and purpose System of collection
o Colored bins
Infected linen handled separately- soaked in sodium hyperchloride Register maintained ndash separate for infected and un-infected linen Floor wise collection Different registers for each type of linen Separate people for ironing and drying from those who collect and wash
20
bull Environment Hygiene
bull Sanitation Hygiene
bull Checking Cleanliness Of All Areas
bull Control amp Reporting Of All
Maintenance Works
bull Hospital Waste Disposal
bull In-Service Training
bull Cooperation with Other Depts
Shared responsibility with nurses in charge Report- washing record submitted to HR dept Due list of linen- expected on Monday
GAPS IDENTIFIED IN STORES MANAGEMENT
No forecasting of requirement done ie Reorder Levels not defined
No analysis like ABC VED done for inventory control
Codification of items still in progress
HIS for Stores still not completely streamlined
AMC amp CMC not maintained for all
Some departments go beyond the indent allowance
Repair and Maintenance of equipments There are instruments which are not used at all
o Non-functionalo Repair requiredo Condemned
For Quality assurance o Quality calibration o Annual Maintenance Contracto Complete Maintenance Contract
Instruments go for regular servicing or they are serviced and examined regularly- Some machines are serviced in the hospital- eg computers printers patient
monitor BP instrument Alternative arrangements are available during that period of time- Patient
monitors from other wards are managedo No back up stock available
Shortage during repair period Patient monitor ndash completely mobile thus record maintenance difficult-
communication gap between the material managers 3 total staff
GAPS IDENTIFIED IN HMIS
Avanttec is a Chennai Based HIS system hence immediate access to providers not available
Strong foundation but HIS is still not fully streamlined Personnel shortage in the department No staff at night
21
GAPS IDENTIFIED IN LAUNDRY DEPARTMENT
6 Set rule per patient not followed Presently only 2 sets per patient No weighing scale No sewing machine for repair No supervision over measured use of detergent and other chemicals
PROJECT ndash 1
A Study on Discharge Procedure with Special Emphasis
on In-Patient Feedback
22
INTRODUCTION
The study was carried out in Shija Hospitals and Research Institute which is a 180 bedded hospital located in Manipur The Hospital is well known for its high end technology and services in the region The Hospital looks forward to continually develop its services and improve the facilities available in order to become a well known health service provider in the South East Asian region in the future The operations management had identified the discharge procedure as an area where there was a scope for improvement Hence the hospital had assigned the project to study the discharge procedure
Discharging a patient is an activity common to every hospital - small large community inner-city teaching or non-teaching The discharge process can have an impact on numerous factors such as patient satisfaction bed availability timely tests and procedures needed for discharge transportation and nursing home arrangements No matter what type of patient is being discharged (maternity medicine orthopedic neurologic) numerous activities must be completed for each before the patient can be released This work toward discharge day should begin upon admission
As part of a progress towards NABH accreditation at Shija Hospital the discharge process is one of the many process improvement projects The discharge process at this hospital also incorporates obtaining feedback from the in-patient regarding the services at the time of discharge Due to inappropriate management the hospital was facing an acute shortage in the feedback response from the patients
The management at the hospital realizes the need and importance of patient satisfaction and a need of a measurable index through feedback analysis In all service industries customer retention is a vital issue Hence the management wanted to do all that they could to obtain feedback from the patients at the time of discharge and make the discharge procedure as smooth as it can get
The objective of this study was to study the process of discharge and find out the probable reasons for the failure to attain feedback from the patients at the time of discharge
23
STUDY METHODOLOGY
AIM
To study the discharge procedure practiced at Shija Hospitals with special emphasis on
analyzing the reasons for the short-fall of In-Patient Feedback
OBJECTIVE
1 To find the steps followed during discharge of an in-patient2 To find the total time taken for a discharge of a single patient3 To find the contributing reasons for the short fall of in-patient feedback
received in the wards
RATIONALE
The discharge of a patient is a very important component of in-patient service and needs to be smooth and efficient On the other hand in-patient feedback is equally important as it provides the performance standards of the hospital which needs to be continually enhanced
METHODOLOGY
Study design-
Area- Shija Hospitals and Research Institute Manipur
Duration- From 11-04-2011 to 30-04-2011
Type of study- Observational and Survey study
Sample size-120 in-patients and the following hospital staff
Nurse Superintendant
RMOs on duty
Staff nurse
Front office executives
Service entry staff
Sampling Method-Convenience sampling
Study tool Questionnaire and personal interviews
24
Type of Data collected -
Interviewer guided questionnaires collected from patients by visiting the different wards
Personal interview of various hospital staff and officials involved in discharge procedure
DISCHARGE PROCESS
25
Doctor prescribes the discharge
Nurse informs the patient about the time of discharge
26
Staff nurse starts discharge formalities by
Asking the Resident Medical Officer Concerned Physician to
make discharge summary
Informing Dietician to make discharge diet report for patient
Counseling of the patient by the dietician and physiotherapist (if
physiotherapy is going on for patient)
Asking the service entry assistants to enter all the details regarding the
patients starting from the no of consultant visits to medicines
consumed
Sending to Pharmacy Daily Billing Activity Sheet
Daily Pharmacy BillsDischarge medication detailsMedicines left unconsumed
In Pharmacy Summary of Pharmacy Bill is prepared
Daily Billing Activity Sheet
Summarized Pharmacy Bill
Giving the feedback form to the patient attendants
Fig1 Communication channels during the discharge procedure
27
Billing department finalizes the bill
Payment taken by billing department from attendants
IPD Billing informs at the nursing station about the clearance of bill
Discharge Summary completion by Medical Transcriptionist
Nurse informs the patient amp patient changes clothes
Nurse checks the checklist given for discharge of patient
All medications + Investigations reports + Patientrsquos file given to the patient
Patient given amp explained about how to take the medications + any special instruction + follow up schedule
Patient Discharged
Collects the filled up feedback form from the patient attendants
There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays
Fig 2 A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital
020406080
100120
82
28 39
102
Compliance to discharge procedure
No
of p
atien
ts
Table1 Duration of various parameters related to discharge
28
DoctorNurseService ward boysBillingofficePatient
Various other departments of the hospital
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
3
INTRODUCTION
Shija Hospitals is a pioneer ISO 90012008 certified private health institute in Manipur providing advanced healthcare technology with humane touch With the recognition by its customer for their holistic approach personal touch and technological advancement Shija Hospitals has been successful to a great extent in bringing highly needed medical technology in the region
Shija Hospitals located at environment friendly Langol Manipur is 200 bedded fully computerized institute having five modern operation theatres and 18 bedded fully functional ICU with all the latest life supporting equipments The hospital currently has 500 trained and dedicated staff
Shija Hospitals has becomes the only centre in Eastern India having under one-roof the total lsquostate of the artrsquo solution for treatment of stones at different locations of the body viz Lap-Chole Lap-CBD Exploration ERCP ESWL PCNL URS CLT and Lap-Urosurgery In Manipur it is the only private hospital having a consolidated Neuroscience centre under one roof has all the requisite resource in its Neurosurgery and Neurology unit Also SHRI is today a premier institute in India for minimally invasive surgery (MIS) viz Laparoscopic Surgery Arthroscopy Thoracoscopy Functional Endoscopic Sinus Surgery (FESS) and Upper and Lower GI Endoscopic procedures
To mention the recognition the hospital has been awarded Guinness World record for removing the largest neck tumor in the world from a 12 days old baby the tumor weighed 40 of the body weight
Facilities
Shija Hospitals Langol has the following departments ndash
Emergency and Trauma Care Pathology Radiology and imaging General Surgery Paediatric Dental ENT Obstetrics amp Gynaecology Ophthalmology Orthopaedics
4
Cardiology Anaesthesiology Medicine and Psychiatry Physiotherapy Surgical Gastroenterology Plastic Surgery Neurosurgery Neurology Urology
Vision 2015
To be a premium amp leading brand in healthcare services in the South East Asia recognized by our customers for our holistic approach personal touch and technological advancement
Mission
1048766 Customer needs 1048766 Research and development1048766 Quality system 1048766 Networking1048766 People development
Core Values -
Integrity Agility Passion for Excellence
5
FRONT OFFICE
In Patient Out PatientI) MAIN RECEPTION
Patient entry
Main reception area
Registered If Not Registered Registration done (At Main Reception)
OPD Billing
OPD Nursing Station
Consultation with Doctor
Advised Medication Advised Investigation Advised Admission
6
CMDMSConsultantsDuty DoctorsNursingMRDPharmacyOP PharmacyIP PharmacyCEOMaterials amp CRSFinanceAccountsCredit CellHRHR AdminRecruitment amp TrainingIR Appraisals Quality AssuranceEducationOperationsEngineering Maintenance amp ProjectsSecurity amp TransportITDHouse KeepingOut Patient ServicesIn Patient ServicesMarketingGR amp PRLiaison Advertising amp MediaSales Promotion amp CampsOrganization Chart
OPD Pharmacy Counter Sample collection Diagnostics Admission amp
Billing Counter
EXIT Report Collection
Registration Procedure
OPD requisition form to be filled
Submitted at the front office
A unique hospital ID is assigned
Cash Memo is issued
Mode of paymentCash payment was accepted Debit Credit card payment were under process
Waiting areaThere were three different OPD complexes
General OPD Eye OPD Obstetrics amp Gynecology
The General OPD waiting area would accommodate 150-200 people whereas the other OPDs had a capacity of 100 with no sub waiting area
In case of empanelled organizations
o The client has to produce an authorisation lettero Compendium of orders by Central Government Health Scheme is strictly
followedo Same charges and rates according to states are followedo In Manipur Delhi rates followed for all examinations and procedures
Payment method for clients from empanelled organizations
7
o IP payments are always due and payments have to be drawn from the empanelled organization
o OP payments have to be collected in cash from the patients which they can refund it on their own
o IP patients can give cheques
SHIJA MASTER HEALTH CHECK
Patient enters hospital
Registration done at Main reception
Billing done at IPD Counter
Sample collection done in Master Health Check Sample Collection Room
Sample sent to Lab
IN PATIENT DEPARTMENT
Categories of wards o Male General Ward
o Female General Ward
o Intensive Care Unit
o Neuro ICU
o Special rooms
o Cabins Twin sharing
o Deluxe Suites
8
In Patient Flow
Patient can come from
OPD ICU EMERGENCY POST -OPERATIVE
WARD
Admission counter - Nursing staff of ward changes the patient status in HIS by
Assistant gives a call doing ldquoCHECK-INrdquo of the patient received
to nursing station to - ICU EMERGENCY POST-OPERATIVE WARDS (from where
confirm for bed the patient is coming) changes the patient status in their
availability HIS by doing ldquoCHECK-OUTrdquo of the patient
Nursing staff prepares the roombed
Entry done in HIS Register White Board
Nurse informs the concerned Doctor
Doctor comes amp prescribes medication and investigation (if any)
Nurse writes the prescribed drugs on Indoor Drug Requisition Form
Ward boy goes and collects the drugs from Pharmacy
Nurse starts medication + prepares the patient for investigation (if any)
9
OPERATION THEATRE
Doctor sends request for OT Availability
OT Incharge confirms OT availability
Entry into OT Booking Register regarding
Scheduled surgeryrsquos Date Time Doctor Patient
A day before surgery verification of
Surgery Set Drugs
10
Instrument Verification
Verification of CSSD amp other consumables
In Non Usable condition
Discarded
Entry into Instrument
Replacement Register
Respective HOD informed
Request send to stores
Request sent
In usable condition
Suitable for use in surgery
Expiry check
Unused amp not
expired
Suitable for use
in surgery
Used
Depleted stock for surgery use
Requisition sent to Pharmacy through Drug Requisition Form
Pharmacy replenishes request
Sufficient stock Inventory
Linen amp Instrument
check
Dirty Linen list formed amp
sent to Laundry amp received
later
Entry made
Surgical set amp consumables prepared
Before start of surgery Inspection of
Before start of surgery Inspection of
Patientrsquos Records
Medical Gas
Pressure Leakage
Sterilization
Daily OT cleaning
records duly filled
Mopping of OT floor with
Bacillocid
Disinfection of OT items
listed on form with 2 Trigene
Instrument checklist
form
Completion of ldquoopened
byrdquo amp ldquocross checkedrdquo columns
Electrical points in
OT
Equipments
Transfer of equipment specific for
surgery into OT
OT Preparation done
Reception of Patient in Pre Operation area 20 minutes before surgery
Patient shifted to OT
11
In Non Usable condition
Discarded
Entry into Instrument
Replacement Register
Respective HOD informed
Request send to stores
Request sent
Depleted stock for surgery use
Requisition sent to Pharmacy through Drug Requisition Form
Pharmacy replenishes request
Linen amp Instrument
check
Dirty Linen list formed amp
sent to Laundry amp received
later
Entry made
Expired
Separated
Entry made into RE-
AUTOCLAVE register
Send to CSSD
Not expired
Suitable for surgery
Patientrsquos Identification done amp verified
Surgery performed
Recording of all consumable used is recorded
Surgery completed
Surgery completed
Collection of OT Waste
Disposal by housekeeping
staff as per rules
Count of instruments
ldquoPostrdquo Column of Instrument
check list form completed
Transfer of patient to Recovery
room
Patient shifted to Ward SICU
Updation of records
Operation notes amp patientrsquos
record completed
Operation Daily charge bill formed
OT Drug inventory checked
Requisition send to
Pharmacy
OT Inventory replenished
OT Prepared for next surgery
Operation Theatre
Layout 1st flooor No of OTrsquos 6
General OTrsquos ndash 3 Eye OT- 1 Minor OT - 2
12
No of beds in Pre operative ward 7 No of beds in post operative wards 8 Utility room 1 Doctorrsquos Lounge 1 Nurse and Technician Lounge 1 Pantry 1 Sterile room 1 Changing rooms 4
Doctor (male) changing room 1 Doctor (female) changing room 1 Nurse (female) changing room 1 Technician + Nurse (male) changing room 1
Patient admission procedure in ICU
Physician
(Desiring admission of a patient in ICU)
contacts
Admission Office
Contacts for Bed Availability with
ICU
(Nurse ndash Ward Supervisor)
Beds Available No ICU Bed available
Admission done Admission office contacts
Nursing Administrator
Nursing Administrator starts
ICU patients ldquostatus evaluationrdquo
13
Any patient can be shifted None can be shifted
to Wards
Patient shifted to ICU after one patient Patient is stabilizedis shifted to Wards
Nursing Supervisor contacts
Administrator on-call
He authorize transfer of
patient to other hospital
HUMAN RESOURCE DEPARTMENT
Layout -Administrative Block Ground Floor
Total Staff 4
Organogram
Head Manager
HR Executives (3)
Trainee
Jobs amp Responsibilities
Manpower Planning
Internal Job Posting Process
CV Selection
Confirmation and Appraisal
Staff Queries
Follow up with selected candidates
Issuing of appointment letters
Disciplinary Policy
Leaves sanctioning
14
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Payroll
Budgeting for departments
Doctors payout
Duty roster
Issuing of Experience letters
STORES
Layout -New Stores Block
Staff 4
Hierarchy
Stores Manager
Store Supervisor
Bio medical Engineer GDA
Records Maintained
Goods Receipt Note Quotations Purchase Requests Capital Sanctioned Record
WORK FLOW
Department in need of material
Through HIS Indentation
or Requisition slip
Store15
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Issue Note Return File Purchase Receipt Purchase Orders
Store checks for the required material and the quantity
YES NO
Material issued and recorded in Issue Register Entry into Shortage Register
Record of the material entered HIS ldquoPurchase Requestrdquo is filled in HIS
Duties of Store In charge
Forecasting requirement Budgetary requirement Inventory control Stock verification Communicate the purchase
department about requirement Minimize pilferage
INFORMATION TECHNOLOGY (IT) DEPARTMENT
Layout -Ground Floor Main Building
Staff 3
Functions and responsibilities
To keep the servers alive
To keep the network alive
To keep internet connection alive
To take care of all the desktops amp laptops in the organization
To track the records of all the desktops
To keep an eye on the employees desktops
To resolve the complaints of the employees
Training of the other staff for the HIS
Major Work Areas General Administration amp HIS
16
Bin card maintained At a time 2800 items maintained in
the stores Random sample check to ensure the
genuinity and authenticity of product Disposal of surplus obsolete
Material Distribution
I) General Administration
Servers
Anti virus server Database server Application server Archive server
II) HIS (Hospital Information System)
Application by Avanttec
Billing Ward management Laboratory services Discharges + Medical Records Housekeeping Pharmacy Payroll Medical equipment
Access to Information
o User specific access according to their roles
HIS Backup
Done once a day Centralized database Internal backups
MEDICAL RECORD DEPARTMENT
Layout -MRD Block
Staff 3
Infrastructure
Desktop 1
Printer 1
Organogram Medical Records Officer Statistician
Medical Records Technician
17
Functions of MRD
To ensure that the Shija Hospital has complete amp accurate medical record for every
patient
Public dealings with respect to Bill verification MLC cases and dealing with
Summons to the doctors hospital
To maintain high level of confidentiality as far as patientrsquos records are concerned
To ensure that the records are Identified and stored safely to prevent unauthorized
changes and easily retrieved whenever required
Issuing Emergency Medical Birth amp Death certificates
To generate Bed Occupancy reports ALOS and other hospital statistics (daily amp
monthly)
Record Retention Periods
IP Record 05 years
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patient
CLINICAL NUTRITION amp DIETICS DEPARTMENT
Layout -Ground floor OPD Block
Head Dietician Ms Bimota
Functions
Catering to Inpatients Diet counseling Education Smooth provision of laid out diets to the patients To check the patient food for quality preparation presentation and packing Coordinating closely with the Nursing shift in charges for changes in the patientrsquos
diet or new admissions etc
Records Maintained
Diet order sheet Meal count register Store register Diet Sheets
18
Counseling Register
Type of Diet Diet Card Color
Normal White
Diabetes Mellitus Yellow
Chronic Renal Failure Blue
Liquid Diet Pink
Flowchart of Dietician and Inpatient Interaction
The Dietician takes details of new patients such as name UHID doctorrsquos name diagnosis and diet prescribed Then Dietician takes a detailed round wherein she meets every patient and determines patientsrsquo actual intake Dietician then provides nutritional counseling and education ensures patientsrsquo compliance to recommended diet She also recognizes personal eating and food preferences
Afterwards the dietician does nutritional screening in order to know about patientsrsquo clinical condition appetite and tolerance to food and acceptance to hospital diet personal preferences disliking and food allergies if any
After the rounds detailed food summary sheets are planned and prepared for every patient keeping in mind medical history and preferences of patient as well
SECURITY
Own security force not outsourced since 2009
Area of Operation (Present)
To deal with 3 ldquoMrdquo- Man Material amp Machinery
Visitorrsquos check Entry restriction at ICU gate Security for doctors and nurse quarter Surveillance of hospital through CCTVrsquos Theft Burglary Violence Material movements in amp out of the hospital Handling visitorrsquos pass In case of patientrsquos death handling emotional chaos of attendants Parking management and traffic control
19
HOUSEKEEPING
Status Own
Department Manager Mr Arju
FUNCTIONS
bull Clean Floor Wall Ceiling
bull Discharge Cleaning
bull Remove Garbage
bull Replace Supplies In Utility Rooms
bull Clean Housekeeping Equipments
bull Clean Room Wards Reception OT ICU Etc
bull Infection Control
bull Pest amp Rodent Control
bull Odour Control
LAUNDRY- Own
Department in charge- MsUmajini
Functions
Segregation of soiled and clean linen Traffic flow of linen before 8am Carrying the linen around the hospital Registered linen and purpose System of collection
o Colored bins
Infected linen handled separately- soaked in sodium hyperchloride Register maintained ndash separate for infected and un-infected linen Floor wise collection Different registers for each type of linen Separate people for ironing and drying from those who collect and wash
20
bull Environment Hygiene
bull Sanitation Hygiene
bull Checking Cleanliness Of All Areas
bull Control amp Reporting Of All
Maintenance Works
bull Hospital Waste Disposal
bull In-Service Training
bull Cooperation with Other Depts
Shared responsibility with nurses in charge Report- washing record submitted to HR dept Due list of linen- expected on Monday
GAPS IDENTIFIED IN STORES MANAGEMENT
No forecasting of requirement done ie Reorder Levels not defined
No analysis like ABC VED done for inventory control
Codification of items still in progress
HIS for Stores still not completely streamlined
AMC amp CMC not maintained for all
Some departments go beyond the indent allowance
Repair and Maintenance of equipments There are instruments which are not used at all
o Non-functionalo Repair requiredo Condemned
For Quality assurance o Quality calibration o Annual Maintenance Contracto Complete Maintenance Contract
Instruments go for regular servicing or they are serviced and examined regularly- Some machines are serviced in the hospital- eg computers printers patient
monitor BP instrument Alternative arrangements are available during that period of time- Patient
monitors from other wards are managedo No back up stock available
Shortage during repair period Patient monitor ndash completely mobile thus record maintenance difficult-
communication gap between the material managers 3 total staff
GAPS IDENTIFIED IN HMIS
Avanttec is a Chennai Based HIS system hence immediate access to providers not available
Strong foundation but HIS is still not fully streamlined Personnel shortage in the department No staff at night
21
GAPS IDENTIFIED IN LAUNDRY DEPARTMENT
6 Set rule per patient not followed Presently only 2 sets per patient No weighing scale No sewing machine for repair No supervision over measured use of detergent and other chemicals
PROJECT ndash 1
A Study on Discharge Procedure with Special Emphasis
on In-Patient Feedback
22
INTRODUCTION
The study was carried out in Shija Hospitals and Research Institute which is a 180 bedded hospital located in Manipur The Hospital is well known for its high end technology and services in the region The Hospital looks forward to continually develop its services and improve the facilities available in order to become a well known health service provider in the South East Asian region in the future The operations management had identified the discharge procedure as an area where there was a scope for improvement Hence the hospital had assigned the project to study the discharge procedure
Discharging a patient is an activity common to every hospital - small large community inner-city teaching or non-teaching The discharge process can have an impact on numerous factors such as patient satisfaction bed availability timely tests and procedures needed for discharge transportation and nursing home arrangements No matter what type of patient is being discharged (maternity medicine orthopedic neurologic) numerous activities must be completed for each before the patient can be released This work toward discharge day should begin upon admission
As part of a progress towards NABH accreditation at Shija Hospital the discharge process is one of the many process improvement projects The discharge process at this hospital also incorporates obtaining feedback from the in-patient regarding the services at the time of discharge Due to inappropriate management the hospital was facing an acute shortage in the feedback response from the patients
The management at the hospital realizes the need and importance of patient satisfaction and a need of a measurable index through feedback analysis In all service industries customer retention is a vital issue Hence the management wanted to do all that they could to obtain feedback from the patients at the time of discharge and make the discharge procedure as smooth as it can get
The objective of this study was to study the process of discharge and find out the probable reasons for the failure to attain feedback from the patients at the time of discharge
23
STUDY METHODOLOGY
AIM
To study the discharge procedure practiced at Shija Hospitals with special emphasis on
analyzing the reasons for the short-fall of In-Patient Feedback
OBJECTIVE
1 To find the steps followed during discharge of an in-patient2 To find the total time taken for a discharge of a single patient3 To find the contributing reasons for the short fall of in-patient feedback
received in the wards
RATIONALE
The discharge of a patient is a very important component of in-patient service and needs to be smooth and efficient On the other hand in-patient feedback is equally important as it provides the performance standards of the hospital which needs to be continually enhanced
METHODOLOGY
Study design-
Area- Shija Hospitals and Research Institute Manipur
Duration- From 11-04-2011 to 30-04-2011
Type of study- Observational and Survey study
Sample size-120 in-patients and the following hospital staff
Nurse Superintendant
RMOs on duty
Staff nurse
Front office executives
Service entry staff
Sampling Method-Convenience sampling
Study tool Questionnaire and personal interviews
24
Type of Data collected -
Interviewer guided questionnaires collected from patients by visiting the different wards
Personal interview of various hospital staff and officials involved in discharge procedure
DISCHARGE PROCESS
25
Doctor prescribes the discharge
Nurse informs the patient about the time of discharge
26
Staff nurse starts discharge formalities by
Asking the Resident Medical Officer Concerned Physician to
make discharge summary
Informing Dietician to make discharge diet report for patient
Counseling of the patient by the dietician and physiotherapist (if
physiotherapy is going on for patient)
Asking the service entry assistants to enter all the details regarding the
patients starting from the no of consultant visits to medicines
consumed
Sending to Pharmacy Daily Billing Activity Sheet
Daily Pharmacy BillsDischarge medication detailsMedicines left unconsumed
In Pharmacy Summary of Pharmacy Bill is prepared
Daily Billing Activity Sheet
Summarized Pharmacy Bill
Giving the feedback form to the patient attendants
Fig1 Communication channels during the discharge procedure
27
Billing department finalizes the bill
Payment taken by billing department from attendants
IPD Billing informs at the nursing station about the clearance of bill
Discharge Summary completion by Medical Transcriptionist
Nurse informs the patient amp patient changes clothes
Nurse checks the checklist given for discharge of patient
All medications + Investigations reports + Patientrsquos file given to the patient
Patient given amp explained about how to take the medications + any special instruction + follow up schedule
Patient Discharged
Collects the filled up feedback form from the patient attendants
There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays
Fig 2 A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital
020406080
100120
82
28 39
102
Compliance to discharge procedure
No
of p
atien
ts
Table1 Duration of various parameters related to discharge
28
DoctorNurseService ward boysBillingofficePatient
Various other departments of the hospital
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
INTRODUCTION
Shija Hospitals is a pioneer ISO 90012008 certified private health institute in Manipur providing advanced healthcare technology with humane touch With the recognition by its customer for their holistic approach personal touch and technological advancement Shija Hospitals has been successful to a great extent in bringing highly needed medical technology in the region
Shija Hospitals located at environment friendly Langol Manipur is 200 bedded fully computerized institute having five modern operation theatres and 18 bedded fully functional ICU with all the latest life supporting equipments The hospital currently has 500 trained and dedicated staff
Shija Hospitals has becomes the only centre in Eastern India having under one-roof the total lsquostate of the artrsquo solution for treatment of stones at different locations of the body viz Lap-Chole Lap-CBD Exploration ERCP ESWL PCNL URS CLT and Lap-Urosurgery In Manipur it is the only private hospital having a consolidated Neuroscience centre under one roof has all the requisite resource in its Neurosurgery and Neurology unit Also SHRI is today a premier institute in India for minimally invasive surgery (MIS) viz Laparoscopic Surgery Arthroscopy Thoracoscopy Functional Endoscopic Sinus Surgery (FESS) and Upper and Lower GI Endoscopic procedures
To mention the recognition the hospital has been awarded Guinness World record for removing the largest neck tumor in the world from a 12 days old baby the tumor weighed 40 of the body weight
Facilities
Shija Hospitals Langol has the following departments ndash
Emergency and Trauma Care Pathology Radiology and imaging General Surgery Paediatric Dental ENT Obstetrics amp Gynaecology Ophthalmology Orthopaedics
4
Cardiology Anaesthesiology Medicine and Psychiatry Physiotherapy Surgical Gastroenterology Plastic Surgery Neurosurgery Neurology Urology
Vision 2015
To be a premium amp leading brand in healthcare services in the South East Asia recognized by our customers for our holistic approach personal touch and technological advancement
Mission
1048766 Customer needs 1048766 Research and development1048766 Quality system 1048766 Networking1048766 People development
Core Values -
Integrity Agility Passion for Excellence
5
FRONT OFFICE
In Patient Out PatientI) MAIN RECEPTION
Patient entry
Main reception area
Registered If Not Registered Registration done (At Main Reception)
OPD Billing
OPD Nursing Station
Consultation with Doctor
Advised Medication Advised Investigation Advised Admission
6
CMDMSConsultantsDuty DoctorsNursingMRDPharmacyOP PharmacyIP PharmacyCEOMaterials amp CRSFinanceAccountsCredit CellHRHR AdminRecruitment amp TrainingIR Appraisals Quality AssuranceEducationOperationsEngineering Maintenance amp ProjectsSecurity amp TransportITDHouse KeepingOut Patient ServicesIn Patient ServicesMarketingGR amp PRLiaison Advertising amp MediaSales Promotion amp CampsOrganization Chart
OPD Pharmacy Counter Sample collection Diagnostics Admission amp
Billing Counter
EXIT Report Collection
Registration Procedure
OPD requisition form to be filled
Submitted at the front office
A unique hospital ID is assigned
Cash Memo is issued
Mode of paymentCash payment was accepted Debit Credit card payment were under process
Waiting areaThere were three different OPD complexes
General OPD Eye OPD Obstetrics amp Gynecology
The General OPD waiting area would accommodate 150-200 people whereas the other OPDs had a capacity of 100 with no sub waiting area
In case of empanelled organizations
o The client has to produce an authorisation lettero Compendium of orders by Central Government Health Scheme is strictly
followedo Same charges and rates according to states are followedo In Manipur Delhi rates followed for all examinations and procedures
Payment method for clients from empanelled organizations
7
o IP payments are always due and payments have to be drawn from the empanelled organization
o OP payments have to be collected in cash from the patients which they can refund it on their own
o IP patients can give cheques
SHIJA MASTER HEALTH CHECK
Patient enters hospital
Registration done at Main reception
Billing done at IPD Counter
Sample collection done in Master Health Check Sample Collection Room
Sample sent to Lab
IN PATIENT DEPARTMENT
Categories of wards o Male General Ward
o Female General Ward
o Intensive Care Unit
o Neuro ICU
o Special rooms
o Cabins Twin sharing
o Deluxe Suites
8
In Patient Flow
Patient can come from
OPD ICU EMERGENCY POST -OPERATIVE
WARD
Admission counter - Nursing staff of ward changes the patient status in HIS by
Assistant gives a call doing ldquoCHECK-INrdquo of the patient received
to nursing station to - ICU EMERGENCY POST-OPERATIVE WARDS (from where
confirm for bed the patient is coming) changes the patient status in their
availability HIS by doing ldquoCHECK-OUTrdquo of the patient
Nursing staff prepares the roombed
Entry done in HIS Register White Board
Nurse informs the concerned Doctor
Doctor comes amp prescribes medication and investigation (if any)
Nurse writes the prescribed drugs on Indoor Drug Requisition Form
Ward boy goes and collects the drugs from Pharmacy
Nurse starts medication + prepares the patient for investigation (if any)
9
OPERATION THEATRE
Doctor sends request for OT Availability
OT Incharge confirms OT availability
Entry into OT Booking Register regarding
Scheduled surgeryrsquos Date Time Doctor Patient
A day before surgery verification of
Surgery Set Drugs
10
Instrument Verification
Verification of CSSD amp other consumables
In Non Usable condition
Discarded
Entry into Instrument
Replacement Register
Respective HOD informed
Request send to stores
Request sent
In usable condition
Suitable for use in surgery
Expiry check
Unused amp not
expired
Suitable for use
in surgery
Used
Depleted stock for surgery use
Requisition sent to Pharmacy through Drug Requisition Form
Pharmacy replenishes request
Sufficient stock Inventory
Linen amp Instrument
check
Dirty Linen list formed amp
sent to Laundry amp received
later
Entry made
Surgical set amp consumables prepared
Before start of surgery Inspection of
Before start of surgery Inspection of
Patientrsquos Records
Medical Gas
Pressure Leakage
Sterilization
Daily OT cleaning
records duly filled
Mopping of OT floor with
Bacillocid
Disinfection of OT items
listed on form with 2 Trigene
Instrument checklist
form
Completion of ldquoopened
byrdquo amp ldquocross checkedrdquo columns
Electrical points in
OT
Equipments
Transfer of equipment specific for
surgery into OT
OT Preparation done
Reception of Patient in Pre Operation area 20 minutes before surgery
Patient shifted to OT
11
In Non Usable condition
Discarded
Entry into Instrument
Replacement Register
Respective HOD informed
Request send to stores
Request sent
Depleted stock for surgery use
Requisition sent to Pharmacy through Drug Requisition Form
Pharmacy replenishes request
Linen amp Instrument
check
Dirty Linen list formed amp
sent to Laundry amp received
later
Entry made
Expired
Separated
Entry made into RE-
AUTOCLAVE register
Send to CSSD
Not expired
Suitable for surgery
Patientrsquos Identification done amp verified
Surgery performed
Recording of all consumable used is recorded
Surgery completed
Surgery completed
Collection of OT Waste
Disposal by housekeeping
staff as per rules
Count of instruments
ldquoPostrdquo Column of Instrument
check list form completed
Transfer of patient to Recovery
room
Patient shifted to Ward SICU
Updation of records
Operation notes amp patientrsquos
record completed
Operation Daily charge bill formed
OT Drug inventory checked
Requisition send to
Pharmacy
OT Inventory replenished
OT Prepared for next surgery
Operation Theatre
Layout 1st flooor No of OTrsquos 6
General OTrsquos ndash 3 Eye OT- 1 Minor OT - 2
12
No of beds in Pre operative ward 7 No of beds in post operative wards 8 Utility room 1 Doctorrsquos Lounge 1 Nurse and Technician Lounge 1 Pantry 1 Sterile room 1 Changing rooms 4
Doctor (male) changing room 1 Doctor (female) changing room 1 Nurse (female) changing room 1 Technician + Nurse (male) changing room 1
Patient admission procedure in ICU
Physician
(Desiring admission of a patient in ICU)
contacts
Admission Office
Contacts for Bed Availability with
ICU
(Nurse ndash Ward Supervisor)
Beds Available No ICU Bed available
Admission done Admission office contacts
Nursing Administrator
Nursing Administrator starts
ICU patients ldquostatus evaluationrdquo
13
Any patient can be shifted None can be shifted
to Wards
Patient shifted to ICU after one patient Patient is stabilizedis shifted to Wards
Nursing Supervisor contacts
Administrator on-call
He authorize transfer of
patient to other hospital
HUMAN RESOURCE DEPARTMENT
Layout -Administrative Block Ground Floor
Total Staff 4
Organogram
Head Manager
HR Executives (3)
Trainee
Jobs amp Responsibilities
Manpower Planning
Internal Job Posting Process
CV Selection
Confirmation and Appraisal
Staff Queries
Follow up with selected candidates
Issuing of appointment letters
Disciplinary Policy
Leaves sanctioning
14
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Payroll
Budgeting for departments
Doctors payout
Duty roster
Issuing of Experience letters
STORES
Layout -New Stores Block
Staff 4
Hierarchy
Stores Manager
Store Supervisor
Bio medical Engineer GDA
Records Maintained
Goods Receipt Note Quotations Purchase Requests Capital Sanctioned Record
WORK FLOW
Department in need of material
Through HIS Indentation
or Requisition slip
Store15
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Issue Note Return File Purchase Receipt Purchase Orders
Store checks for the required material and the quantity
YES NO
Material issued and recorded in Issue Register Entry into Shortage Register
Record of the material entered HIS ldquoPurchase Requestrdquo is filled in HIS
Duties of Store In charge
Forecasting requirement Budgetary requirement Inventory control Stock verification Communicate the purchase
department about requirement Minimize pilferage
INFORMATION TECHNOLOGY (IT) DEPARTMENT
Layout -Ground Floor Main Building
Staff 3
Functions and responsibilities
To keep the servers alive
To keep the network alive
To keep internet connection alive
To take care of all the desktops amp laptops in the organization
To track the records of all the desktops
To keep an eye on the employees desktops
To resolve the complaints of the employees
Training of the other staff for the HIS
Major Work Areas General Administration amp HIS
16
Bin card maintained At a time 2800 items maintained in
the stores Random sample check to ensure the
genuinity and authenticity of product Disposal of surplus obsolete
Material Distribution
I) General Administration
Servers
Anti virus server Database server Application server Archive server
II) HIS (Hospital Information System)
Application by Avanttec
Billing Ward management Laboratory services Discharges + Medical Records Housekeeping Pharmacy Payroll Medical equipment
Access to Information
o User specific access according to their roles
HIS Backup
Done once a day Centralized database Internal backups
MEDICAL RECORD DEPARTMENT
Layout -MRD Block
Staff 3
Infrastructure
Desktop 1
Printer 1
Organogram Medical Records Officer Statistician
Medical Records Technician
17
Functions of MRD
To ensure that the Shija Hospital has complete amp accurate medical record for every
patient
Public dealings with respect to Bill verification MLC cases and dealing with
Summons to the doctors hospital
To maintain high level of confidentiality as far as patientrsquos records are concerned
To ensure that the records are Identified and stored safely to prevent unauthorized
changes and easily retrieved whenever required
Issuing Emergency Medical Birth amp Death certificates
To generate Bed Occupancy reports ALOS and other hospital statistics (daily amp
monthly)
Record Retention Periods
IP Record 05 years
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patient
CLINICAL NUTRITION amp DIETICS DEPARTMENT
Layout -Ground floor OPD Block
Head Dietician Ms Bimota
Functions
Catering to Inpatients Diet counseling Education Smooth provision of laid out diets to the patients To check the patient food for quality preparation presentation and packing Coordinating closely with the Nursing shift in charges for changes in the patientrsquos
diet or new admissions etc
Records Maintained
Diet order sheet Meal count register Store register Diet Sheets
18
Counseling Register
Type of Diet Diet Card Color
Normal White
Diabetes Mellitus Yellow
Chronic Renal Failure Blue
Liquid Diet Pink
Flowchart of Dietician and Inpatient Interaction
The Dietician takes details of new patients such as name UHID doctorrsquos name diagnosis and diet prescribed Then Dietician takes a detailed round wherein she meets every patient and determines patientsrsquo actual intake Dietician then provides nutritional counseling and education ensures patientsrsquo compliance to recommended diet She also recognizes personal eating and food preferences
Afterwards the dietician does nutritional screening in order to know about patientsrsquo clinical condition appetite and tolerance to food and acceptance to hospital diet personal preferences disliking and food allergies if any
After the rounds detailed food summary sheets are planned and prepared for every patient keeping in mind medical history and preferences of patient as well
SECURITY
Own security force not outsourced since 2009
Area of Operation (Present)
To deal with 3 ldquoMrdquo- Man Material amp Machinery
Visitorrsquos check Entry restriction at ICU gate Security for doctors and nurse quarter Surveillance of hospital through CCTVrsquos Theft Burglary Violence Material movements in amp out of the hospital Handling visitorrsquos pass In case of patientrsquos death handling emotional chaos of attendants Parking management and traffic control
19
HOUSEKEEPING
Status Own
Department Manager Mr Arju
FUNCTIONS
bull Clean Floor Wall Ceiling
bull Discharge Cleaning
bull Remove Garbage
bull Replace Supplies In Utility Rooms
bull Clean Housekeeping Equipments
bull Clean Room Wards Reception OT ICU Etc
bull Infection Control
bull Pest amp Rodent Control
bull Odour Control
LAUNDRY- Own
Department in charge- MsUmajini
Functions
Segregation of soiled and clean linen Traffic flow of linen before 8am Carrying the linen around the hospital Registered linen and purpose System of collection
o Colored bins
Infected linen handled separately- soaked in sodium hyperchloride Register maintained ndash separate for infected and un-infected linen Floor wise collection Different registers for each type of linen Separate people for ironing and drying from those who collect and wash
20
bull Environment Hygiene
bull Sanitation Hygiene
bull Checking Cleanliness Of All Areas
bull Control amp Reporting Of All
Maintenance Works
bull Hospital Waste Disposal
bull In-Service Training
bull Cooperation with Other Depts
Shared responsibility with nurses in charge Report- washing record submitted to HR dept Due list of linen- expected on Monday
GAPS IDENTIFIED IN STORES MANAGEMENT
No forecasting of requirement done ie Reorder Levels not defined
No analysis like ABC VED done for inventory control
Codification of items still in progress
HIS for Stores still not completely streamlined
AMC amp CMC not maintained for all
Some departments go beyond the indent allowance
Repair and Maintenance of equipments There are instruments which are not used at all
o Non-functionalo Repair requiredo Condemned
For Quality assurance o Quality calibration o Annual Maintenance Contracto Complete Maintenance Contract
Instruments go for regular servicing or they are serviced and examined regularly- Some machines are serviced in the hospital- eg computers printers patient
monitor BP instrument Alternative arrangements are available during that period of time- Patient
monitors from other wards are managedo No back up stock available
Shortage during repair period Patient monitor ndash completely mobile thus record maintenance difficult-
communication gap between the material managers 3 total staff
GAPS IDENTIFIED IN HMIS
Avanttec is a Chennai Based HIS system hence immediate access to providers not available
Strong foundation but HIS is still not fully streamlined Personnel shortage in the department No staff at night
21
GAPS IDENTIFIED IN LAUNDRY DEPARTMENT
6 Set rule per patient not followed Presently only 2 sets per patient No weighing scale No sewing machine for repair No supervision over measured use of detergent and other chemicals
PROJECT ndash 1
A Study on Discharge Procedure with Special Emphasis
on In-Patient Feedback
22
INTRODUCTION
The study was carried out in Shija Hospitals and Research Institute which is a 180 bedded hospital located in Manipur The Hospital is well known for its high end technology and services in the region The Hospital looks forward to continually develop its services and improve the facilities available in order to become a well known health service provider in the South East Asian region in the future The operations management had identified the discharge procedure as an area where there was a scope for improvement Hence the hospital had assigned the project to study the discharge procedure
Discharging a patient is an activity common to every hospital - small large community inner-city teaching or non-teaching The discharge process can have an impact on numerous factors such as patient satisfaction bed availability timely tests and procedures needed for discharge transportation and nursing home arrangements No matter what type of patient is being discharged (maternity medicine orthopedic neurologic) numerous activities must be completed for each before the patient can be released This work toward discharge day should begin upon admission
As part of a progress towards NABH accreditation at Shija Hospital the discharge process is one of the many process improvement projects The discharge process at this hospital also incorporates obtaining feedback from the in-patient regarding the services at the time of discharge Due to inappropriate management the hospital was facing an acute shortage in the feedback response from the patients
The management at the hospital realizes the need and importance of patient satisfaction and a need of a measurable index through feedback analysis In all service industries customer retention is a vital issue Hence the management wanted to do all that they could to obtain feedback from the patients at the time of discharge and make the discharge procedure as smooth as it can get
The objective of this study was to study the process of discharge and find out the probable reasons for the failure to attain feedback from the patients at the time of discharge
23
STUDY METHODOLOGY
AIM
To study the discharge procedure practiced at Shija Hospitals with special emphasis on
analyzing the reasons for the short-fall of In-Patient Feedback
OBJECTIVE
1 To find the steps followed during discharge of an in-patient2 To find the total time taken for a discharge of a single patient3 To find the contributing reasons for the short fall of in-patient feedback
received in the wards
RATIONALE
The discharge of a patient is a very important component of in-patient service and needs to be smooth and efficient On the other hand in-patient feedback is equally important as it provides the performance standards of the hospital which needs to be continually enhanced
METHODOLOGY
Study design-
Area- Shija Hospitals and Research Institute Manipur
Duration- From 11-04-2011 to 30-04-2011
Type of study- Observational and Survey study
Sample size-120 in-patients and the following hospital staff
Nurse Superintendant
RMOs on duty
Staff nurse
Front office executives
Service entry staff
Sampling Method-Convenience sampling
Study tool Questionnaire and personal interviews
24
Type of Data collected -
Interviewer guided questionnaires collected from patients by visiting the different wards
Personal interview of various hospital staff and officials involved in discharge procedure
DISCHARGE PROCESS
25
Doctor prescribes the discharge
Nurse informs the patient about the time of discharge
26
Staff nurse starts discharge formalities by
Asking the Resident Medical Officer Concerned Physician to
make discharge summary
Informing Dietician to make discharge diet report for patient
Counseling of the patient by the dietician and physiotherapist (if
physiotherapy is going on for patient)
Asking the service entry assistants to enter all the details regarding the
patients starting from the no of consultant visits to medicines
consumed
Sending to Pharmacy Daily Billing Activity Sheet
Daily Pharmacy BillsDischarge medication detailsMedicines left unconsumed
In Pharmacy Summary of Pharmacy Bill is prepared
Daily Billing Activity Sheet
Summarized Pharmacy Bill
Giving the feedback form to the patient attendants
Fig1 Communication channels during the discharge procedure
27
Billing department finalizes the bill
Payment taken by billing department from attendants
IPD Billing informs at the nursing station about the clearance of bill
Discharge Summary completion by Medical Transcriptionist
Nurse informs the patient amp patient changes clothes
Nurse checks the checklist given for discharge of patient
All medications + Investigations reports + Patientrsquos file given to the patient
Patient given amp explained about how to take the medications + any special instruction + follow up schedule
Patient Discharged
Collects the filled up feedback form from the patient attendants
There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays
Fig 2 A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital
020406080
100120
82
28 39
102
Compliance to discharge procedure
No
of p
atien
ts
Table1 Duration of various parameters related to discharge
28
DoctorNurseService ward boysBillingofficePatient
Various other departments of the hospital
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
Vision 2015
To be a premium amp leading brand in healthcare services in the South East Asia recognized by our customers for our holistic approach personal touch and technological advancement
Mission
1048766 Customer needs 1048766 Research and development1048766 Quality system 1048766 Networking1048766 People development
Core Values -
Integrity Agility Passion for Excellence
5
FRONT OFFICE
In Patient Out PatientI) MAIN RECEPTION
Patient entry
Main reception area
Registered If Not Registered Registration done (At Main Reception)
OPD Billing
OPD Nursing Station
Consultation with Doctor
Advised Medication Advised Investigation Advised Admission
6
CMDMSConsultantsDuty DoctorsNursingMRDPharmacyOP PharmacyIP PharmacyCEOMaterials amp CRSFinanceAccountsCredit CellHRHR AdminRecruitment amp TrainingIR Appraisals Quality AssuranceEducationOperationsEngineering Maintenance amp ProjectsSecurity amp TransportITDHouse KeepingOut Patient ServicesIn Patient ServicesMarketingGR amp PRLiaison Advertising amp MediaSales Promotion amp CampsOrganization Chart
OPD Pharmacy Counter Sample collection Diagnostics Admission amp
Billing Counter
EXIT Report Collection
Registration Procedure
OPD requisition form to be filled
Submitted at the front office
A unique hospital ID is assigned
Cash Memo is issued
Mode of paymentCash payment was accepted Debit Credit card payment were under process
Waiting areaThere were three different OPD complexes
General OPD Eye OPD Obstetrics amp Gynecology
The General OPD waiting area would accommodate 150-200 people whereas the other OPDs had a capacity of 100 with no sub waiting area
In case of empanelled organizations
o The client has to produce an authorisation lettero Compendium of orders by Central Government Health Scheme is strictly
followedo Same charges and rates according to states are followedo In Manipur Delhi rates followed for all examinations and procedures
Payment method for clients from empanelled organizations
7
o IP payments are always due and payments have to be drawn from the empanelled organization
o OP payments have to be collected in cash from the patients which they can refund it on their own
o IP patients can give cheques
SHIJA MASTER HEALTH CHECK
Patient enters hospital
Registration done at Main reception
Billing done at IPD Counter
Sample collection done in Master Health Check Sample Collection Room
Sample sent to Lab
IN PATIENT DEPARTMENT
Categories of wards o Male General Ward
o Female General Ward
o Intensive Care Unit
o Neuro ICU
o Special rooms
o Cabins Twin sharing
o Deluxe Suites
8
In Patient Flow
Patient can come from
OPD ICU EMERGENCY POST -OPERATIVE
WARD
Admission counter - Nursing staff of ward changes the patient status in HIS by
Assistant gives a call doing ldquoCHECK-INrdquo of the patient received
to nursing station to - ICU EMERGENCY POST-OPERATIVE WARDS (from where
confirm for bed the patient is coming) changes the patient status in their
availability HIS by doing ldquoCHECK-OUTrdquo of the patient
Nursing staff prepares the roombed
Entry done in HIS Register White Board
Nurse informs the concerned Doctor
Doctor comes amp prescribes medication and investigation (if any)
Nurse writes the prescribed drugs on Indoor Drug Requisition Form
Ward boy goes and collects the drugs from Pharmacy
Nurse starts medication + prepares the patient for investigation (if any)
9
OPERATION THEATRE
Doctor sends request for OT Availability
OT Incharge confirms OT availability
Entry into OT Booking Register regarding
Scheduled surgeryrsquos Date Time Doctor Patient
A day before surgery verification of
Surgery Set Drugs
10
Instrument Verification
Verification of CSSD amp other consumables
In Non Usable condition
Discarded
Entry into Instrument
Replacement Register
Respective HOD informed
Request send to stores
Request sent
In usable condition
Suitable for use in surgery
Expiry check
Unused amp not
expired
Suitable for use
in surgery
Used
Depleted stock for surgery use
Requisition sent to Pharmacy through Drug Requisition Form
Pharmacy replenishes request
Sufficient stock Inventory
Linen amp Instrument
check
Dirty Linen list formed amp
sent to Laundry amp received
later
Entry made
Surgical set amp consumables prepared
Before start of surgery Inspection of
Before start of surgery Inspection of
Patientrsquos Records
Medical Gas
Pressure Leakage
Sterilization
Daily OT cleaning
records duly filled
Mopping of OT floor with
Bacillocid
Disinfection of OT items
listed on form with 2 Trigene
Instrument checklist
form
Completion of ldquoopened
byrdquo amp ldquocross checkedrdquo columns
Electrical points in
OT
Equipments
Transfer of equipment specific for
surgery into OT
OT Preparation done
Reception of Patient in Pre Operation area 20 minutes before surgery
Patient shifted to OT
11
In Non Usable condition
Discarded
Entry into Instrument
Replacement Register
Respective HOD informed
Request send to stores
Request sent
Depleted stock for surgery use
Requisition sent to Pharmacy through Drug Requisition Form
Pharmacy replenishes request
Linen amp Instrument
check
Dirty Linen list formed amp
sent to Laundry amp received
later
Entry made
Expired
Separated
Entry made into RE-
AUTOCLAVE register
Send to CSSD
Not expired
Suitable for surgery
Patientrsquos Identification done amp verified
Surgery performed
Recording of all consumable used is recorded
Surgery completed
Surgery completed
Collection of OT Waste
Disposal by housekeeping
staff as per rules
Count of instruments
ldquoPostrdquo Column of Instrument
check list form completed
Transfer of patient to Recovery
room
Patient shifted to Ward SICU
Updation of records
Operation notes amp patientrsquos
record completed
Operation Daily charge bill formed
OT Drug inventory checked
Requisition send to
Pharmacy
OT Inventory replenished
OT Prepared for next surgery
Operation Theatre
Layout 1st flooor No of OTrsquos 6
General OTrsquos ndash 3 Eye OT- 1 Minor OT - 2
12
No of beds in Pre operative ward 7 No of beds in post operative wards 8 Utility room 1 Doctorrsquos Lounge 1 Nurse and Technician Lounge 1 Pantry 1 Sterile room 1 Changing rooms 4
Doctor (male) changing room 1 Doctor (female) changing room 1 Nurse (female) changing room 1 Technician + Nurse (male) changing room 1
Patient admission procedure in ICU
Physician
(Desiring admission of a patient in ICU)
contacts
Admission Office
Contacts for Bed Availability with
ICU
(Nurse ndash Ward Supervisor)
Beds Available No ICU Bed available
Admission done Admission office contacts
Nursing Administrator
Nursing Administrator starts
ICU patients ldquostatus evaluationrdquo
13
Any patient can be shifted None can be shifted
to Wards
Patient shifted to ICU after one patient Patient is stabilizedis shifted to Wards
Nursing Supervisor contacts
Administrator on-call
He authorize transfer of
patient to other hospital
HUMAN RESOURCE DEPARTMENT
Layout -Administrative Block Ground Floor
Total Staff 4
Organogram
Head Manager
HR Executives (3)
Trainee
Jobs amp Responsibilities
Manpower Planning
Internal Job Posting Process
CV Selection
Confirmation and Appraisal
Staff Queries
Follow up with selected candidates
Issuing of appointment letters
Disciplinary Policy
Leaves sanctioning
14
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Payroll
Budgeting for departments
Doctors payout
Duty roster
Issuing of Experience letters
STORES
Layout -New Stores Block
Staff 4
Hierarchy
Stores Manager
Store Supervisor
Bio medical Engineer GDA
Records Maintained
Goods Receipt Note Quotations Purchase Requests Capital Sanctioned Record
WORK FLOW
Department in need of material
Through HIS Indentation
or Requisition slip
Store15
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Issue Note Return File Purchase Receipt Purchase Orders
Store checks for the required material and the quantity
YES NO
Material issued and recorded in Issue Register Entry into Shortage Register
Record of the material entered HIS ldquoPurchase Requestrdquo is filled in HIS
Duties of Store In charge
Forecasting requirement Budgetary requirement Inventory control Stock verification Communicate the purchase
department about requirement Minimize pilferage
INFORMATION TECHNOLOGY (IT) DEPARTMENT
Layout -Ground Floor Main Building
Staff 3
Functions and responsibilities
To keep the servers alive
To keep the network alive
To keep internet connection alive
To take care of all the desktops amp laptops in the organization
To track the records of all the desktops
To keep an eye on the employees desktops
To resolve the complaints of the employees
Training of the other staff for the HIS
Major Work Areas General Administration amp HIS
16
Bin card maintained At a time 2800 items maintained in
the stores Random sample check to ensure the
genuinity and authenticity of product Disposal of surplus obsolete
Material Distribution
I) General Administration
Servers
Anti virus server Database server Application server Archive server
II) HIS (Hospital Information System)
Application by Avanttec
Billing Ward management Laboratory services Discharges + Medical Records Housekeeping Pharmacy Payroll Medical equipment
Access to Information
o User specific access according to their roles
HIS Backup
Done once a day Centralized database Internal backups
MEDICAL RECORD DEPARTMENT
Layout -MRD Block
Staff 3
Infrastructure
Desktop 1
Printer 1
Organogram Medical Records Officer Statistician
Medical Records Technician
17
Functions of MRD
To ensure that the Shija Hospital has complete amp accurate medical record for every
patient
Public dealings with respect to Bill verification MLC cases and dealing with
Summons to the doctors hospital
To maintain high level of confidentiality as far as patientrsquos records are concerned
To ensure that the records are Identified and stored safely to prevent unauthorized
changes and easily retrieved whenever required
Issuing Emergency Medical Birth amp Death certificates
To generate Bed Occupancy reports ALOS and other hospital statistics (daily amp
monthly)
Record Retention Periods
IP Record 05 years
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patient
CLINICAL NUTRITION amp DIETICS DEPARTMENT
Layout -Ground floor OPD Block
Head Dietician Ms Bimota
Functions
Catering to Inpatients Diet counseling Education Smooth provision of laid out diets to the patients To check the patient food for quality preparation presentation and packing Coordinating closely with the Nursing shift in charges for changes in the patientrsquos
diet or new admissions etc
Records Maintained
Diet order sheet Meal count register Store register Diet Sheets
18
Counseling Register
Type of Diet Diet Card Color
Normal White
Diabetes Mellitus Yellow
Chronic Renal Failure Blue
Liquid Diet Pink
Flowchart of Dietician and Inpatient Interaction
The Dietician takes details of new patients such as name UHID doctorrsquos name diagnosis and diet prescribed Then Dietician takes a detailed round wherein she meets every patient and determines patientsrsquo actual intake Dietician then provides nutritional counseling and education ensures patientsrsquo compliance to recommended diet She also recognizes personal eating and food preferences
Afterwards the dietician does nutritional screening in order to know about patientsrsquo clinical condition appetite and tolerance to food and acceptance to hospital diet personal preferences disliking and food allergies if any
After the rounds detailed food summary sheets are planned and prepared for every patient keeping in mind medical history and preferences of patient as well
SECURITY
Own security force not outsourced since 2009
Area of Operation (Present)
To deal with 3 ldquoMrdquo- Man Material amp Machinery
Visitorrsquos check Entry restriction at ICU gate Security for doctors and nurse quarter Surveillance of hospital through CCTVrsquos Theft Burglary Violence Material movements in amp out of the hospital Handling visitorrsquos pass In case of patientrsquos death handling emotional chaos of attendants Parking management and traffic control
19
HOUSEKEEPING
Status Own
Department Manager Mr Arju
FUNCTIONS
bull Clean Floor Wall Ceiling
bull Discharge Cleaning
bull Remove Garbage
bull Replace Supplies In Utility Rooms
bull Clean Housekeeping Equipments
bull Clean Room Wards Reception OT ICU Etc
bull Infection Control
bull Pest amp Rodent Control
bull Odour Control
LAUNDRY- Own
Department in charge- MsUmajini
Functions
Segregation of soiled and clean linen Traffic flow of linen before 8am Carrying the linen around the hospital Registered linen and purpose System of collection
o Colored bins
Infected linen handled separately- soaked in sodium hyperchloride Register maintained ndash separate for infected and un-infected linen Floor wise collection Different registers for each type of linen Separate people for ironing and drying from those who collect and wash
20
bull Environment Hygiene
bull Sanitation Hygiene
bull Checking Cleanliness Of All Areas
bull Control amp Reporting Of All
Maintenance Works
bull Hospital Waste Disposal
bull In-Service Training
bull Cooperation with Other Depts
Shared responsibility with nurses in charge Report- washing record submitted to HR dept Due list of linen- expected on Monday
GAPS IDENTIFIED IN STORES MANAGEMENT
No forecasting of requirement done ie Reorder Levels not defined
No analysis like ABC VED done for inventory control
Codification of items still in progress
HIS for Stores still not completely streamlined
AMC amp CMC not maintained for all
Some departments go beyond the indent allowance
Repair and Maintenance of equipments There are instruments which are not used at all
o Non-functionalo Repair requiredo Condemned
For Quality assurance o Quality calibration o Annual Maintenance Contracto Complete Maintenance Contract
Instruments go for regular servicing or they are serviced and examined regularly- Some machines are serviced in the hospital- eg computers printers patient
monitor BP instrument Alternative arrangements are available during that period of time- Patient
monitors from other wards are managedo No back up stock available
Shortage during repair period Patient monitor ndash completely mobile thus record maintenance difficult-
communication gap between the material managers 3 total staff
GAPS IDENTIFIED IN HMIS
Avanttec is a Chennai Based HIS system hence immediate access to providers not available
Strong foundation but HIS is still not fully streamlined Personnel shortage in the department No staff at night
21
GAPS IDENTIFIED IN LAUNDRY DEPARTMENT
6 Set rule per patient not followed Presently only 2 sets per patient No weighing scale No sewing machine for repair No supervision over measured use of detergent and other chemicals
PROJECT ndash 1
A Study on Discharge Procedure with Special Emphasis
on In-Patient Feedback
22
INTRODUCTION
The study was carried out in Shija Hospitals and Research Institute which is a 180 bedded hospital located in Manipur The Hospital is well known for its high end technology and services in the region The Hospital looks forward to continually develop its services and improve the facilities available in order to become a well known health service provider in the South East Asian region in the future The operations management had identified the discharge procedure as an area where there was a scope for improvement Hence the hospital had assigned the project to study the discharge procedure
Discharging a patient is an activity common to every hospital - small large community inner-city teaching or non-teaching The discharge process can have an impact on numerous factors such as patient satisfaction bed availability timely tests and procedures needed for discharge transportation and nursing home arrangements No matter what type of patient is being discharged (maternity medicine orthopedic neurologic) numerous activities must be completed for each before the patient can be released This work toward discharge day should begin upon admission
As part of a progress towards NABH accreditation at Shija Hospital the discharge process is one of the many process improvement projects The discharge process at this hospital also incorporates obtaining feedback from the in-patient regarding the services at the time of discharge Due to inappropriate management the hospital was facing an acute shortage in the feedback response from the patients
The management at the hospital realizes the need and importance of patient satisfaction and a need of a measurable index through feedback analysis In all service industries customer retention is a vital issue Hence the management wanted to do all that they could to obtain feedback from the patients at the time of discharge and make the discharge procedure as smooth as it can get
The objective of this study was to study the process of discharge and find out the probable reasons for the failure to attain feedback from the patients at the time of discharge
23
STUDY METHODOLOGY
AIM
To study the discharge procedure practiced at Shija Hospitals with special emphasis on
analyzing the reasons for the short-fall of In-Patient Feedback
OBJECTIVE
1 To find the steps followed during discharge of an in-patient2 To find the total time taken for a discharge of a single patient3 To find the contributing reasons for the short fall of in-patient feedback
received in the wards
RATIONALE
The discharge of a patient is a very important component of in-patient service and needs to be smooth and efficient On the other hand in-patient feedback is equally important as it provides the performance standards of the hospital which needs to be continually enhanced
METHODOLOGY
Study design-
Area- Shija Hospitals and Research Institute Manipur
Duration- From 11-04-2011 to 30-04-2011
Type of study- Observational and Survey study
Sample size-120 in-patients and the following hospital staff
Nurse Superintendant
RMOs on duty
Staff nurse
Front office executives
Service entry staff
Sampling Method-Convenience sampling
Study tool Questionnaire and personal interviews
24
Type of Data collected -
Interviewer guided questionnaires collected from patients by visiting the different wards
Personal interview of various hospital staff and officials involved in discharge procedure
DISCHARGE PROCESS
25
Doctor prescribes the discharge
Nurse informs the patient about the time of discharge
26
Staff nurse starts discharge formalities by
Asking the Resident Medical Officer Concerned Physician to
make discharge summary
Informing Dietician to make discharge diet report for patient
Counseling of the patient by the dietician and physiotherapist (if
physiotherapy is going on for patient)
Asking the service entry assistants to enter all the details regarding the
patients starting from the no of consultant visits to medicines
consumed
Sending to Pharmacy Daily Billing Activity Sheet
Daily Pharmacy BillsDischarge medication detailsMedicines left unconsumed
In Pharmacy Summary of Pharmacy Bill is prepared
Daily Billing Activity Sheet
Summarized Pharmacy Bill
Giving the feedback form to the patient attendants
Fig1 Communication channels during the discharge procedure
27
Billing department finalizes the bill
Payment taken by billing department from attendants
IPD Billing informs at the nursing station about the clearance of bill
Discharge Summary completion by Medical Transcriptionist
Nurse informs the patient amp patient changes clothes
Nurse checks the checklist given for discharge of patient
All medications + Investigations reports + Patientrsquos file given to the patient
Patient given amp explained about how to take the medications + any special instruction + follow up schedule
Patient Discharged
Collects the filled up feedback form from the patient attendants
There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays
Fig 2 A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital
020406080
100120
82
28 39
102
Compliance to discharge procedure
No
of p
atien
ts
Table1 Duration of various parameters related to discharge
28
DoctorNurseService ward boysBillingofficePatient
Various other departments of the hospital
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
FRONT OFFICE
In Patient Out PatientI) MAIN RECEPTION
Patient entry
Main reception area
Registered If Not Registered Registration done (At Main Reception)
OPD Billing
OPD Nursing Station
Consultation with Doctor
Advised Medication Advised Investigation Advised Admission
6
CMDMSConsultantsDuty DoctorsNursingMRDPharmacyOP PharmacyIP PharmacyCEOMaterials amp CRSFinanceAccountsCredit CellHRHR AdminRecruitment amp TrainingIR Appraisals Quality AssuranceEducationOperationsEngineering Maintenance amp ProjectsSecurity amp TransportITDHouse KeepingOut Patient ServicesIn Patient ServicesMarketingGR amp PRLiaison Advertising amp MediaSales Promotion amp CampsOrganization Chart
OPD Pharmacy Counter Sample collection Diagnostics Admission amp
Billing Counter
EXIT Report Collection
Registration Procedure
OPD requisition form to be filled
Submitted at the front office
A unique hospital ID is assigned
Cash Memo is issued
Mode of paymentCash payment was accepted Debit Credit card payment were under process
Waiting areaThere were three different OPD complexes
General OPD Eye OPD Obstetrics amp Gynecology
The General OPD waiting area would accommodate 150-200 people whereas the other OPDs had a capacity of 100 with no sub waiting area
In case of empanelled organizations
o The client has to produce an authorisation lettero Compendium of orders by Central Government Health Scheme is strictly
followedo Same charges and rates according to states are followedo In Manipur Delhi rates followed for all examinations and procedures
Payment method for clients from empanelled organizations
7
o IP payments are always due and payments have to be drawn from the empanelled organization
o OP payments have to be collected in cash from the patients which they can refund it on their own
o IP patients can give cheques
SHIJA MASTER HEALTH CHECK
Patient enters hospital
Registration done at Main reception
Billing done at IPD Counter
Sample collection done in Master Health Check Sample Collection Room
Sample sent to Lab
IN PATIENT DEPARTMENT
Categories of wards o Male General Ward
o Female General Ward
o Intensive Care Unit
o Neuro ICU
o Special rooms
o Cabins Twin sharing
o Deluxe Suites
8
In Patient Flow
Patient can come from
OPD ICU EMERGENCY POST -OPERATIVE
WARD
Admission counter - Nursing staff of ward changes the patient status in HIS by
Assistant gives a call doing ldquoCHECK-INrdquo of the patient received
to nursing station to - ICU EMERGENCY POST-OPERATIVE WARDS (from where
confirm for bed the patient is coming) changes the patient status in their
availability HIS by doing ldquoCHECK-OUTrdquo of the patient
Nursing staff prepares the roombed
Entry done in HIS Register White Board
Nurse informs the concerned Doctor
Doctor comes amp prescribes medication and investigation (if any)
Nurse writes the prescribed drugs on Indoor Drug Requisition Form
Ward boy goes and collects the drugs from Pharmacy
Nurse starts medication + prepares the patient for investigation (if any)
9
OPERATION THEATRE
Doctor sends request for OT Availability
OT Incharge confirms OT availability
Entry into OT Booking Register regarding
Scheduled surgeryrsquos Date Time Doctor Patient
A day before surgery verification of
Surgery Set Drugs
10
Instrument Verification
Verification of CSSD amp other consumables
In Non Usable condition
Discarded
Entry into Instrument
Replacement Register
Respective HOD informed
Request send to stores
Request sent
In usable condition
Suitable for use in surgery
Expiry check
Unused amp not
expired
Suitable for use
in surgery
Used
Depleted stock for surgery use
Requisition sent to Pharmacy through Drug Requisition Form
Pharmacy replenishes request
Sufficient stock Inventory
Linen amp Instrument
check
Dirty Linen list formed amp
sent to Laundry amp received
later
Entry made
Surgical set amp consumables prepared
Before start of surgery Inspection of
Before start of surgery Inspection of
Patientrsquos Records
Medical Gas
Pressure Leakage
Sterilization
Daily OT cleaning
records duly filled
Mopping of OT floor with
Bacillocid
Disinfection of OT items
listed on form with 2 Trigene
Instrument checklist
form
Completion of ldquoopened
byrdquo amp ldquocross checkedrdquo columns
Electrical points in
OT
Equipments
Transfer of equipment specific for
surgery into OT
OT Preparation done
Reception of Patient in Pre Operation area 20 minutes before surgery
Patient shifted to OT
11
In Non Usable condition
Discarded
Entry into Instrument
Replacement Register
Respective HOD informed
Request send to stores
Request sent
Depleted stock for surgery use
Requisition sent to Pharmacy through Drug Requisition Form
Pharmacy replenishes request
Linen amp Instrument
check
Dirty Linen list formed amp
sent to Laundry amp received
later
Entry made
Expired
Separated
Entry made into RE-
AUTOCLAVE register
Send to CSSD
Not expired
Suitable for surgery
Patientrsquos Identification done amp verified
Surgery performed
Recording of all consumable used is recorded
Surgery completed
Surgery completed
Collection of OT Waste
Disposal by housekeeping
staff as per rules
Count of instruments
ldquoPostrdquo Column of Instrument
check list form completed
Transfer of patient to Recovery
room
Patient shifted to Ward SICU
Updation of records
Operation notes amp patientrsquos
record completed
Operation Daily charge bill formed
OT Drug inventory checked
Requisition send to
Pharmacy
OT Inventory replenished
OT Prepared for next surgery
Operation Theatre
Layout 1st flooor No of OTrsquos 6
General OTrsquos ndash 3 Eye OT- 1 Minor OT - 2
12
No of beds in Pre operative ward 7 No of beds in post operative wards 8 Utility room 1 Doctorrsquos Lounge 1 Nurse and Technician Lounge 1 Pantry 1 Sterile room 1 Changing rooms 4
Doctor (male) changing room 1 Doctor (female) changing room 1 Nurse (female) changing room 1 Technician + Nurse (male) changing room 1
Patient admission procedure in ICU
Physician
(Desiring admission of a patient in ICU)
contacts
Admission Office
Contacts for Bed Availability with
ICU
(Nurse ndash Ward Supervisor)
Beds Available No ICU Bed available
Admission done Admission office contacts
Nursing Administrator
Nursing Administrator starts
ICU patients ldquostatus evaluationrdquo
13
Any patient can be shifted None can be shifted
to Wards
Patient shifted to ICU after one patient Patient is stabilizedis shifted to Wards
Nursing Supervisor contacts
Administrator on-call
He authorize transfer of
patient to other hospital
HUMAN RESOURCE DEPARTMENT
Layout -Administrative Block Ground Floor
Total Staff 4
Organogram
Head Manager
HR Executives (3)
Trainee
Jobs amp Responsibilities
Manpower Planning
Internal Job Posting Process
CV Selection
Confirmation and Appraisal
Staff Queries
Follow up with selected candidates
Issuing of appointment letters
Disciplinary Policy
Leaves sanctioning
14
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Payroll
Budgeting for departments
Doctors payout
Duty roster
Issuing of Experience letters
STORES
Layout -New Stores Block
Staff 4
Hierarchy
Stores Manager
Store Supervisor
Bio medical Engineer GDA
Records Maintained
Goods Receipt Note Quotations Purchase Requests Capital Sanctioned Record
WORK FLOW
Department in need of material
Through HIS Indentation
or Requisition slip
Store15
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Issue Note Return File Purchase Receipt Purchase Orders
Store checks for the required material and the quantity
YES NO
Material issued and recorded in Issue Register Entry into Shortage Register
Record of the material entered HIS ldquoPurchase Requestrdquo is filled in HIS
Duties of Store In charge
Forecasting requirement Budgetary requirement Inventory control Stock verification Communicate the purchase
department about requirement Minimize pilferage
INFORMATION TECHNOLOGY (IT) DEPARTMENT
Layout -Ground Floor Main Building
Staff 3
Functions and responsibilities
To keep the servers alive
To keep the network alive
To keep internet connection alive
To take care of all the desktops amp laptops in the organization
To track the records of all the desktops
To keep an eye on the employees desktops
To resolve the complaints of the employees
Training of the other staff for the HIS
Major Work Areas General Administration amp HIS
16
Bin card maintained At a time 2800 items maintained in
the stores Random sample check to ensure the
genuinity and authenticity of product Disposal of surplus obsolete
Material Distribution
I) General Administration
Servers
Anti virus server Database server Application server Archive server
II) HIS (Hospital Information System)
Application by Avanttec
Billing Ward management Laboratory services Discharges + Medical Records Housekeeping Pharmacy Payroll Medical equipment
Access to Information
o User specific access according to their roles
HIS Backup
Done once a day Centralized database Internal backups
MEDICAL RECORD DEPARTMENT
Layout -MRD Block
Staff 3
Infrastructure
Desktop 1
Printer 1
Organogram Medical Records Officer Statistician
Medical Records Technician
17
Functions of MRD
To ensure that the Shija Hospital has complete amp accurate medical record for every
patient
Public dealings with respect to Bill verification MLC cases and dealing with
Summons to the doctors hospital
To maintain high level of confidentiality as far as patientrsquos records are concerned
To ensure that the records are Identified and stored safely to prevent unauthorized
changes and easily retrieved whenever required
Issuing Emergency Medical Birth amp Death certificates
To generate Bed Occupancy reports ALOS and other hospital statistics (daily amp
monthly)
Record Retention Periods
IP Record 05 years
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patient
CLINICAL NUTRITION amp DIETICS DEPARTMENT
Layout -Ground floor OPD Block
Head Dietician Ms Bimota
Functions
Catering to Inpatients Diet counseling Education Smooth provision of laid out diets to the patients To check the patient food for quality preparation presentation and packing Coordinating closely with the Nursing shift in charges for changes in the patientrsquos
diet or new admissions etc
Records Maintained
Diet order sheet Meal count register Store register Diet Sheets
18
Counseling Register
Type of Diet Diet Card Color
Normal White
Diabetes Mellitus Yellow
Chronic Renal Failure Blue
Liquid Diet Pink
Flowchart of Dietician and Inpatient Interaction
The Dietician takes details of new patients such as name UHID doctorrsquos name diagnosis and diet prescribed Then Dietician takes a detailed round wherein she meets every patient and determines patientsrsquo actual intake Dietician then provides nutritional counseling and education ensures patientsrsquo compliance to recommended diet She also recognizes personal eating and food preferences
Afterwards the dietician does nutritional screening in order to know about patientsrsquo clinical condition appetite and tolerance to food and acceptance to hospital diet personal preferences disliking and food allergies if any
After the rounds detailed food summary sheets are planned and prepared for every patient keeping in mind medical history and preferences of patient as well
SECURITY
Own security force not outsourced since 2009
Area of Operation (Present)
To deal with 3 ldquoMrdquo- Man Material amp Machinery
Visitorrsquos check Entry restriction at ICU gate Security for doctors and nurse quarter Surveillance of hospital through CCTVrsquos Theft Burglary Violence Material movements in amp out of the hospital Handling visitorrsquos pass In case of patientrsquos death handling emotional chaos of attendants Parking management and traffic control
19
HOUSEKEEPING
Status Own
Department Manager Mr Arju
FUNCTIONS
bull Clean Floor Wall Ceiling
bull Discharge Cleaning
bull Remove Garbage
bull Replace Supplies In Utility Rooms
bull Clean Housekeeping Equipments
bull Clean Room Wards Reception OT ICU Etc
bull Infection Control
bull Pest amp Rodent Control
bull Odour Control
LAUNDRY- Own
Department in charge- MsUmajini
Functions
Segregation of soiled and clean linen Traffic flow of linen before 8am Carrying the linen around the hospital Registered linen and purpose System of collection
o Colored bins
Infected linen handled separately- soaked in sodium hyperchloride Register maintained ndash separate for infected and un-infected linen Floor wise collection Different registers for each type of linen Separate people for ironing and drying from those who collect and wash
20
bull Environment Hygiene
bull Sanitation Hygiene
bull Checking Cleanliness Of All Areas
bull Control amp Reporting Of All
Maintenance Works
bull Hospital Waste Disposal
bull In-Service Training
bull Cooperation with Other Depts
Shared responsibility with nurses in charge Report- washing record submitted to HR dept Due list of linen- expected on Monday
GAPS IDENTIFIED IN STORES MANAGEMENT
No forecasting of requirement done ie Reorder Levels not defined
No analysis like ABC VED done for inventory control
Codification of items still in progress
HIS for Stores still not completely streamlined
AMC amp CMC not maintained for all
Some departments go beyond the indent allowance
Repair and Maintenance of equipments There are instruments which are not used at all
o Non-functionalo Repair requiredo Condemned
For Quality assurance o Quality calibration o Annual Maintenance Contracto Complete Maintenance Contract
Instruments go for regular servicing or they are serviced and examined regularly- Some machines are serviced in the hospital- eg computers printers patient
monitor BP instrument Alternative arrangements are available during that period of time- Patient
monitors from other wards are managedo No back up stock available
Shortage during repair period Patient monitor ndash completely mobile thus record maintenance difficult-
communication gap between the material managers 3 total staff
GAPS IDENTIFIED IN HMIS
Avanttec is a Chennai Based HIS system hence immediate access to providers not available
Strong foundation but HIS is still not fully streamlined Personnel shortage in the department No staff at night
21
GAPS IDENTIFIED IN LAUNDRY DEPARTMENT
6 Set rule per patient not followed Presently only 2 sets per patient No weighing scale No sewing machine for repair No supervision over measured use of detergent and other chemicals
PROJECT ndash 1
A Study on Discharge Procedure with Special Emphasis
on In-Patient Feedback
22
INTRODUCTION
The study was carried out in Shija Hospitals and Research Institute which is a 180 bedded hospital located in Manipur The Hospital is well known for its high end technology and services in the region The Hospital looks forward to continually develop its services and improve the facilities available in order to become a well known health service provider in the South East Asian region in the future The operations management had identified the discharge procedure as an area where there was a scope for improvement Hence the hospital had assigned the project to study the discharge procedure
Discharging a patient is an activity common to every hospital - small large community inner-city teaching or non-teaching The discharge process can have an impact on numerous factors such as patient satisfaction bed availability timely tests and procedures needed for discharge transportation and nursing home arrangements No matter what type of patient is being discharged (maternity medicine orthopedic neurologic) numerous activities must be completed for each before the patient can be released This work toward discharge day should begin upon admission
As part of a progress towards NABH accreditation at Shija Hospital the discharge process is one of the many process improvement projects The discharge process at this hospital also incorporates obtaining feedback from the in-patient regarding the services at the time of discharge Due to inappropriate management the hospital was facing an acute shortage in the feedback response from the patients
The management at the hospital realizes the need and importance of patient satisfaction and a need of a measurable index through feedback analysis In all service industries customer retention is a vital issue Hence the management wanted to do all that they could to obtain feedback from the patients at the time of discharge and make the discharge procedure as smooth as it can get
The objective of this study was to study the process of discharge and find out the probable reasons for the failure to attain feedback from the patients at the time of discharge
23
STUDY METHODOLOGY
AIM
To study the discharge procedure practiced at Shija Hospitals with special emphasis on
analyzing the reasons for the short-fall of In-Patient Feedback
OBJECTIVE
1 To find the steps followed during discharge of an in-patient2 To find the total time taken for a discharge of a single patient3 To find the contributing reasons for the short fall of in-patient feedback
received in the wards
RATIONALE
The discharge of a patient is a very important component of in-patient service and needs to be smooth and efficient On the other hand in-patient feedback is equally important as it provides the performance standards of the hospital which needs to be continually enhanced
METHODOLOGY
Study design-
Area- Shija Hospitals and Research Institute Manipur
Duration- From 11-04-2011 to 30-04-2011
Type of study- Observational and Survey study
Sample size-120 in-patients and the following hospital staff
Nurse Superintendant
RMOs on duty
Staff nurse
Front office executives
Service entry staff
Sampling Method-Convenience sampling
Study tool Questionnaire and personal interviews
24
Type of Data collected -
Interviewer guided questionnaires collected from patients by visiting the different wards
Personal interview of various hospital staff and officials involved in discharge procedure
DISCHARGE PROCESS
25
Doctor prescribes the discharge
Nurse informs the patient about the time of discharge
26
Staff nurse starts discharge formalities by
Asking the Resident Medical Officer Concerned Physician to
make discharge summary
Informing Dietician to make discharge diet report for patient
Counseling of the patient by the dietician and physiotherapist (if
physiotherapy is going on for patient)
Asking the service entry assistants to enter all the details regarding the
patients starting from the no of consultant visits to medicines
consumed
Sending to Pharmacy Daily Billing Activity Sheet
Daily Pharmacy BillsDischarge medication detailsMedicines left unconsumed
In Pharmacy Summary of Pharmacy Bill is prepared
Daily Billing Activity Sheet
Summarized Pharmacy Bill
Giving the feedback form to the patient attendants
Fig1 Communication channels during the discharge procedure
27
Billing department finalizes the bill
Payment taken by billing department from attendants
IPD Billing informs at the nursing station about the clearance of bill
Discharge Summary completion by Medical Transcriptionist
Nurse informs the patient amp patient changes clothes
Nurse checks the checklist given for discharge of patient
All medications + Investigations reports + Patientrsquos file given to the patient
Patient given amp explained about how to take the medications + any special instruction + follow up schedule
Patient Discharged
Collects the filled up feedback form from the patient attendants
There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays
Fig 2 A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital
020406080
100120
82
28 39
102
Compliance to discharge procedure
No
of p
atien
ts
Table1 Duration of various parameters related to discharge
28
DoctorNurseService ward boysBillingofficePatient
Various other departments of the hospital
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
OPD Pharmacy Counter Sample collection Diagnostics Admission amp
Billing Counter
EXIT Report Collection
Registration Procedure
OPD requisition form to be filled
Submitted at the front office
A unique hospital ID is assigned
Cash Memo is issued
Mode of paymentCash payment was accepted Debit Credit card payment were under process
Waiting areaThere were three different OPD complexes
General OPD Eye OPD Obstetrics amp Gynecology
The General OPD waiting area would accommodate 150-200 people whereas the other OPDs had a capacity of 100 with no sub waiting area
In case of empanelled organizations
o The client has to produce an authorisation lettero Compendium of orders by Central Government Health Scheme is strictly
followedo Same charges and rates according to states are followedo In Manipur Delhi rates followed for all examinations and procedures
Payment method for clients from empanelled organizations
7
o IP payments are always due and payments have to be drawn from the empanelled organization
o OP payments have to be collected in cash from the patients which they can refund it on their own
o IP patients can give cheques
SHIJA MASTER HEALTH CHECK
Patient enters hospital
Registration done at Main reception
Billing done at IPD Counter
Sample collection done in Master Health Check Sample Collection Room
Sample sent to Lab
IN PATIENT DEPARTMENT
Categories of wards o Male General Ward
o Female General Ward
o Intensive Care Unit
o Neuro ICU
o Special rooms
o Cabins Twin sharing
o Deluxe Suites
8
In Patient Flow
Patient can come from
OPD ICU EMERGENCY POST -OPERATIVE
WARD
Admission counter - Nursing staff of ward changes the patient status in HIS by
Assistant gives a call doing ldquoCHECK-INrdquo of the patient received
to nursing station to - ICU EMERGENCY POST-OPERATIVE WARDS (from where
confirm for bed the patient is coming) changes the patient status in their
availability HIS by doing ldquoCHECK-OUTrdquo of the patient
Nursing staff prepares the roombed
Entry done in HIS Register White Board
Nurse informs the concerned Doctor
Doctor comes amp prescribes medication and investigation (if any)
Nurse writes the prescribed drugs on Indoor Drug Requisition Form
Ward boy goes and collects the drugs from Pharmacy
Nurse starts medication + prepares the patient for investigation (if any)
9
OPERATION THEATRE
Doctor sends request for OT Availability
OT Incharge confirms OT availability
Entry into OT Booking Register regarding
Scheduled surgeryrsquos Date Time Doctor Patient
A day before surgery verification of
Surgery Set Drugs
10
Instrument Verification
Verification of CSSD amp other consumables
In Non Usable condition
Discarded
Entry into Instrument
Replacement Register
Respective HOD informed
Request send to stores
Request sent
In usable condition
Suitable for use in surgery
Expiry check
Unused amp not
expired
Suitable for use
in surgery
Used
Depleted stock for surgery use
Requisition sent to Pharmacy through Drug Requisition Form
Pharmacy replenishes request
Sufficient stock Inventory
Linen amp Instrument
check
Dirty Linen list formed amp
sent to Laundry amp received
later
Entry made
Surgical set amp consumables prepared
Before start of surgery Inspection of
Before start of surgery Inspection of
Patientrsquos Records
Medical Gas
Pressure Leakage
Sterilization
Daily OT cleaning
records duly filled
Mopping of OT floor with
Bacillocid
Disinfection of OT items
listed on form with 2 Trigene
Instrument checklist
form
Completion of ldquoopened
byrdquo amp ldquocross checkedrdquo columns
Electrical points in
OT
Equipments
Transfer of equipment specific for
surgery into OT
OT Preparation done
Reception of Patient in Pre Operation area 20 minutes before surgery
Patient shifted to OT
11
In Non Usable condition
Discarded
Entry into Instrument
Replacement Register
Respective HOD informed
Request send to stores
Request sent
Depleted stock for surgery use
Requisition sent to Pharmacy through Drug Requisition Form
Pharmacy replenishes request
Linen amp Instrument
check
Dirty Linen list formed amp
sent to Laundry amp received
later
Entry made
Expired
Separated
Entry made into RE-
AUTOCLAVE register
Send to CSSD
Not expired
Suitable for surgery
Patientrsquos Identification done amp verified
Surgery performed
Recording of all consumable used is recorded
Surgery completed
Surgery completed
Collection of OT Waste
Disposal by housekeeping
staff as per rules
Count of instruments
ldquoPostrdquo Column of Instrument
check list form completed
Transfer of patient to Recovery
room
Patient shifted to Ward SICU
Updation of records
Operation notes amp patientrsquos
record completed
Operation Daily charge bill formed
OT Drug inventory checked
Requisition send to
Pharmacy
OT Inventory replenished
OT Prepared for next surgery
Operation Theatre
Layout 1st flooor No of OTrsquos 6
General OTrsquos ndash 3 Eye OT- 1 Minor OT - 2
12
No of beds in Pre operative ward 7 No of beds in post operative wards 8 Utility room 1 Doctorrsquos Lounge 1 Nurse and Technician Lounge 1 Pantry 1 Sterile room 1 Changing rooms 4
Doctor (male) changing room 1 Doctor (female) changing room 1 Nurse (female) changing room 1 Technician + Nurse (male) changing room 1
Patient admission procedure in ICU
Physician
(Desiring admission of a patient in ICU)
contacts
Admission Office
Contacts for Bed Availability with
ICU
(Nurse ndash Ward Supervisor)
Beds Available No ICU Bed available
Admission done Admission office contacts
Nursing Administrator
Nursing Administrator starts
ICU patients ldquostatus evaluationrdquo
13
Any patient can be shifted None can be shifted
to Wards
Patient shifted to ICU after one patient Patient is stabilizedis shifted to Wards
Nursing Supervisor contacts
Administrator on-call
He authorize transfer of
patient to other hospital
HUMAN RESOURCE DEPARTMENT
Layout -Administrative Block Ground Floor
Total Staff 4
Organogram
Head Manager
HR Executives (3)
Trainee
Jobs amp Responsibilities
Manpower Planning
Internal Job Posting Process
CV Selection
Confirmation and Appraisal
Staff Queries
Follow up with selected candidates
Issuing of appointment letters
Disciplinary Policy
Leaves sanctioning
14
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Payroll
Budgeting for departments
Doctors payout
Duty roster
Issuing of Experience letters
STORES
Layout -New Stores Block
Staff 4
Hierarchy
Stores Manager
Store Supervisor
Bio medical Engineer GDA
Records Maintained
Goods Receipt Note Quotations Purchase Requests Capital Sanctioned Record
WORK FLOW
Department in need of material
Through HIS Indentation
or Requisition slip
Store15
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Issue Note Return File Purchase Receipt Purchase Orders
Store checks for the required material and the quantity
YES NO
Material issued and recorded in Issue Register Entry into Shortage Register
Record of the material entered HIS ldquoPurchase Requestrdquo is filled in HIS
Duties of Store In charge
Forecasting requirement Budgetary requirement Inventory control Stock verification Communicate the purchase
department about requirement Minimize pilferage
INFORMATION TECHNOLOGY (IT) DEPARTMENT
Layout -Ground Floor Main Building
Staff 3
Functions and responsibilities
To keep the servers alive
To keep the network alive
To keep internet connection alive
To take care of all the desktops amp laptops in the organization
To track the records of all the desktops
To keep an eye on the employees desktops
To resolve the complaints of the employees
Training of the other staff for the HIS
Major Work Areas General Administration amp HIS
16
Bin card maintained At a time 2800 items maintained in
the stores Random sample check to ensure the
genuinity and authenticity of product Disposal of surplus obsolete
Material Distribution
I) General Administration
Servers
Anti virus server Database server Application server Archive server
II) HIS (Hospital Information System)
Application by Avanttec
Billing Ward management Laboratory services Discharges + Medical Records Housekeeping Pharmacy Payroll Medical equipment
Access to Information
o User specific access according to their roles
HIS Backup
Done once a day Centralized database Internal backups
MEDICAL RECORD DEPARTMENT
Layout -MRD Block
Staff 3
Infrastructure
Desktop 1
Printer 1
Organogram Medical Records Officer Statistician
Medical Records Technician
17
Functions of MRD
To ensure that the Shija Hospital has complete amp accurate medical record for every
patient
Public dealings with respect to Bill verification MLC cases and dealing with
Summons to the doctors hospital
To maintain high level of confidentiality as far as patientrsquos records are concerned
To ensure that the records are Identified and stored safely to prevent unauthorized
changes and easily retrieved whenever required
Issuing Emergency Medical Birth amp Death certificates
To generate Bed Occupancy reports ALOS and other hospital statistics (daily amp
monthly)
Record Retention Periods
IP Record 05 years
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patient
CLINICAL NUTRITION amp DIETICS DEPARTMENT
Layout -Ground floor OPD Block
Head Dietician Ms Bimota
Functions
Catering to Inpatients Diet counseling Education Smooth provision of laid out diets to the patients To check the patient food for quality preparation presentation and packing Coordinating closely with the Nursing shift in charges for changes in the patientrsquos
diet or new admissions etc
Records Maintained
Diet order sheet Meal count register Store register Diet Sheets
18
Counseling Register
Type of Diet Diet Card Color
Normal White
Diabetes Mellitus Yellow
Chronic Renal Failure Blue
Liquid Diet Pink
Flowchart of Dietician and Inpatient Interaction
The Dietician takes details of new patients such as name UHID doctorrsquos name diagnosis and diet prescribed Then Dietician takes a detailed round wherein she meets every patient and determines patientsrsquo actual intake Dietician then provides nutritional counseling and education ensures patientsrsquo compliance to recommended diet She also recognizes personal eating and food preferences
Afterwards the dietician does nutritional screening in order to know about patientsrsquo clinical condition appetite and tolerance to food and acceptance to hospital diet personal preferences disliking and food allergies if any
After the rounds detailed food summary sheets are planned and prepared for every patient keeping in mind medical history and preferences of patient as well
SECURITY
Own security force not outsourced since 2009
Area of Operation (Present)
To deal with 3 ldquoMrdquo- Man Material amp Machinery
Visitorrsquos check Entry restriction at ICU gate Security for doctors and nurse quarter Surveillance of hospital through CCTVrsquos Theft Burglary Violence Material movements in amp out of the hospital Handling visitorrsquos pass In case of patientrsquos death handling emotional chaos of attendants Parking management and traffic control
19
HOUSEKEEPING
Status Own
Department Manager Mr Arju
FUNCTIONS
bull Clean Floor Wall Ceiling
bull Discharge Cleaning
bull Remove Garbage
bull Replace Supplies In Utility Rooms
bull Clean Housekeeping Equipments
bull Clean Room Wards Reception OT ICU Etc
bull Infection Control
bull Pest amp Rodent Control
bull Odour Control
LAUNDRY- Own
Department in charge- MsUmajini
Functions
Segregation of soiled and clean linen Traffic flow of linen before 8am Carrying the linen around the hospital Registered linen and purpose System of collection
o Colored bins
Infected linen handled separately- soaked in sodium hyperchloride Register maintained ndash separate for infected and un-infected linen Floor wise collection Different registers for each type of linen Separate people for ironing and drying from those who collect and wash
20
bull Environment Hygiene
bull Sanitation Hygiene
bull Checking Cleanliness Of All Areas
bull Control amp Reporting Of All
Maintenance Works
bull Hospital Waste Disposal
bull In-Service Training
bull Cooperation with Other Depts
Shared responsibility with nurses in charge Report- washing record submitted to HR dept Due list of linen- expected on Monday
GAPS IDENTIFIED IN STORES MANAGEMENT
No forecasting of requirement done ie Reorder Levels not defined
No analysis like ABC VED done for inventory control
Codification of items still in progress
HIS for Stores still not completely streamlined
AMC amp CMC not maintained for all
Some departments go beyond the indent allowance
Repair and Maintenance of equipments There are instruments which are not used at all
o Non-functionalo Repair requiredo Condemned
For Quality assurance o Quality calibration o Annual Maintenance Contracto Complete Maintenance Contract
Instruments go for regular servicing or they are serviced and examined regularly- Some machines are serviced in the hospital- eg computers printers patient
monitor BP instrument Alternative arrangements are available during that period of time- Patient
monitors from other wards are managedo No back up stock available
Shortage during repair period Patient monitor ndash completely mobile thus record maintenance difficult-
communication gap between the material managers 3 total staff
GAPS IDENTIFIED IN HMIS
Avanttec is a Chennai Based HIS system hence immediate access to providers not available
Strong foundation but HIS is still not fully streamlined Personnel shortage in the department No staff at night
21
GAPS IDENTIFIED IN LAUNDRY DEPARTMENT
6 Set rule per patient not followed Presently only 2 sets per patient No weighing scale No sewing machine for repair No supervision over measured use of detergent and other chemicals
PROJECT ndash 1
A Study on Discharge Procedure with Special Emphasis
on In-Patient Feedback
22
INTRODUCTION
The study was carried out in Shija Hospitals and Research Institute which is a 180 bedded hospital located in Manipur The Hospital is well known for its high end technology and services in the region The Hospital looks forward to continually develop its services and improve the facilities available in order to become a well known health service provider in the South East Asian region in the future The operations management had identified the discharge procedure as an area where there was a scope for improvement Hence the hospital had assigned the project to study the discharge procedure
Discharging a patient is an activity common to every hospital - small large community inner-city teaching or non-teaching The discharge process can have an impact on numerous factors such as patient satisfaction bed availability timely tests and procedures needed for discharge transportation and nursing home arrangements No matter what type of patient is being discharged (maternity medicine orthopedic neurologic) numerous activities must be completed for each before the patient can be released This work toward discharge day should begin upon admission
As part of a progress towards NABH accreditation at Shija Hospital the discharge process is one of the many process improvement projects The discharge process at this hospital also incorporates obtaining feedback from the in-patient regarding the services at the time of discharge Due to inappropriate management the hospital was facing an acute shortage in the feedback response from the patients
The management at the hospital realizes the need and importance of patient satisfaction and a need of a measurable index through feedback analysis In all service industries customer retention is a vital issue Hence the management wanted to do all that they could to obtain feedback from the patients at the time of discharge and make the discharge procedure as smooth as it can get
The objective of this study was to study the process of discharge and find out the probable reasons for the failure to attain feedback from the patients at the time of discharge
23
STUDY METHODOLOGY
AIM
To study the discharge procedure practiced at Shija Hospitals with special emphasis on
analyzing the reasons for the short-fall of In-Patient Feedback
OBJECTIVE
1 To find the steps followed during discharge of an in-patient2 To find the total time taken for a discharge of a single patient3 To find the contributing reasons for the short fall of in-patient feedback
received in the wards
RATIONALE
The discharge of a patient is a very important component of in-patient service and needs to be smooth and efficient On the other hand in-patient feedback is equally important as it provides the performance standards of the hospital which needs to be continually enhanced
METHODOLOGY
Study design-
Area- Shija Hospitals and Research Institute Manipur
Duration- From 11-04-2011 to 30-04-2011
Type of study- Observational and Survey study
Sample size-120 in-patients and the following hospital staff
Nurse Superintendant
RMOs on duty
Staff nurse
Front office executives
Service entry staff
Sampling Method-Convenience sampling
Study tool Questionnaire and personal interviews
24
Type of Data collected -
Interviewer guided questionnaires collected from patients by visiting the different wards
Personal interview of various hospital staff and officials involved in discharge procedure
DISCHARGE PROCESS
25
Doctor prescribes the discharge
Nurse informs the patient about the time of discharge
26
Staff nurse starts discharge formalities by
Asking the Resident Medical Officer Concerned Physician to
make discharge summary
Informing Dietician to make discharge diet report for patient
Counseling of the patient by the dietician and physiotherapist (if
physiotherapy is going on for patient)
Asking the service entry assistants to enter all the details regarding the
patients starting from the no of consultant visits to medicines
consumed
Sending to Pharmacy Daily Billing Activity Sheet
Daily Pharmacy BillsDischarge medication detailsMedicines left unconsumed
In Pharmacy Summary of Pharmacy Bill is prepared
Daily Billing Activity Sheet
Summarized Pharmacy Bill
Giving the feedback form to the patient attendants
Fig1 Communication channels during the discharge procedure
27
Billing department finalizes the bill
Payment taken by billing department from attendants
IPD Billing informs at the nursing station about the clearance of bill
Discharge Summary completion by Medical Transcriptionist
Nurse informs the patient amp patient changes clothes
Nurse checks the checklist given for discharge of patient
All medications + Investigations reports + Patientrsquos file given to the patient
Patient given amp explained about how to take the medications + any special instruction + follow up schedule
Patient Discharged
Collects the filled up feedback form from the patient attendants
There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays
Fig 2 A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital
020406080
100120
82
28 39
102
Compliance to discharge procedure
No
of p
atien
ts
Table1 Duration of various parameters related to discharge
28
DoctorNurseService ward boysBillingofficePatient
Various other departments of the hospital
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
o IP payments are always due and payments have to be drawn from the empanelled organization
o OP payments have to be collected in cash from the patients which they can refund it on their own
o IP patients can give cheques
SHIJA MASTER HEALTH CHECK
Patient enters hospital
Registration done at Main reception
Billing done at IPD Counter
Sample collection done in Master Health Check Sample Collection Room
Sample sent to Lab
IN PATIENT DEPARTMENT
Categories of wards o Male General Ward
o Female General Ward
o Intensive Care Unit
o Neuro ICU
o Special rooms
o Cabins Twin sharing
o Deluxe Suites
8
In Patient Flow
Patient can come from
OPD ICU EMERGENCY POST -OPERATIVE
WARD
Admission counter - Nursing staff of ward changes the patient status in HIS by
Assistant gives a call doing ldquoCHECK-INrdquo of the patient received
to nursing station to - ICU EMERGENCY POST-OPERATIVE WARDS (from where
confirm for bed the patient is coming) changes the patient status in their
availability HIS by doing ldquoCHECK-OUTrdquo of the patient
Nursing staff prepares the roombed
Entry done in HIS Register White Board
Nurse informs the concerned Doctor
Doctor comes amp prescribes medication and investigation (if any)
Nurse writes the prescribed drugs on Indoor Drug Requisition Form
Ward boy goes and collects the drugs from Pharmacy
Nurse starts medication + prepares the patient for investigation (if any)
9
OPERATION THEATRE
Doctor sends request for OT Availability
OT Incharge confirms OT availability
Entry into OT Booking Register regarding
Scheduled surgeryrsquos Date Time Doctor Patient
A day before surgery verification of
Surgery Set Drugs
10
Instrument Verification
Verification of CSSD amp other consumables
In Non Usable condition
Discarded
Entry into Instrument
Replacement Register
Respective HOD informed
Request send to stores
Request sent
In usable condition
Suitable for use in surgery
Expiry check
Unused amp not
expired
Suitable for use
in surgery
Used
Depleted stock for surgery use
Requisition sent to Pharmacy through Drug Requisition Form
Pharmacy replenishes request
Sufficient stock Inventory
Linen amp Instrument
check
Dirty Linen list formed amp
sent to Laundry amp received
later
Entry made
Surgical set amp consumables prepared
Before start of surgery Inspection of
Before start of surgery Inspection of
Patientrsquos Records
Medical Gas
Pressure Leakage
Sterilization
Daily OT cleaning
records duly filled
Mopping of OT floor with
Bacillocid
Disinfection of OT items
listed on form with 2 Trigene
Instrument checklist
form
Completion of ldquoopened
byrdquo amp ldquocross checkedrdquo columns
Electrical points in
OT
Equipments
Transfer of equipment specific for
surgery into OT
OT Preparation done
Reception of Patient in Pre Operation area 20 minutes before surgery
Patient shifted to OT
11
In Non Usable condition
Discarded
Entry into Instrument
Replacement Register
Respective HOD informed
Request send to stores
Request sent
Depleted stock for surgery use
Requisition sent to Pharmacy through Drug Requisition Form
Pharmacy replenishes request
Linen amp Instrument
check
Dirty Linen list formed amp
sent to Laundry amp received
later
Entry made
Expired
Separated
Entry made into RE-
AUTOCLAVE register
Send to CSSD
Not expired
Suitable for surgery
Patientrsquos Identification done amp verified
Surgery performed
Recording of all consumable used is recorded
Surgery completed
Surgery completed
Collection of OT Waste
Disposal by housekeeping
staff as per rules
Count of instruments
ldquoPostrdquo Column of Instrument
check list form completed
Transfer of patient to Recovery
room
Patient shifted to Ward SICU
Updation of records
Operation notes amp patientrsquos
record completed
Operation Daily charge bill formed
OT Drug inventory checked
Requisition send to
Pharmacy
OT Inventory replenished
OT Prepared for next surgery
Operation Theatre
Layout 1st flooor No of OTrsquos 6
General OTrsquos ndash 3 Eye OT- 1 Minor OT - 2
12
No of beds in Pre operative ward 7 No of beds in post operative wards 8 Utility room 1 Doctorrsquos Lounge 1 Nurse and Technician Lounge 1 Pantry 1 Sterile room 1 Changing rooms 4
Doctor (male) changing room 1 Doctor (female) changing room 1 Nurse (female) changing room 1 Technician + Nurse (male) changing room 1
Patient admission procedure in ICU
Physician
(Desiring admission of a patient in ICU)
contacts
Admission Office
Contacts for Bed Availability with
ICU
(Nurse ndash Ward Supervisor)
Beds Available No ICU Bed available
Admission done Admission office contacts
Nursing Administrator
Nursing Administrator starts
ICU patients ldquostatus evaluationrdquo
13
Any patient can be shifted None can be shifted
to Wards
Patient shifted to ICU after one patient Patient is stabilizedis shifted to Wards
Nursing Supervisor contacts
Administrator on-call
He authorize transfer of
patient to other hospital
HUMAN RESOURCE DEPARTMENT
Layout -Administrative Block Ground Floor
Total Staff 4
Organogram
Head Manager
HR Executives (3)
Trainee
Jobs amp Responsibilities
Manpower Planning
Internal Job Posting Process
CV Selection
Confirmation and Appraisal
Staff Queries
Follow up with selected candidates
Issuing of appointment letters
Disciplinary Policy
Leaves sanctioning
14
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Payroll
Budgeting for departments
Doctors payout
Duty roster
Issuing of Experience letters
STORES
Layout -New Stores Block
Staff 4
Hierarchy
Stores Manager
Store Supervisor
Bio medical Engineer GDA
Records Maintained
Goods Receipt Note Quotations Purchase Requests Capital Sanctioned Record
WORK FLOW
Department in need of material
Through HIS Indentation
or Requisition slip
Store15
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Issue Note Return File Purchase Receipt Purchase Orders
Store checks for the required material and the quantity
YES NO
Material issued and recorded in Issue Register Entry into Shortage Register
Record of the material entered HIS ldquoPurchase Requestrdquo is filled in HIS
Duties of Store In charge
Forecasting requirement Budgetary requirement Inventory control Stock verification Communicate the purchase
department about requirement Minimize pilferage
INFORMATION TECHNOLOGY (IT) DEPARTMENT
Layout -Ground Floor Main Building
Staff 3
Functions and responsibilities
To keep the servers alive
To keep the network alive
To keep internet connection alive
To take care of all the desktops amp laptops in the organization
To track the records of all the desktops
To keep an eye on the employees desktops
To resolve the complaints of the employees
Training of the other staff for the HIS
Major Work Areas General Administration amp HIS
16
Bin card maintained At a time 2800 items maintained in
the stores Random sample check to ensure the
genuinity and authenticity of product Disposal of surplus obsolete
Material Distribution
I) General Administration
Servers
Anti virus server Database server Application server Archive server
II) HIS (Hospital Information System)
Application by Avanttec
Billing Ward management Laboratory services Discharges + Medical Records Housekeeping Pharmacy Payroll Medical equipment
Access to Information
o User specific access according to their roles
HIS Backup
Done once a day Centralized database Internal backups
MEDICAL RECORD DEPARTMENT
Layout -MRD Block
Staff 3
Infrastructure
Desktop 1
Printer 1
Organogram Medical Records Officer Statistician
Medical Records Technician
17
Functions of MRD
To ensure that the Shija Hospital has complete amp accurate medical record for every
patient
Public dealings with respect to Bill verification MLC cases and dealing with
Summons to the doctors hospital
To maintain high level of confidentiality as far as patientrsquos records are concerned
To ensure that the records are Identified and stored safely to prevent unauthorized
changes and easily retrieved whenever required
Issuing Emergency Medical Birth amp Death certificates
To generate Bed Occupancy reports ALOS and other hospital statistics (daily amp
monthly)
Record Retention Periods
IP Record 05 years
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patient
CLINICAL NUTRITION amp DIETICS DEPARTMENT
Layout -Ground floor OPD Block
Head Dietician Ms Bimota
Functions
Catering to Inpatients Diet counseling Education Smooth provision of laid out diets to the patients To check the patient food for quality preparation presentation and packing Coordinating closely with the Nursing shift in charges for changes in the patientrsquos
diet or new admissions etc
Records Maintained
Diet order sheet Meal count register Store register Diet Sheets
18
Counseling Register
Type of Diet Diet Card Color
Normal White
Diabetes Mellitus Yellow
Chronic Renal Failure Blue
Liquid Diet Pink
Flowchart of Dietician and Inpatient Interaction
The Dietician takes details of new patients such as name UHID doctorrsquos name diagnosis and diet prescribed Then Dietician takes a detailed round wherein she meets every patient and determines patientsrsquo actual intake Dietician then provides nutritional counseling and education ensures patientsrsquo compliance to recommended diet She also recognizes personal eating and food preferences
Afterwards the dietician does nutritional screening in order to know about patientsrsquo clinical condition appetite and tolerance to food and acceptance to hospital diet personal preferences disliking and food allergies if any
After the rounds detailed food summary sheets are planned and prepared for every patient keeping in mind medical history and preferences of patient as well
SECURITY
Own security force not outsourced since 2009
Area of Operation (Present)
To deal with 3 ldquoMrdquo- Man Material amp Machinery
Visitorrsquos check Entry restriction at ICU gate Security for doctors and nurse quarter Surveillance of hospital through CCTVrsquos Theft Burglary Violence Material movements in amp out of the hospital Handling visitorrsquos pass In case of patientrsquos death handling emotional chaos of attendants Parking management and traffic control
19
HOUSEKEEPING
Status Own
Department Manager Mr Arju
FUNCTIONS
bull Clean Floor Wall Ceiling
bull Discharge Cleaning
bull Remove Garbage
bull Replace Supplies In Utility Rooms
bull Clean Housekeeping Equipments
bull Clean Room Wards Reception OT ICU Etc
bull Infection Control
bull Pest amp Rodent Control
bull Odour Control
LAUNDRY- Own
Department in charge- MsUmajini
Functions
Segregation of soiled and clean linen Traffic flow of linen before 8am Carrying the linen around the hospital Registered linen and purpose System of collection
o Colored bins
Infected linen handled separately- soaked in sodium hyperchloride Register maintained ndash separate for infected and un-infected linen Floor wise collection Different registers for each type of linen Separate people for ironing and drying from those who collect and wash
20
bull Environment Hygiene
bull Sanitation Hygiene
bull Checking Cleanliness Of All Areas
bull Control amp Reporting Of All
Maintenance Works
bull Hospital Waste Disposal
bull In-Service Training
bull Cooperation with Other Depts
Shared responsibility with nurses in charge Report- washing record submitted to HR dept Due list of linen- expected on Monday
GAPS IDENTIFIED IN STORES MANAGEMENT
No forecasting of requirement done ie Reorder Levels not defined
No analysis like ABC VED done for inventory control
Codification of items still in progress
HIS for Stores still not completely streamlined
AMC amp CMC not maintained for all
Some departments go beyond the indent allowance
Repair and Maintenance of equipments There are instruments which are not used at all
o Non-functionalo Repair requiredo Condemned
For Quality assurance o Quality calibration o Annual Maintenance Contracto Complete Maintenance Contract
Instruments go for regular servicing or they are serviced and examined regularly- Some machines are serviced in the hospital- eg computers printers patient
monitor BP instrument Alternative arrangements are available during that period of time- Patient
monitors from other wards are managedo No back up stock available
Shortage during repair period Patient monitor ndash completely mobile thus record maintenance difficult-
communication gap between the material managers 3 total staff
GAPS IDENTIFIED IN HMIS
Avanttec is a Chennai Based HIS system hence immediate access to providers not available
Strong foundation but HIS is still not fully streamlined Personnel shortage in the department No staff at night
21
GAPS IDENTIFIED IN LAUNDRY DEPARTMENT
6 Set rule per patient not followed Presently only 2 sets per patient No weighing scale No sewing machine for repair No supervision over measured use of detergent and other chemicals
PROJECT ndash 1
A Study on Discharge Procedure with Special Emphasis
on In-Patient Feedback
22
INTRODUCTION
The study was carried out in Shija Hospitals and Research Institute which is a 180 bedded hospital located in Manipur The Hospital is well known for its high end technology and services in the region The Hospital looks forward to continually develop its services and improve the facilities available in order to become a well known health service provider in the South East Asian region in the future The operations management had identified the discharge procedure as an area where there was a scope for improvement Hence the hospital had assigned the project to study the discharge procedure
Discharging a patient is an activity common to every hospital - small large community inner-city teaching or non-teaching The discharge process can have an impact on numerous factors such as patient satisfaction bed availability timely tests and procedures needed for discharge transportation and nursing home arrangements No matter what type of patient is being discharged (maternity medicine orthopedic neurologic) numerous activities must be completed for each before the patient can be released This work toward discharge day should begin upon admission
As part of a progress towards NABH accreditation at Shija Hospital the discharge process is one of the many process improvement projects The discharge process at this hospital also incorporates obtaining feedback from the in-patient regarding the services at the time of discharge Due to inappropriate management the hospital was facing an acute shortage in the feedback response from the patients
The management at the hospital realizes the need and importance of patient satisfaction and a need of a measurable index through feedback analysis In all service industries customer retention is a vital issue Hence the management wanted to do all that they could to obtain feedback from the patients at the time of discharge and make the discharge procedure as smooth as it can get
The objective of this study was to study the process of discharge and find out the probable reasons for the failure to attain feedback from the patients at the time of discharge
23
STUDY METHODOLOGY
AIM
To study the discharge procedure practiced at Shija Hospitals with special emphasis on
analyzing the reasons for the short-fall of In-Patient Feedback
OBJECTIVE
1 To find the steps followed during discharge of an in-patient2 To find the total time taken for a discharge of a single patient3 To find the contributing reasons for the short fall of in-patient feedback
received in the wards
RATIONALE
The discharge of a patient is a very important component of in-patient service and needs to be smooth and efficient On the other hand in-patient feedback is equally important as it provides the performance standards of the hospital which needs to be continually enhanced
METHODOLOGY
Study design-
Area- Shija Hospitals and Research Institute Manipur
Duration- From 11-04-2011 to 30-04-2011
Type of study- Observational and Survey study
Sample size-120 in-patients and the following hospital staff
Nurse Superintendant
RMOs on duty
Staff nurse
Front office executives
Service entry staff
Sampling Method-Convenience sampling
Study tool Questionnaire and personal interviews
24
Type of Data collected -
Interviewer guided questionnaires collected from patients by visiting the different wards
Personal interview of various hospital staff and officials involved in discharge procedure
DISCHARGE PROCESS
25
Doctor prescribes the discharge
Nurse informs the patient about the time of discharge
26
Staff nurse starts discharge formalities by
Asking the Resident Medical Officer Concerned Physician to
make discharge summary
Informing Dietician to make discharge diet report for patient
Counseling of the patient by the dietician and physiotherapist (if
physiotherapy is going on for patient)
Asking the service entry assistants to enter all the details regarding the
patients starting from the no of consultant visits to medicines
consumed
Sending to Pharmacy Daily Billing Activity Sheet
Daily Pharmacy BillsDischarge medication detailsMedicines left unconsumed
In Pharmacy Summary of Pharmacy Bill is prepared
Daily Billing Activity Sheet
Summarized Pharmacy Bill
Giving the feedback form to the patient attendants
Fig1 Communication channels during the discharge procedure
27
Billing department finalizes the bill
Payment taken by billing department from attendants
IPD Billing informs at the nursing station about the clearance of bill
Discharge Summary completion by Medical Transcriptionist
Nurse informs the patient amp patient changes clothes
Nurse checks the checklist given for discharge of patient
All medications + Investigations reports + Patientrsquos file given to the patient
Patient given amp explained about how to take the medications + any special instruction + follow up schedule
Patient Discharged
Collects the filled up feedback form from the patient attendants
There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays
Fig 2 A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital
020406080
100120
82
28 39
102
Compliance to discharge procedure
No
of p
atien
ts
Table1 Duration of various parameters related to discharge
28
DoctorNurseService ward boysBillingofficePatient
Various other departments of the hospital
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
In Patient Flow
Patient can come from
OPD ICU EMERGENCY POST -OPERATIVE
WARD
Admission counter - Nursing staff of ward changes the patient status in HIS by
Assistant gives a call doing ldquoCHECK-INrdquo of the patient received
to nursing station to - ICU EMERGENCY POST-OPERATIVE WARDS (from where
confirm for bed the patient is coming) changes the patient status in their
availability HIS by doing ldquoCHECK-OUTrdquo of the patient
Nursing staff prepares the roombed
Entry done in HIS Register White Board
Nurse informs the concerned Doctor
Doctor comes amp prescribes medication and investigation (if any)
Nurse writes the prescribed drugs on Indoor Drug Requisition Form
Ward boy goes and collects the drugs from Pharmacy
Nurse starts medication + prepares the patient for investigation (if any)
9
OPERATION THEATRE
Doctor sends request for OT Availability
OT Incharge confirms OT availability
Entry into OT Booking Register regarding
Scheduled surgeryrsquos Date Time Doctor Patient
A day before surgery verification of
Surgery Set Drugs
10
Instrument Verification
Verification of CSSD amp other consumables
In Non Usable condition
Discarded
Entry into Instrument
Replacement Register
Respective HOD informed
Request send to stores
Request sent
In usable condition
Suitable for use in surgery
Expiry check
Unused amp not
expired
Suitable for use
in surgery
Used
Depleted stock for surgery use
Requisition sent to Pharmacy through Drug Requisition Form
Pharmacy replenishes request
Sufficient stock Inventory
Linen amp Instrument
check
Dirty Linen list formed amp
sent to Laundry amp received
later
Entry made
Surgical set amp consumables prepared
Before start of surgery Inspection of
Before start of surgery Inspection of
Patientrsquos Records
Medical Gas
Pressure Leakage
Sterilization
Daily OT cleaning
records duly filled
Mopping of OT floor with
Bacillocid
Disinfection of OT items
listed on form with 2 Trigene
Instrument checklist
form
Completion of ldquoopened
byrdquo amp ldquocross checkedrdquo columns
Electrical points in
OT
Equipments
Transfer of equipment specific for
surgery into OT
OT Preparation done
Reception of Patient in Pre Operation area 20 minutes before surgery
Patient shifted to OT
11
In Non Usable condition
Discarded
Entry into Instrument
Replacement Register
Respective HOD informed
Request send to stores
Request sent
Depleted stock for surgery use
Requisition sent to Pharmacy through Drug Requisition Form
Pharmacy replenishes request
Linen amp Instrument
check
Dirty Linen list formed amp
sent to Laundry amp received
later
Entry made
Expired
Separated
Entry made into RE-
AUTOCLAVE register
Send to CSSD
Not expired
Suitable for surgery
Patientrsquos Identification done amp verified
Surgery performed
Recording of all consumable used is recorded
Surgery completed
Surgery completed
Collection of OT Waste
Disposal by housekeeping
staff as per rules
Count of instruments
ldquoPostrdquo Column of Instrument
check list form completed
Transfer of patient to Recovery
room
Patient shifted to Ward SICU
Updation of records
Operation notes amp patientrsquos
record completed
Operation Daily charge bill formed
OT Drug inventory checked
Requisition send to
Pharmacy
OT Inventory replenished
OT Prepared for next surgery
Operation Theatre
Layout 1st flooor No of OTrsquos 6
General OTrsquos ndash 3 Eye OT- 1 Minor OT - 2
12
No of beds in Pre operative ward 7 No of beds in post operative wards 8 Utility room 1 Doctorrsquos Lounge 1 Nurse and Technician Lounge 1 Pantry 1 Sterile room 1 Changing rooms 4
Doctor (male) changing room 1 Doctor (female) changing room 1 Nurse (female) changing room 1 Technician + Nurse (male) changing room 1
Patient admission procedure in ICU
Physician
(Desiring admission of a patient in ICU)
contacts
Admission Office
Contacts for Bed Availability with
ICU
(Nurse ndash Ward Supervisor)
Beds Available No ICU Bed available
Admission done Admission office contacts
Nursing Administrator
Nursing Administrator starts
ICU patients ldquostatus evaluationrdquo
13
Any patient can be shifted None can be shifted
to Wards
Patient shifted to ICU after one patient Patient is stabilizedis shifted to Wards
Nursing Supervisor contacts
Administrator on-call
He authorize transfer of
patient to other hospital
HUMAN RESOURCE DEPARTMENT
Layout -Administrative Block Ground Floor
Total Staff 4
Organogram
Head Manager
HR Executives (3)
Trainee
Jobs amp Responsibilities
Manpower Planning
Internal Job Posting Process
CV Selection
Confirmation and Appraisal
Staff Queries
Follow up with selected candidates
Issuing of appointment letters
Disciplinary Policy
Leaves sanctioning
14
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Payroll
Budgeting for departments
Doctors payout
Duty roster
Issuing of Experience letters
STORES
Layout -New Stores Block
Staff 4
Hierarchy
Stores Manager
Store Supervisor
Bio medical Engineer GDA
Records Maintained
Goods Receipt Note Quotations Purchase Requests Capital Sanctioned Record
WORK FLOW
Department in need of material
Through HIS Indentation
or Requisition slip
Store15
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Issue Note Return File Purchase Receipt Purchase Orders
Store checks for the required material and the quantity
YES NO
Material issued and recorded in Issue Register Entry into Shortage Register
Record of the material entered HIS ldquoPurchase Requestrdquo is filled in HIS
Duties of Store In charge
Forecasting requirement Budgetary requirement Inventory control Stock verification Communicate the purchase
department about requirement Minimize pilferage
INFORMATION TECHNOLOGY (IT) DEPARTMENT
Layout -Ground Floor Main Building
Staff 3
Functions and responsibilities
To keep the servers alive
To keep the network alive
To keep internet connection alive
To take care of all the desktops amp laptops in the organization
To track the records of all the desktops
To keep an eye on the employees desktops
To resolve the complaints of the employees
Training of the other staff for the HIS
Major Work Areas General Administration amp HIS
16
Bin card maintained At a time 2800 items maintained in
the stores Random sample check to ensure the
genuinity and authenticity of product Disposal of surplus obsolete
Material Distribution
I) General Administration
Servers
Anti virus server Database server Application server Archive server
II) HIS (Hospital Information System)
Application by Avanttec
Billing Ward management Laboratory services Discharges + Medical Records Housekeeping Pharmacy Payroll Medical equipment
Access to Information
o User specific access according to their roles
HIS Backup
Done once a day Centralized database Internal backups
MEDICAL RECORD DEPARTMENT
Layout -MRD Block
Staff 3
Infrastructure
Desktop 1
Printer 1
Organogram Medical Records Officer Statistician
Medical Records Technician
17
Functions of MRD
To ensure that the Shija Hospital has complete amp accurate medical record for every
patient
Public dealings with respect to Bill verification MLC cases and dealing with
Summons to the doctors hospital
To maintain high level of confidentiality as far as patientrsquos records are concerned
To ensure that the records are Identified and stored safely to prevent unauthorized
changes and easily retrieved whenever required
Issuing Emergency Medical Birth amp Death certificates
To generate Bed Occupancy reports ALOS and other hospital statistics (daily amp
monthly)
Record Retention Periods
IP Record 05 years
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patient
CLINICAL NUTRITION amp DIETICS DEPARTMENT
Layout -Ground floor OPD Block
Head Dietician Ms Bimota
Functions
Catering to Inpatients Diet counseling Education Smooth provision of laid out diets to the patients To check the patient food for quality preparation presentation and packing Coordinating closely with the Nursing shift in charges for changes in the patientrsquos
diet or new admissions etc
Records Maintained
Diet order sheet Meal count register Store register Diet Sheets
18
Counseling Register
Type of Diet Diet Card Color
Normal White
Diabetes Mellitus Yellow
Chronic Renal Failure Blue
Liquid Diet Pink
Flowchart of Dietician and Inpatient Interaction
The Dietician takes details of new patients such as name UHID doctorrsquos name diagnosis and diet prescribed Then Dietician takes a detailed round wherein she meets every patient and determines patientsrsquo actual intake Dietician then provides nutritional counseling and education ensures patientsrsquo compliance to recommended diet She also recognizes personal eating and food preferences
Afterwards the dietician does nutritional screening in order to know about patientsrsquo clinical condition appetite and tolerance to food and acceptance to hospital diet personal preferences disliking and food allergies if any
After the rounds detailed food summary sheets are planned and prepared for every patient keeping in mind medical history and preferences of patient as well
SECURITY
Own security force not outsourced since 2009
Area of Operation (Present)
To deal with 3 ldquoMrdquo- Man Material amp Machinery
Visitorrsquos check Entry restriction at ICU gate Security for doctors and nurse quarter Surveillance of hospital through CCTVrsquos Theft Burglary Violence Material movements in amp out of the hospital Handling visitorrsquos pass In case of patientrsquos death handling emotional chaos of attendants Parking management and traffic control
19
HOUSEKEEPING
Status Own
Department Manager Mr Arju
FUNCTIONS
bull Clean Floor Wall Ceiling
bull Discharge Cleaning
bull Remove Garbage
bull Replace Supplies In Utility Rooms
bull Clean Housekeeping Equipments
bull Clean Room Wards Reception OT ICU Etc
bull Infection Control
bull Pest amp Rodent Control
bull Odour Control
LAUNDRY- Own
Department in charge- MsUmajini
Functions
Segregation of soiled and clean linen Traffic flow of linen before 8am Carrying the linen around the hospital Registered linen and purpose System of collection
o Colored bins
Infected linen handled separately- soaked in sodium hyperchloride Register maintained ndash separate for infected and un-infected linen Floor wise collection Different registers for each type of linen Separate people for ironing and drying from those who collect and wash
20
bull Environment Hygiene
bull Sanitation Hygiene
bull Checking Cleanliness Of All Areas
bull Control amp Reporting Of All
Maintenance Works
bull Hospital Waste Disposal
bull In-Service Training
bull Cooperation with Other Depts
Shared responsibility with nurses in charge Report- washing record submitted to HR dept Due list of linen- expected on Monday
GAPS IDENTIFIED IN STORES MANAGEMENT
No forecasting of requirement done ie Reorder Levels not defined
No analysis like ABC VED done for inventory control
Codification of items still in progress
HIS for Stores still not completely streamlined
AMC amp CMC not maintained for all
Some departments go beyond the indent allowance
Repair and Maintenance of equipments There are instruments which are not used at all
o Non-functionalo Repair requiredo Condemned
For Quality assurance o Quality calibration o Annual Maintenance Contracto Complete Maintenance Contract
Instruments go for regular servicing or they are serviced and examined regularly- Some machines are serviced in the hospital- eg computers printers patient
monitor BP instrument Alternative arrangements are available during that period of time- Patient
monitors from other wards are managedo No back up stock available
Shortage during repair period Patient monitor ndash completely mobile thus record maintenance difficult-
communication gap between the material managers 3 total staff
GAPS IDENTIFIED IN HMIS
Avanttec is a Chennai Based HIS system hence immediate access to providers not available
Strong foundation but HIS is still not fully streamlined Personnel shortage in the department No staff at night
21
GAPS IDENTIFIED IN LAUNDRY DEPARTMENT
6 Set rule per patient not followed Presently only 2 sets per patient No weighing scale No sewing machine for repair No supervision over measured use of detergent and other chemicals
PROJECT ndash 1
A Study on Discharge Procedure with Special Emphasis
on In-Patient Feedback
22
INTRODUCTION
The study was carried out in Shija Hospitals and Research Institute which is a 180 bedded hospital located in Manipur The Hospital is well known for its high end technology and services in the region The Hospital looks forward to continually develop its services and improve the facilities available in order to become a well known health service provider in the South East Asian region in the future The operations management had identified the discharge procedure as an area where there was a scope for improvement Hence the hospital had assigned the project to study the discharge procedure
Discharging a patient is an activity common to every hospital - small large community inner-city teaching or non-teaching The discharge process can have an impact on numerous factors such as patient satisfaction bed availability timely tests and procedures needed for discharge transportation and nursing home arrangements No matter what type of patient is being discharged (maternity medicine orthopedic neurologic) numerous activities must be completed for each before the patient can be released This work toward discharge day should begin upon admission
As part of a progress towards NABH accreditation at Shija Hospital the discharge process is one of the many process improvement projects The discharge process at this hospital also incorporates obtaining feedback from the in-patient regarding the services at the time of discharge Due to inappropriate management the hospital was facing an acute shortage in the feedback response from the patients
The management at the hospital realizes the need and importance of patient satisfaction and a need of a measurable index through feedback analysis In all service industries customer retention is a vital issue Hence the management wanted to do all that they could to obtain feedback from the patients at the time of discharge and make the discharge procedure as smooth as it can get
The objective of this study was to study the process of discharge and find out the probable reasons for the failure to attain feedback from the patients at the time of discharge
23
STUDY METHODOLOGY
AIM
To study the discharge procedure practiced at Shija Hospitals with special emphasis on
analyzing the reasons for the short-fall of In-Patient Feedback
OBJECTIVE
1 To find the steps followed during discharge of an in-patient2 To find the total time taken for a discharge of a single patient3 To find the contributing reasons for the short fall of in-patient feedback
received in the wards
RATIONALE
The discharge of a patient is a very important component of in-patient service and needs to be smooth and efficient On the other hand in-patient feedback is equally important as it provides the performance standards of the hospital which needs to be continually enhanced
METHODOLOGY
Study design-
Area- Shija Hospitals and Research Institute Manipur
Duration- From 11-04-2011 to 30-04-2011
Type of study- Observational and Survey study
Sample size-120 in-patients and the following hospital staff
Nurse Superintendant
RMOs on duty
Staff nurse
Front office executives
Service entry staff
Sampling Method-Convenience sampling
Study tool Questionnaire and personal interviews
24
Type of Data collected -
Interviewer guided questionnaires collected from patients by visiting the different wards
Personal interview of various hospital staff and officials involved in discharge procedure
DISCHARGE PROCESS
25
Doctor prescribes the discharge
Nurse informs the patient about the time of discharge
26
Staff nurse starts discharge formalities by
Asking the Resident Medical Officer Concerned Physician to
make discharge summary
Informing Dietician to make discharge diet report for patient
Counseling of the patient by the dietician and physiotherapist (if
physiotherapy is going on for patient)
Asking the service entry assistants to enter all the details regarding the
patients starting from the no of consultant visits to medicines
consumed
Sending to Pharmacy Daily Billing Activity Sheet
Daily Pharmacy BillsDischarge medication detailsMedicines left unconsumed
In Pharmacy Summary of Pharmacy Bill is prepared
Daily Billing Activity Sheet
Summarized Pharmacy Bill
Giving the feedback form to the patient attendants
Fig1 Communication channels during the discharge procedure
27
Billing department finalizes the bill
Payment taken by billing department from attendants
IPD Billing informs at the nursing station about the clearance of bill
Discharge Summary completion by Medical Transcriptionist
Nurse informs the patient amp patient changes clothes
Nurse checks the checklist given for discharge of patient
All medications + Investigations reports + Patientrsquos file given to the patient
Patient given amp explained about how to take the medications + any special instruction + follow up schedule
Patient Discharged
Collects the filled up feedback form from the patient attendants
There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays
Fig 2 A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital
020406080
100120
82
28 39
102
Compliance to discharge procedure
No
of p
atien
ts
Table1 Duration of various parameters related to discharge
28
DoctorNurseService ward boysBillingofficePatient
Various other departments of the hospital
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
OPERATION THEATRE
Doctor sends request for OT Availability
OT Incharge confirms OT availability
Entry into OT Booking Register regarding
Scheduled surgeryrsquos Date Time Doctor Patient
A day before surgery verification of
Surgery Set Drugs
10
Instrument Verification
Verification of CSSD amp other consumables
In Non Usable condition
Discarded
Entry into Instrument
Replacement Register
Respective HOD informed
Request send to stores
Request sent
In usable condition
Suitable for use in surgery
Expiry check
Unused amp not
expired
Suitable for use
in surgery
Used
Depleted stock for surgery use
Requisition sent to Pharmacy through Drug Requisition Form
Pharmacy replenishes request
Sufficient stock Inventory
Linen amp Instrument
check
Dirty Linen list formed amp
sent to Laundry amp received
later
Entry made
Surgical set amp consumables prepared
Before start of surgery Inspection of
Before start of surgery Inspection of
Patientrsquos Records
Medical Gas
Pressure Leakage
Sterilization
Daily OT cleaning
records duly filled
Mopping of OT floor with
Bacillocid
Disinfection of OT items
listed on form with 2 Trigene
Instrument checklist
form
Completion of ldquoopened
byrdquo amp ldquocross checkedrdquo columns
Electrical points in
OT
Equipments
Transfer of equipment specific for
surgery into OT
OT Preparation done
Reception of Patient in Pre Operation area 20 minutes before surgery
Patient shifted to OT
11
In Non Usable condition
Discarded
Entry into Instrument
Replacement Register
Respective HOD informed
Request send to stores
Request sent
Depleted stock for surgery use
Requisition sent to Pharmacy through Drug Requisition Form
Pharmacy replenishes request
Linen amp Instrument
check
Dirty Linen list formed amp
sent to Laundry amp received
later
Entry made
Expired
Separated
Entry made into RE-
AUTOCLAVE register
Send to CSSD
Not expired
Suitable for surgery
Patientrsquos Identification done amp verified
Surgery performed
Recording of all consumable used is recorded
Surgery completed
Surgery completed
Collection of OT Waste
Disposal by housekeeping
staff as per rules
Count of instruments
ldquoPostrdquo Column of Instrument
check list form completed
Transfer of patient to Recovery
room
Patient shifted to Ward SICU
Updation of records
Operation notes amp patientrsquos
record completed
Operation Daily charge bill formed
OT Drug inventory checked
Requisition send to
Pharmacy
OT Inventory replenished
OT Prepared for next surgery
Operation Theatre
Layout 1st flooor No of OTrsquos 6
General OTrsquos ndash 3 Eye OT- 1 Minor OT - 2
12
No of beds in Pre operative ward 7 No of beds in post operative wards 8 Utility room 1 Doctorrsquos Lounge 1 Nurse and Technician Lounge 1 Pantry 1 Sterile room 1 Changing rooms 4
Doctor (male) changing room 1 Doctor (female) changing room 1 Nurse (female) changing room 1 Technician + Nurse (male) changing room 1
Patient admission procedure in ICU
Physician
(Desiring admission of a patient in ICU)
contacts
Admission Office
Contacts for Bed Availability with
ICU
(Nurse ndash Ward Supervisor)
Beds Available No ICU Bed available
Admission done Admission office contacts
Nursing Administrator
Nursing Administrator starts
ICU patients ldquostatus evaluationrdquo
13
Any patient can be shifted None can be shifted
to Wards
Patient shifted to ICU after one patient Patient is stabilizedis shifted to Wards
Nursing Supervisor contacts
Administrator on-call
He authorize transfer of
patient to other hospital
HUMAN RESOURCE DEPARTMENT
Layout -Administrative Block Ground Floor
Total Staff 4
Organogram
Head Manager
HR Executives (3)
Trainee
Jobs amp Responsibilities
Manpower Planning
Internal Job Posting Process
CV Selection
Confirmation and Appraisal
Staff Queries
Follow up with selected candidates
Issuing of appointment letters
Disciplinary Policy
Leaves sanctioning
14
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Payroll
Budgeting for departments
Doctors payout
Duty roster
Issuing of Experience letters
STORES
Layout -New Stores Block
Staff 4
Hierarchy
Stores Manager
Store Supervisor
Bio medical Engineer GDA
Records Maintained
Goods Receipt Note Quotations Purchase Requests Capital Sanctioned Record
WORK FLOW
Department in need of material
Through HIS Indentation
or Requisition slip
Store15
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Issue Note Return File Purchase Receipt Purchase Orders
Store checks for the required material and the quantity
YES NO
Material issued and recorded in Issue Register Entry into Shortage Register
Record of the material entered HIS ldquoPurchase Requestrdquo is filled in HIS
Duties of Store In charge
Forecasting requirement Budgetary requirement Inventory control Stock verification Communicate the purchase
department about requirement Minimize pilferage
INFORMATION TECHNOLOGY (IT) DEPARTMENT
Layout -Ground Floor Main Building
Staff 3
Functions and responsibilities
To keep the servers alive
To keep the network alive
To keep internet connection alive
To take care of all the desktops amp laptops in the organization
To track the records of all the desktops
To keep an eye on the employees desktops
To resolve the complaints of the employees
Training of the other staff for the HIS
Major Work Areas General Administration amp HIS
16
Bin card maintained At a time 2800 items maintained in
the stores Random sample check to ensure the
genuinity and authenticity of product Disposal of surplus obsolete
Material Distribution
I) General Administration
Servers
Anti virus server Database server Application server Archive server
II) HIS (Hospital Information System)
Application by Avanttec
Billing Ward management Laboratory services Discharges + Medical Records Housekeeping Pharmacy Payroll Medical equipment
Access to Information
o User specific access according to their roles
HIS Backup
Done once a day Centralized database Internal backups
MEDICAL RECORD DEPARTMENT
Layout -MRD Block
Staff 3
Infrastructure
Desktop 1
Printer 1
Organogram Medical Records Officer Statistician
Medical Records Technician
17
Functions of MRD
To ensure that the Shija Hospital has complete amp accurate medical record for every
patient
Public dealings with respect to Bill verification MLC cases and dealing with
Summons to the doctors hospital
To maintain high level of confidentiality as far as patientrsquos records are concerned
To ensure that the records are Identified and stored safely to prevent unauthorized
changes and easily retrieved whenever required
Issuing Emergency Medical Birth amp Death certificates
To generate Bed Occupancy reports ALOS and other hospital statistics (daily amp
monthly)
Record Retention Periods
IP Record 05 years
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patient
CLINICAL NUTRITION amp DIETICS DEPARTMENT
Layout -Ground floor OPD Block
Head Dietician Ms Bimota
Functions
Catering to Inpatients Diet counseling Education Smooth provision of laid out diets to the patients To check the patient food for quality preparation presentation and packing Coordinating closely with the Nursing shift in charges for changes in the patientrsquos
diet or new admissions etc
Records Maintained
Diet order sheet Meal count register Store register Diet Sheets
18
Counseling Register
Type of Diet Diet Card Color
Normal White
Diabetes Mellitus Yellow
Chronic Renal Failure Blue
Liquid Diet Pink
Flowchart of Dietician and Inpatient Interaction
The Dietician takes details of new patients such as name UHID doctorrsquos name diagnosis and diet prescribed Then Dietician takes a detailed round wherein she meets every patient and determines patientsrsquo actual intake Dietician then provides nutritional counseling and education ensures patientsrsquo compliance to recommended diet She also recognizes personal eating and food preferences
Afterwards the dietician does nutritional screening in order to know about patientsrsquo clinical condition appetite and tolerance to food and acceptance to hospital diet personal preferences disliking and food allergies if any
After the rounds detailed food summary sheets are planned and prepared for every patient keeping in mind medical history and preferences of patient as well
SECURITY
Own security force not outsourced since 2009
Area of Operation (Present)
To deal with 3 ldquoMrdquo- Man Material amp Machinery
Visitorrsquos check Entry restriction at ICU gate Security for doctors and nurse quarter Surveillance of hospital through CCTVrsquos Theft Burglary Violence Material movements in amp out of the hospital Handling visitorrsquos pass In case of patientrsquos death handling emotional chaos of attendants Parking management and traffic control
19
HOUSEKEEPING
Status Own
Department Manager Mr Arju
FUNCTIONS
bull Clean Floor Wall Ceiling
bull Discharge Cleaning
bull Remove Garbage
bull Replace Supplies In Utility Rooms
bull Clean Housekeeping Equipments
bull Clean Room Wards Reception OT ICU Etc
bull Infection Control
bull Pest amp Rodent Control
bull Odour Control
LAUNDRY- Own
Department in charge- MsUmajini
Functions
Segregation of soiled and clean linen Traffic flow of linen before 8am Carrying the linen around the hospital Registered linen and purpose System of collection
o Colored bins
Infected linen handled separately- soaked in sodium hyperchloride Register maintained ndash separate for infected and un-infected linen Floor wise collection Different registers for each type of linen Separate people for ironing and drying from those who collect and wash
20
bull Environment Hygiene
bull Sanitation Hygiene
bull Checking Cleanliness Of All Areas
bull Control amp Reporting Of All
Maintenance Works
bull Hospital Waste Disposal
bull In-Service Training
bull Cooperation with Other Depts
Shared responsibility with nurses in charge Report- washing record submitted to HR dept Due list of linen- expected on Monday
GAPS IDENTIFIED IN STORES MANAGEMENT
No forecasting of requirement done ie Reorder Levels not defined
No analysis like ABC VED done for inventory control
Codification of items still in progress
HIS for Stores still not completely streamlined
AMC amp CMC not maintained for all
Some departments go beyond the indent allowance
Repair and Maintenance of equipments There are instruments which are not used at all
o Non-functionalo Repair requiredo Condemned
For Quality assurance o Quality calibration o Annual Maintenance Contracto Complete Maintenance Contract
Instruments go for regular servicing or they are serviced and examined regularly- Some machines are serviced in the hospital- eg computers printers patient
monitor BP instrument Alternative arrangements are available during that period of time- Patient
monitors from other wards are managedo No back up stock available
Shortage during repair period Patient monitor ndash completely mobile thus record maintenance difficult-
communication gap between the material managers 3 total staff
GAPS IDENTIFIED IN HMIS
Avanttec is a Chennai Based HIS system hence immediate access to providers not available
Strong foundation but HIS is still not fully streamlined Personnel shortage in the department No staff at night
21
GAPS IDENTIFIED IN LAUNDRY DEPARTMENT
6 Set rule per patient not followed Presently only 2 sets per patient No weighing scale No sewing machine for repair No supervision over measured use of detergent and other chemicals
PROJECT ndash 1
A Study on Discharge Procedure with Special Emphasis
on In-Patient Feedback
22
INTRODUCTION
The study was carried out in Shija Hospitals and Research Institute which is a 180 bedded hospital located in Manipur The Hospital is well known for its high end technology and services in the region The Hospital looks forward to continually develop its services and improve the facilities available in order to become a well known health service provider in the South East Asian region in the future The operations management had identified the discharge procedure as an area where there was a scope for improvement Hence the hospital had assigned the project to study the discharge procedure
Discharging a patient is an activity common to every hospital - small large community inner-city teaching or non-teaching The discharge process can have an impact on numerous factors such as patient satisfaction bed availability timely tests and procedures needed for discharge transportation and nursing home arrangements No matter what type of patient is being discharged (maternity medicine orthopedic neurologic) numerous activities must be completed for each before the patient can be released This work toward discharge day should begin upon admission
As part of a progress towards NABH accreditation at Shija Hospital the discharge process is one of the many process improvement projects The discharge process at this hospital also incorporates obtaining feedback from the in-patient regarding the services at the time of discharge Due to inappropriate management the hospital was facing an acute shortage in the feedback response from the patients
The management at the hospital realizes the need and importance of patient satisfaction and a need of a measurable index through feedback analysis In all service industries customer retention is a vital issue Hence the management wanted to do all that they could to obtain feedback from the patients at the time of discharge and make the discharge procedure as smooth as it can get
The objective of this study was to study the process of discharge and find out the probable reasons for the failure to attain feedback from the patients at the time of discharge
23
STUDY METHODOLOGY
AIM
To study the discharge procedure practiced at Shija Hospitals with special emphasis on
analyzing the reasons for the short-fall of In-Patient Feedback
OBJECTIVE
1 To find the steps followed during discharge of an in-patient2 To find the total time taken for a discharge of a single patient3 To find the contributing reasons for the short fall of in-patient feedback
received in the wards
RATIONALE
The discharge of a patient is a very important component of in-patient service and needs to be smooth and efficient On the other hand in-patient feedback is equally important as it provides the performance standards of the hospital which needs to be continually enhanced
METHODOLOGY
Study design-
Area- Shija Hospitals and Research Institute Manipur
Duration- From 11-04-2011 to 30-04-2011
Type of study- Observational and Survey study
Sample size-120 in-patients and the following hospital staff
Nurse Superintendant
RMOs on duty
Staff nurse
Front office executives
Service entry staff
Sampling Method-Convenience sampling
Study tool Questionnaire and personal interviews
24
Type of Data collected -
Interviewer guided questionnaires collected from patients by visiting the different wards
Personal interview of various hospital staff and officials involved in discharge procedure
DISCHARGE PROCESS
25
Doctor prescribes the discharge
Nurse informs the patient about the time of discharge
26
Staff nurse starts discharge formalities by
Asking the Resident Medical Officer Concerned Physician to
make discharge summary
Informing Dietician to make discharge diet report for patient
Counseling of the patient by the dietician and physiotherapist (if
physiotherapy is going on for patient)
Asking the service entry assistants to enter all the details regarding the
patients starting from the no of consultant visits to medicines
consumed
Sending to Pharmacy Daily Billing Activity Sheet
Daily Pharmacy BillsDischarge medication detailsMedicines left unconsumed
In Pharmacy Summary of Pharmacy Bill is prepared
Daily Billing Activity Sheet
Summarized Pharmacy Bill
Giving the feedback form to the patient attendants
Fig1 Communication channels during the discharge procedure
27
Billing department finalizes the bill
Payment taken by billing department from attendants
IPD Billing informs at the nursing station about the clearance of bill
Discharge Summary completion by Medical Transcriptionist
Nurse informs the patient amp patient changes clothes
Nurse checks the checklist given for discharge of patient
All medications + Investigations reports + Patientrsquos file given to the patient
Patient given amp explained about how to take the medications + any special instruction + follow up schedule
Patient Discharged
Collects the filled up feedback form from the patient attendants
There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays
Fig 2 A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital
020406080
100120
82
28 39
102
Compliance to discharge procedure
No
of p
atien
ts
Table1 Duration of various parameters related to discharge
28
DoctorNurseService ward boysBillingofficePatient
Various other departments of the hospital
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
Surgical set amp consumables prepared
Before start of surgery Inspection of
Before start of surgery Inspection of
Patientrsquos Records
Medical Gas
Pressure Leakage
Sterilization
Daily OT cleaning
records duly filled
Mopping of OT floor with
Bacillocid
Disinfection of OT items
listed on form with 2 Trigene
Instrument checklist
form
Completion of ldquoopened
byrdquo amp ldquocross checkedrdquo columns
Electrical points in
OT
Equipments
Transfer of equipment specific for
surgery into OT
OT Preparation done
Reception of Patient in Pre Operation area 20 minutes before surgery
Patient shifted to OT
11
In Non Usable condition
Discarded
Entry into Instrument
Replacement Register
Respective HOD informed
Request send to stores
Request sent
Depleted stock for surgery use
Requisition sent to Pharmacy through Drug Requisition Form
Pharmacy replenishes request
Linen amp Instrument
check
Dirty Linen list formed amp
sent to Laundry amp received
later
Entry made
Expired
Separated
Entry made into RE-
AUTOCLAVE register
Send to CSSD
Not expired
Suitable for surgery
Patientrsquos Identification done amp verified
Surgery performed
Recording of all consumable used is recorded
Surgery completed
Surgery completed
Collection of OT Waste
Disposal by housekeeping
staff as per rules
Count of instruments
ldquoPostrdquo Column of Instrument
check list form completed
Transfer of patient to Recovery
room
Patient shifted to Ward SICU
Updation of records
Operation notes amp patientrsquos
record completed
Operation Daily charge bill formed
OT Drug inventory checked
Requisition send to
Pharmacy
OT Inventory replenished
OT Prepared for next surgery
Operation Theatre
Layout 1st flooor No of OTrsquos 6
General OTrsquos ndash 3 Eye OT- 1 Minor OT - 2
12
No of beds in Pre operative ward 7 No of beds in post operative wards 8 Utility room 1 Doctorrsquos Lounge 1 Nurse and Technician Lounge 1 Pantry 1 Sterile room 1 Changing rooms 4
Doctor (male) changing room 1 Doctor (female) changing room 1 Nurse (female) changing room 1 Technician + Nurse (male) changing room 1
Patient admission procedure in ICU
Physician
(Desiring admission of a patient in ICU)
contacts
Admission Office
Contacts for Bed Availability with
ICU
(Nurse ndash Ward Supervisor)
Beds Available No ICU Bed available
Admission done Admission office contacts
Nursing Administrator
Nursing Administrator starts
ICU patients ldquostatus evaluationrdquo
13
Any patient can be shifted None can be shifted
to Wards
Patient shifted to ICU after one patient Patient is stabilizedis shifted to Wards
Nursing Supervisor contacts
Administrator on-call
He authorize transfer of
patient to other hospital
HUMAN RESOURCE DEPARTMENT
Layout -Administrative Block Ground Floor
Total Staff 4
Organogram
Head Manager
HR Executives (3)
Trainee
Jobs amp Responsibilities
Manpower Planning
Internal Job Posting Process
CV Selection
Confirmation and Appraisal
Staff Queries
Follow up with selected candidates
Issuing of appointment letters
Disciplinary Policy
Leaves sanctioning
14
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Payroll
Budgeting for departments
Doctors payout
Duty roster
Issuing of Experience letters
STORES
Layout -New Stores Block
Staff 4
Hierarchy
Stores Manager
Store Supervisor
Bio medical Engineer GDA
Records Maintained
Goods Receipt Note Quotations Purchase Requests Capital Sanctioned Record
WORK FLOW
Department in need of material
Through HIS Indentation
or Requisition slip
Store15
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Issue Note Return File Purchase Receipt Purchase Orders
Store checks for the required material and the quantity
YES NO
Material issued and recorded in Issue Register Entry into Shortage Register
Record of the material entered HIS ldquoPurchase Requestrdquo is filled in HIS
Duties of Store In charge
Forecasting requirement Budgetary requirement Inventory control Stock verification Communicate the purchase
department about requirement Minimize pilferage
INFORMATION TECHNOLOGY (IT) DEPARTMENT
Layout -Ground Floor Main Building
Staff 3
Functions and responsibilities
To keep the servers alive
To keep the network alive
To keep internet connection alive
To take care of all the desktops amp laptops in the organization
To track the records of all the desktops
To keep an eye on the employees desktops
To resolve the complaints of the employees
Training of the other staff for the HIS
Major Work Areas General Administration amp HIS
16
Bin card maintained At a time 2800 items maintained in
the stores Random sample check to ensure the
genuinity and authenticity of product Disposal of surplus obsolete
Material Distribution
I) General Administration
Servers
Anti virus server Database server Application server Archive server
II) HIS (Hospital Information System)
Application by Avanttec
Billing Ward management Laboratory services Discharges + Medical Records Housekeeping Pharmacy Payroll Medical equipment
Access to Information
o User specific access according to their roles
HIS Backup
Done once a day Centralized database Internal backups
MEDICAL RECORD DEPARTMENT
Layout -MRD Block
Staff 3
Infrastructure
Desktop 1
Printer 1
Organogram Medical Records Officer Statistician
Medical Records Technician
17
Functions of MRD
To ensure that the Shija Hospital has complete amp accurate medical record for every
patient
Public dealings with respect to Bill verification MLC cases and dealing with
Summons to the doctors hospital
To maintain high level of confidentiality as far as patientrsquos records are concerned
To ensure that the records are Identified and stored safely to prevent unauthorized
changes and easily retrieved whenever required
Issuing Emergency Medical Birth amp Death certificates
To generate Bed Occupancy reports ALOS and other hospital statistics (daily amp
monthly)
Record Retention Periods
IP Record 05 years
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patient
CLINICAL NUTRITION amp DIETICS DEPARTMENT
Layout -Ground floor OPD Block
Head Dietician Ms Bimota
Functions
Catering to Inpatients Diet counseling Education Smooth provision of laid out diets to the patients To check the patient food for quality preparation presentation and packing Coordinating closely with the Nursing shift in charges for changes in the patientrsquos
diet or new admissions etc
Records Maintained
Diet order sheet Meal count register Store register Diet Sheets
18
Counseling Register
Type of Diet Diet Card Color
Normal White
Diabetes Mellitus Yellow
Chronic Renal Failure Blue
Liquid Diet Pink
Flowchart of Dietician and Inpatient Interaction
The Dietician takes details of new patients such as name UHID doctorrsquos name diagnosis and diet prescribed Then Dietician takes a detailed round wherein she meets every patient and determines patientsrsquo actual intake Dietician then provides nutritional counseling and education ensures patientsrsquo compliance to recommended diet She also recognizes personal eating and food preferences
Afterwards the dietician does nutritional screening in order to know about patientsrsquo clinical condition appetite and tolerance to food and acceptance to hospital diet personal preferences disliking and food allergies if any
After the rounds detailed food summary sheets are planned and prepared for every patient keeping in mind medical history and preferences of patient as well
SECURITY
Own security force not outsourced since 2009
Area of Operation (Present)
To deal with 3 ldquoMrdquo- Man Material amp Machinery
Visitorrsquos check Entry restriction at ICU gate Security for doctors and nurse quarter Surveillance of hospital through CCTVrsquos Theft Burglary Violence Material movements in amp out of the hospital Handling visitorrsquos pass In case of patientrsquos death handling emotional chaos of attendants Parking management and traffic control
19
HOUSEKEEPING
Status Own
Department Manager Mr Arju
FUNCTIONS
bull Clean Floor Wall Ceiling
bull Discharge Cleaning
bull Remove Garbage
bull Replace Supplies In Utility Rooms
bull Clean Housekeeping Equipments
bull Clean Room Wards Reception OT ICU Etc
bull Infection Control
bull Pest amp Rodent Control
bull Odour Control
LAUNDRY- Own
Department in charge- MsUmajini
Functions
Segregation of soiled and clean linen Traffic flow of linen before 8am Carrying the linen around the hospital Registered linen and purpose System of collection
o Colored bins
Infected linen handled separately- soaked in sodium hyperchloride Register maintained ndash separate for infected and un-infected linen Floor wise collection Different registers for each type of linen Separate people for ironing and drying from those who collect and wash
20
bull Environment Hygiene
bull Sanitation Hygiene
bull Checking Cleanliness Of All Areas
bull Control amp Reporting Of All
Maintenance Works
bull Hospital Waste Disposal
bull In-Service Training
bull Cooperation with Other Depts
Shared responsibility with nurses in charge Report- washing record submitted to HR dept Due list of linen- expected on Monday
GAPS IDENTIFIED IN STORES MANAGEMENT
No forecasting of requirement done ie Reorder Levels not defined
No analysis like ABC VED done for inventory control
Codification of items still in progress
HIS for Stores still not completely streamlined
AMC amp CMC not maintained for all
Some departments go beyond the indent allowance
Repair and Maintenance of equipments There are instruments which are not used at all
o Non-functionalo Repair requiredo Condemned
For Quality assurance o Quality calibration o Annual Maintenance Contracto Complete Maintenance Contract
Instruments go for regular servicing or they are serviced and examined regularly- Some machines are serviced in the hospital- eg computers printers patient
monitor BP instrument Alternative arrangements are available during that period of time- Patient
monitors from other wards are managedo No back up stock available
Shortage during repair period Patient monitor ndash completely mobile thus record maintenance difficult-
communication gap between the material managers 3 total staff
GAPS IDENTIFIED IN HMIS
Avanttec is a Chennai Based HIS system hence immediate access to providers not available
Strong foundation but HIS is still not fully streamlined Personnel shortage in the department No staff at night
21
GAPS IDENTIFIED IN LAUNDRY DEPARTMENT
6 Set rule per patient not followed Presently only 2 sets per patient No weighing scale No sewing machine for repair No supervision over measured use of detergent and other chemicals
PROJECT ndash 1
A Study on Discharge Procedure with Special Emphasis
on In-Patient Feedback
22
INTRODUCTION
The study was carried out in Shija Hospitals and Research Institute which is a 180 bedded hospital located in Manipur The Hospital is well known for its high end technology and services in the region The Hospital looks forward to continually develop its services and improve the facilities available in order to become a well known health service provider in the South East Asian region in the future The operations management had identified the discharge procedure as an area where there was a scope for improvement Hence the hospital had assigned the project to study the discharge procedure
Discharging a patient is an activity common to every hospital - small large community inner-city teaching or non-teaching The discharge process can have an impact on numerous factors such as patient satisfaction bed availability timely tests and procedures needed for discharge transportation and nursing home arrangements No matter what type of patient is being discharged (maternity medicine orthopedic neurologic) numerous activities must be completed for each before the patient can be released This work toward discharge day should begin upon admission
As part of a progress towards NABH accreditation at Shija Hospital the discharge process is one of the many process improvement projects The discharge process at this hospital also incorporates obtaining feedback from the in-patient regarding the services at the time of discharge Due to inappropriate management the hospital was facing an acute shortage in the feedback response from the patients
The management at the hospital realizes the need and importance of patient satisfaction and a need of a measurable index through feedback analysis In all service industries customer retention is a vital issue Hence the management wanted to do all that they could to obtain feedback from the patients at the time of discharge and make the discharge procedure as smooth as it can get
The objective of this study was to study the process of discharge and find out the probable reasons for the failure to attain feedback from the patients at the time of discharge
23
STUDY METHODOLOGY
AIM
To study the discharge procedure practiced at Shija Hospitals with special emphasis on
analyzing the reasons for the short-fall of In-Patient Feedback
OBJECTIVE
1 To find the steps followed during discharge of an in-patient2 To find the total time taken for a discharge of a single patient3 To find the contributing reasons for the short fall of in-patient feedback
received in the wards
RATIONALE
The discharge of a patient is a very important component of in-patient service and needs to be smooth and efficient On the other hand in-patient feedback is equally important as it provides the performance standards of the hospital which needs to be continually enhanced
METHODOLOGY
Study design-
Area- Shija Hospitals and Research Institute Manipur
Duration- From 11-04-2011 to 30-04-2011
Type of study- Observational and Survey study
Sample size-120 in-patients and the following hospital staff
Nurse Superintendant
RMOs on duty
Staff nurse
Front office executives
Service entry staff
Sampling Method-Convenience sampling
Study tool Questionnaire and personal interviews
24
Type of Data collected -
Interviewer guided questionnaires collected from patients by visiting the different wards
Personal interview of various hospital staff and officials involved in discharge procedure
DISCHARGE PROCESS
25
Doctor prescribes the discharge
Nurse informs the patient about the time of discharge
26
Staff nurse starts discharge formalities by
Asking the Resident Medical Officer Concerned Physician to
make discharge summary
Informing Dietician to make discharge diet report for patient
Counseling of the patient by the dietician and physiotherapist (if
physiotherapy is going on for patient)
Asking the service entry assistants to enter all the details regarding the
patients starting from the no of consultant visits to medicines
consumed
Sending to Pharmacy Daily Billing Activity Sheet
Daily Pharmacy BillsDischarge medication detailsMedicines left unconsumed
In Pharmacy Summary of Pharmacy Bill is prepared
Daily Billing Activity Sheet
Summarized Pharmacy Bill
Giving the feedback form to the patient attendants
Fig1 Communication channels during the discharge procedure
27
Billing department finalizes the bill
Payment taken by billing department from attendants
IPD Billing informs at the nursing station about the clearance of bill
Discharge Summary completion by Medical Transcriptionist
Nurse informs the patient amp patient changes clothes
Nurse checks the checklist given for discharge of patient
All medications + Investigations reports + Patientrsquos file given to the patient
Patient given amp explained about how to take the medications + any special instruction + follow up schedule
Patient Discharged
Collects the filled up feedback form from the patient attendants
There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays
Fig 2 A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital
020406080
100120
82
28 39
102
Compliance to discharge procedure
No
of p
atien
ts
Table1 Duration of various parameters related to discharge
28
DoctorNurseService ward boysBillingofficePatient
Various other departments of the hospital
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
Patientrsquos Identification done amp verified
Surgery performed
Recording of all consumable used is recorded
Surgery completed
Surgery completed
Collection of OT Waste
Disposal by housekeeping
staff as per rules
Count of instruments
ldquoPostrdquo Column of Instrument
check list form completed
Transfer of patient to Recovery
room
Patient shifted to Ward SICU
Updation of records
Operation notes amp patientrsquos
record completed
Operation Daily charge bill formed
OT Drug inventory checked
Requisition send to
Pharmacy
OT Inventory replenished
OT Prepared for next surgery
Operation Theatre
Layout 1st flooor No of OTrsquos 6
General OTrsquos ndash 3 Eye OT- 1 Minor OT - 2
12
No of beds in Pre operative ward 7 No of beds in post operative wards 8 Utility room 1 Doctorrsquos Lounge 1 Nurse and Technician Lounge 1 Pantry 1 Sterile room 1 Changing rooms 4
Doctor (male) changing room 1 Doctor (female) changing room 1 Nurse (female) changing room 1 Technician + Nurse (male) changing room 1
Patient admission procedure in ICU
Physician
(Desiring admission of a patient in ICU)
contacts
Admission Office
Contacts for Bed Availability with
ICU
(Nurse ndash Ward Supervisor)
Beds Available No ICU Bed available
Admission done Admission office contacts
Nursing Administrator
Nursing Administrator starts
ICU patients ldquostatus evaluationrdquo
13
Any patient can be shifted None can be shifted
to Wards
Patient shifted to ICU after one patient Patient is stabilizedis shifted to Wards
Nursing Supervisor contacts
Administrator on-call
He authorize transfer of
patient to other hospital
HUMAN RESOURCE DEPARTMENT
Layout -Administrative Block Ground Floor
Total Staff 4
Organogram
Head Manager
HR Executives (3)
Trainee
Jobs amp Responsibilities
Manpower Planning
Internal Job Posting Process
CV Selection
Confirmation and Appraisal
Staff Queries
Follow up with selected candidates
Issuing of appointment letters
Disciplinary Policy
Leaves sanctioning
14
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Payroll
Budgeting for departments
Doctors payout
Duty roster
Issuing of Experience letters
STORES
Layout -New Stores Block
Staff 4
Hierarchy
Stores Manager
Store Supervisor
Bio medical Engineer GDA
Records Maintained
Goods Receipt Note Quotations Purchase Requests Capital Sanctioned Record
WORK FLOW
Department in need of material
Through HIS Indentation
or Requisition slip
Store15
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Issue Note Return File Purchase Receipt Purchase Orders
Store checks for the required material and the quantity
YES NO
Material issued and recorded in Issue Register Entry into Shortage Register
Record of the material entered HIS ldquoPurchase Requestrdquo is filled in HIS
Duties of Store In charge
Forecasting requirement Budgetary requirement Inventory control Stock verification Communicate the purchase
department about requirement Minimize pilferage
INFORMATION TECHNOLOGY (IT) DEPARTMENT
Layout -Ground Floor Main Building
Staff 3
Functions and responsibilities
To keep the servers alive
To keep the network alive
To keep internet connection alive
To take care of all the desktops amp laptops in the organization
To track the records of all the desktops
To keep an eye on the employees desktops
To resolve the complaints of the employees
Training of the other staff for the HIS
Major Work Areas General Administration amp HIS
16
Bin card maintained At a time 2800 items maintained in
the stores Random sample check to ensure the
genuinity and authenticity of product Disposal of surplus obsolete
Material Distribution
I) General Administration
Servers
Anti virus server Database server Application server Archive server
II) HIS (Hospital Information System)
Application by Avanttec
Billing Ward management Laboratory services Discharges + Medical Records Housekeeping Pharmacy Payroll Medical equipment
Access to Information
o User specific access according to their roles
HIS Backup
Done once a day Centralized database Internal backups
MEDICAL RECORD DEPARTMENT
Layout -MRD Block
Staff 3
Infrastructure
Desktop 1
Printer 1
Organogram Medical Records Officer Statistician
Medical Records Technician
17
Functions of MRD
To ensure that the Shija Hospital has complete amp accurate medical record for every
patient
Public dealings with respect to Bill verification MLC cases and dealing with
Summons to the doctors hospital
To maintain high level of confidentiality as far as patientrsquos records are concerned
To ensure that the records are Identified and stored safely to prevent unauthorized
changes and easily retrieved whenever required
Issuing Emergency Medical Birth amp Death certificates
To generate Bed Occupancy reports ALOS and other hospital statistics (daily amp
monthly)
Record Retention Periods
IP Record 05 years
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patient
CLINICAL NUTRITION amp DIETICS DEPARTMENT
Layout -Ground floor OPD Block
Head Dietician Ms Bimota
Functions
Catering to Inpatients Diet counseling Education Smooth provision of laid out diets to the patients To check the patient food for quality preparation presentation and packing Coordinating closely with the Nursing shift in charges for changes in the patientrsquos
diet or new admissions etc
Records Maintained
Diet order sheet Meal count register Store register Diet Sheets
18
Counseling Register
Type of Diet Diet Card Color
Normal White
Diabetes Mellitus Yellow
Chronic Renal Failure Blue
Liquid Diet Pink
Flowchart of Dietician and Inpatient Interaction
The Dietician takes details of new patients such as name UHID doctorrsquos name diagnosis and diet prescribed Then Dietician takes a detailed round wherein she meets every patient and determines patientsrsquo actual intake Dietician then provides nutritional counseling and education ensures patientsrsquo compliance to recommended diet She also recognizes personal eating and food preferences
Afterwards the dietician does nutritional screening in order to know about patientsrsquo clinical condition appetite and tolerance to food and acceptance to hospital diet personal preferences disliking and food allergies if any
After the rounds detailed food summary sheets are planned and prepared for every patient keeping in mind medical history and preferences of patient as well
SECURITY
Own security force not outsourced since 2009
Area of Operation (Present)
To deal with 3 ldquoMrdquo- Man Material amp Machinery
Visitorrsquos check Entry restriction at ICU gate Security for doctors and nurse quarter Surveillance of hospital through CCTVrsquos Theft Burglary Violence Material movements in amp out of the hospital Handling visitorrsquos pass In case of patientrsquos death handling emotional chaos of attendants Parking management and traffic control
19
HOUSEKEEPING
Status Own
Department Manager Mr Arju
FUNCTIONS
bull Clean Floor Wall Ceiling
bull Discharge Cleaning
bull Remove Garbage
bull Replace Supplies In Utility Rooms
bull Clean Housekeeping Equipments
bull Clean Room Wards Reception OT ICU Etc
bull Infection Control
bull Pest amp Rodent Control
bull Odour Control
LAUNDRY- Own
Department in charge- MsUmajini
Functions
Segregation of soiled and clean linen Traffic flow of linen before 8am Carrying the linen around the hospital Registered linen and purpose System of collection
o Colored bins
Infected linen handled separately- soaked in sodium hyperchloride Register maintained ndash separate for infected and un-infected linen Floor wise collection Different registers for each type of linen Separate people for ironing and drying from those who collect and wash
20
bull Environment Hygiene
bull Sanitation Hygiene
bull Checking Cleanliness Of All Areas
bull Control amp Reporting Of All
Maintenance Works
bull Hospital Waste Disposal
bull In-Service Training
bull Cooperation with Other Depts
Shared responsibility with nurses in charge Report- washing record submitted to HR dept Due list of linen- expected on Monday
GAPS IDENTIFIED IN STORES MANAGEMENT
No forecasting of requirement done ie Reorder Levels not defined
No analysis like ABC VED done for inventory control
Codification of items still in progress
HIS for Stores still not completely streamlined
AMC amp CMC not maintained for all
Some departments go beyond the indent allowance
Repair and Maintenance of equipments There are instruments which are not used at all
o Non-functionalo Repair requiredo Condemned
For Quality assurance o Quality calibration o Annual Maintenance Contracto Complete Maintenance Contract
Instruments go for regular servicing or they are serviced and examined regularly- Some machines are serviced in the hospital- eg computers printers patient
monitor BP instrument Alternative arrangements are available during that period of time- Patient
monitors from other wards are managedo No back up stock available
Shortage during repair period Patient monitor ndash completely mobile thus record maintenance difficult-
communication gap between the material managers 3 total staff
GAPS IDENTIFIED IN HMIS
Avanttec is a Chennai Based HIS system hence immediate access to providers not available
Strong foundation but HIS is still not fully streamlined Personnel shortage in the department No staff at night
21
GAPS IDENTIFIED IN LAUNDRY DEPARTMENT
6 Set rule per patient not followed Presently only 2 sets per patient No weighing scale No sewing machine for repair No supervision over measured use of detergent and other chemicals
PROJECT ndash 1
A Study on Discharge Procedure with Special Emphasis
on In-Patient Feedback
22
INTRODUCTION
The study was carried out in Shija Hospitals and Research Institute which is a 180 bedded hospital located in Manipur The Hospital is well known for its high end technology and services in the region The Hospital looks forward to continually develop its services and improve the facilities available in order to become a well known health service provider in the South East Asian region in the future The operations management had identified the discharge procedure as an area where there was a scope for improvement Hence the hospital had assigned the project to study the discharge procedure
Discharging a patient is an activity common to every hospital - small large community inner-city teaching or non-teaching The discharge process can have an impact on numerous factors such as patient satisfaction bed availability timely tests and procedures needed for discharge transportation and nursing home arrangements No matter what type of patient is being discharged (maternity medicine orthopedic neurologic) numerous activities must be completed for each before the patient can be released This work toward discharge day should begin upon admission
As part of a progress towards NABH accreditation at Shija Hospital the discharge process is one of the many process improvement projects The discharge process at this hospital also incorporates obtaining feedback from the in-patient regarding the services at the time of discharge Due to inappropriate management the hospital was facing an acute shortage in the feedback response from the patients
The management at the hospital realizes the need and importance of patient satisfaction and a need of a measurable index through feedback analysis In all service industries customer retention is a vital issue Hence the management wanted to do all that they could to obtain feedback from the patients at the time of discharge and make the discharge procedure as smooth as it can get
The objective of this study was to study the process of discharge and find out the probable reasons for the failure to attain feedback from the patients at the time of discharge
23
STUDY METHODOLOGY
AIM
To study the discharge procedure practiced at Shija Hospitals with special emphasis on
analyzing the reasons for the short-fall of In-Patient Feedback
OBJECTIVE
1 To find the steps followed during discharge of an in-patient2 To find the total time taken for a discharge of a single patient3 To find the contributing reasons for the short fall of in-patient feedback
received in the wards
RATIONALE
The discharge of a patient is a very important component of in-patient service and needs to be smooth and efficient On the other hand in-patient feedback is equally important as it provides the performance standards of the hospital which needs to be continually enhanced
METHODOLOGY
Study design-
Area- Shija Hospitals and Research Institute Manipur
Duration- From 11-04-2011 to 30-04-2011
Type of study- Observational and Survey study
Sample size-120 in-patients and the following hospital staff
Nurse Superintendant
RMOs on duty
Staff nurse
Front office executives
Service entry staff
Sampling Method-Convenience sampling
Study tool Questionnaire and personal interviews
24
Type of Data collected -
Interviewer guided questionnaires collected from patients by visiting the different wards
Personal interview of various hospital staff and officials involved in discharge procedure
DISCHARGE PROCESS
25
Doctor prescribes the discharge
Nurse informs the patient about the time of discharge
26
Staff nurse starts discharge formalities by
Asking the Resident Medical Officer Concerned Physician to
make discharge summary
Informing Dietician to make discharge diet report for patient
Counseling of the patient by the dietician and physiotherapist (if
physiotherapy is going on for patient)
Asking the service entry assistants to enter all the details regarding the
patients starting from the no of consultant visits to medicines
consumed
Sending to Pharmacy Daily Billing Activity Sheet
Daily Pharmacy BillsDischarge medication detailsMedicines left unconsumed
In Pharmacy Summary of Pharmacy Bill is prepared
Daily Billing Activity Sheet
Summarized Pharmacy Bill
Giving the feedback form to the patient attendants
Fig1 Communication channels during the discharge procedure
27
Billing department finalizes the bill
Payment taken by billing department from attendants
IPD Billing informs at the nursing station about the clearance of bill
Discharge Summary completion by Medical Transcriptionist
Nurse informs the patient amp patient changes clothes
Nurse checks the checklist given for discharge of patient
All medications + Investigations reports + Patientrsquos file given to the patient
Patient given amp explained about how to take the medications + any special instruction + follow up schedule
Patient Discharged
Collects the filled up feedback form from the patient attendants
There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays
Fig 2 A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital
020406080
100120
82
28 39
102
Compliance to discharge procedure
No
of p
atien
ts
Table1 Duration of various parameters related to discharge
28
DoctorNurseService ward boysBillingofficePatient
Various other departments of the hospital
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
No of beds in Pre operative ward 7 No of beds in post operative wards 8 Utility room 1 Doctorrsquos Lounge 1 Nurse and Technician Lounge 1 Pantry 1 Sterile room 1 Changing rooms 4
Doctor (male) changing room 1 Doctor (female) changing room 1 Nurse (female) changing room 1 Technician + Nurse (male) changing room 1
Patient admission procedure in ICU
Physician
(Desiring admission of a patient in ICU)
contacts
Admission Office
Contacts for Bed Availability with
ICU
(Nurse ndash Ward Supervisor)
Beds Available No ICU Bed available
Admission done Admission office contacts
Nursing Administrator
Nursing Administrator starts
ICU patients ldquostatus evaluationrdquo
13
Any patient can be shifted None can be shifted
to Wards
Patient shifted to ICU after one patient Patient is stabilizedis shifted to Wards
Nursing Supervisor contacts
Administrator on-call
He authorize transfer of
patient to other hospital
HUMAN RESOURCE DEPARTMENT
Layout -Administrative Block Ground Floor
Total Staff 4
Organogram
Head Manager
HR Executives (3)
Trainee
Jobs amp Responsibilities
Manpower Planning
Internal Job Posting Process
CV Selection
Confirmation and Appraisal
Staff Queries
Follow up with selected candidates
Issuing of appointment letters
Disciplinary Policy
Leaves sanctioning
14
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Payroll
Budgeting for departments
Doctors payout
Duty roster
Issuing of Experience letters
STORES
Layout -New Stores Block
Staff 4
Hierarchy
Stores Manager
Store Supervisor
Bio medical Engineer GDA
Records Maintained
Goods Receipt Note Quotations Purchase Requests Capital Sanctioned Record
WORK FLOW
Department in need of material
Through HIS Indentation
or Requisition slip
Store15
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Issue Note Return File Purchase Receipt Purchase Orders
Store checks for the required material and the quantity
YES NO
Material issued and recorded in Issue Register Entry into Shortage Register
Record of the material entered HIS ldquoPurchase Requestrdquo is filled in HIS
Duties of Store In charge
Forecasting requirement Budgetary requirement Inventory control Stock verification Communicate the purchase
department about requirement Minimize pilferage
INFORMATION TECHNOLOGY (IT) DEPARTMENT
Layout -Ground Floor Main Building
Staff 3
Functions and responsibilities
To keep the servers alive
To keep the network alive
To keep internet connection alive
To take care of all the desktops amp laptops in the organization
To track the records of all the desktops
To keep an eye on the employees desktops
To resolve the complaints of the employees
Training of the other staff for the HIS
Major Work Areas General Administration amp HIS
16
Bin card maintained At a time 2800 items maintained in
the stores Random sample check to ensure the
genuinity and authenticity of product Disposal of surplus obsolete
Material Distribution
I) General Administration
Servers
Anti virus server Database server Application server Archive server
II) HIS (Hospital Information System)
Application by Avanttec
Billing Ward management Laboratory services Discharges + Medical Records Housekeeping Pharmacy Payroll Medical equipment
Access to Information
o User specific access according to their roles
HIS Backup
Done once a day Centralized database Internal backups
MEDICAL RECORD DEPARTMENT
Layout -MRD Block
Staff 3
Infrastructure
Desktop 1
Printer 1
Organogram Medical Records Officer Statistician
Medical Records Technician
17
Functions of MRD
To ensure that the Shija Hospital has complete amp accurate medical record for every
patient
Public dealings with respect to Bill verification MLC cases and dealing with
Summons to the doctors hospital
To maintain high level of confidentiality as far as patientrsquos records are concerned
To ensure that the records are Identified and stored safely to prevent unauthorized
changes and easily retrieved whenever required
Issuing Emergency Medical Birth amp Death certificates
To generate Bed Occupancy reports ALOS and other hospital statistics (daily amp
monthly)
Record Retention Periods
IP Record 05 years
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patient
CLINICAL NUTRITION amp DIETICS DEPARTMENT
Layout -Ground floor OPD Block
Head Dietician Ms Bimota
Functions
Catering to Inpatients Diet counseling Education Smooth provision of laid out diets to the patients To check the patient food for quality preparation presentation and packing Coordinating closely with the Nursing shift in charges for changes in the patientrsquos
diet or new admissions etc
Records Maintained
Diet order sheet Meal count register Store register Diet Sheets
18
Counseling Register
Type of Diet Diet Card Color
Normal White
Diabetes Mellitus Yellow
Chronic Renal Failure Blue
Liquid Diet Pink
Flowchart of Dietician and Inpatient Interaction
The Dietician takes details of new patients such as name UHID doctorrsquos name diagnosis and diet prescribed Then Dietician takes a detailed round wherein she meets every patient and determines patientsrsquo actual intake Dietician then provides nutritional counseling and education ensures patientsrsquo compliance to recommended diet She also recognizes personal eating and food preferences
Afterwards the dietician does nutritional screening in order to know about patientsrsquo clinical condition appetite and tolerance to food and acceptance to hospital diet personal preferences disliking and food allergies if any
After the rounds detailed food summary sheets are planned and prepared for every patient keeping in mind medical history and preferences of patient as well
SECURITY
Own security force not outsourced since 2009
Area of Operation (Present)
To deal with 3 ldquoMrdquo- Man Material amp Machinery
Visitorrsquos check Entry restriction at ICU gate Security for doctors and nurse quarter Surveillance of hospital through CCTVrsquos Theft Burglary Violence Material movements in amp out of the hospital Handling visitorrsquos pass In case of patientrsquos death handling emotional chaos of attendants Parking management and traffic control
19
HOUSEKEEPING
Status Own
Department Manager Mr Arju
FUNCTIONS
bull Clean Floor Wall Ceiling
bull Discharge Cleaning
bull Remove Garbage
bull Replace Supplies In Utility Rooms
bull Clean Housekeeping Equipments
bull Clean Room Wards Reception OT ICU Etc
bull Infection Control
bull Pest amp Rodent Control
bull Odour Control
LAUNDRY- Own
Department in charge- MsUmajini
Functions
Segregation of soiled and clean linen Traffic flow of linen before 8am Carrying the linen around the hospital Registered linen and purpose System of collection
o Colored bins
Infected linen handled separately- soaked in sodium hyperchloride Register maintained ndash separate for infected and un-infected linen Floor wise collection Different registers for each type of linen Separate people for ironing and drying from those who collect and wash
20
bull Environment Hygiene
bull Sanitation Hygiene
bull Checking Cleanliness Of All Areas
bull Control amp Reporting Of All
Maintenance Works
bull Hospital Waste Disposal
bull In-Service Training
bull Cooperation with Other Depts
Shared responsibility with nurses in charge Report- washing record submitted to HR dept Due list of linen- expected on Monday
GAPS IDENTIFIED IN STORES MANAGEMENT
No forecasting of requirement done ie Reorder Levels not defined
No analysis like ABC VED done for inventory control
Codification of items still in progress
HIS for Stores still not completely streamlined
AMC amp CMC not maintained for all
Some departments go beyond the indent allowance
Repair and Maintenance of equipments There are instruments which are not used at all
o Non-functionalo Repair requiredo Condemned
For Quality assurance o Quality calibration o Annual Maintenance Contracto Complete Maintenance Contract
Instruments go for regular servicing or they are serviced and examined regularly- Some machines are serviced in the hospital- eg computers printers patient
monitor BP instrument Alternative arrangements are available during that period of time- Patient
monitors from other wards are managedo No back up stock available
Shortage during repair period Patient monitor ndash completely mobile thus record maintenance difficult-
communication gap between the material managers 3 total staff
GAPS IDENTIFIED IN HMIS
Avanttec is a Chennai Based HIS system hence immediate access to providers not available
Strong foundation but HIS is still not fully streamlined Personnel shortage in the department No staff at night
21
GAPS IDENTIFIED IN LAUNDRY DEPARTMENT
6 Set rule per patient not followed Presently only 2 sets per patient No weighing scale No sewing machine for repair No supervision over measured use of detergent and other chemicals
PROJECT ndash 1
A Study on Discharge Procedure with Special Emphasis
on In-Patient Feedback
22
INTRODUCTION
The study was carried out in Shija Hospitals and Research Institute which is a 180 bedded hospital located in Manipur The Hospital is well known for its high end technology and services in the region The Hospital looks forward to continually develop its services and improve the facilities available in order to become a well known health service provider in the South East Asian region in the future The operations management had identified the discharge procedure as an area where there was a scope for improvement Hence the hospital had assigned the project to study the discharge procedure
Discharging a patient is an activity common to every hospital - small large community inner-city teaching or non-teaching The discharge process can have an impact on numerous factors such as patient satisfaction bed availability timely tests and procedures needed for discharge transportation and nursing home arrangements No matter what type of patient is being discharged (maternity medicine orthopedic neurologic) numerous activities must be completed for each before the patient can be released This work toward discharge day should begin upon admission
As part of a progress towards NABH accreditation at Shija Hospital the discharge process is one of the many process improvement projects The discharge process at this hospital also incorporates obtaining feedback from the in-patient regarding the services at the time of discharge Due to inappropriate management the hospital was facing an acute shortage in the feedback response from the patients
The management at the hospital realizes the need and importance of patient satisfaction and a need of a measurable index through feedback analysis In all service industries customer retention is a vital issue Hence the management wanted to do all that they could to obtain feedback from the patients at the time of discharge and make the discharge procedure as smooth as it can get
The objective of this study was to study the process of discharge and find out the probable reasons for the failure to attain feedback from the patients at the time of discharge
23
STUDY METHODOLOGY
AIM
To study the discharge procedure practiced at Shija Hospitals with special emphasis on
analyzing the reasons for the short-fall of In-Patient Feedback
OBJECTIVE
1 To find the steps followed during discharge of an in-patient2 To find the total time taken for a discharge of a single patient3 To find the contributing reasons for the short fall of in-patient feedback
received in the wards
RATIONALE
The discharge of a patient is a very important component of in-patient service and needs to be smooth and efficient On the other hand in-patient feedback is equally important as it provides the performance standards of the hospital which needs to be continually enhanced
METHODOLOGY
Study design-
Area- Shija Hospitals and Research Institute Manipur
Duration- From 11-04-2011 to 30-04-2011
Type of study- Observational and Survey study
Sample size-120 in-patients and the following hospital staff
Nurse Superintendant
RMOs on duty
Staff nurse
Front office executives
Service entry staff
Sampling Method-Convenience sampling
Study tool Questionnaire and personal interviews
24
Type of Data collected -
Interviewer guided questionnaires collected from patients by visiting the different wards
Personal interview of various hospital staff and officials involved in discharge procedure
DISCHARGE PROCESS
25
Doctor prescribes the discharge
Nurse informs the patient about the time of discharge
26
Staff nurse starts discharge formalities by
Asking the Resident Medical Officer Concerned Physician to
make discharge summary
Informing Dietician to make discharge diet report for patient
Counseling of the patient by the dietician and physiotherapist (if
physiotherapy is going on for patient)
Asking the service entry assistants to enter all the details regarding the
patients starting from the no of consultant visits to medicines
consumed
Sending to Pharmacy Daily Billing Activity Sheet
Daily Pharmacy BillsDischarge medication detailsMedicines left unconsumed
In Pharmacy Summary of Pharmacy Bill is prepared
Daily Billing Activity Sheet
Summarized Pharmacy Bill
Giving the feedback form to the patient attendants
Fig1 Communication channels during the discharge procedure
27
Billing department finalizes the bill
Payment taken by billing department from attendants
IPD Billing informs at the nursing station about the clearance of bill
Discharge Summary completion by Medical Transcriptionist
Nurse informs the patient amp patient changes clothes
Nurse checks the checklist given for discharge of patient
All medications + Investigations reports + Patientrsquos file given to the patient
Patient given amp explained about how to take the medications + any special instruction + follow up schedule
Patient Discharged
Collects the filled up feedback form from the patient attendants
There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays
Fig 2 A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital
020406080
100120
82
28 39
102
Compliance to discharge procedure
No
of p
atien
ts
Table1 Duration of various parameters related to discharge
28
DoctorNurseService ward boysBillingofficePatient
Various other departments of the hospital
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
Any patient can be shifted None can be shifted
to Wards
Patient shifted to ICU after one patient Patient is stabilizedis shifted to Wards
Nursing Supervisor contacts
Administrator on-call
He authorize transfer of
patient to other hospital
HUMAN RESOURCE DEPARTMENT
Layout -Administrative Block Ground Floor
Total Staff 4
Organogram
Head Manager
HR Executives (3)
Trainee
Jobs amp Responsibilities
Manpower Planning
Internal Job Posting Process
CV Selection
Confirmation and Appraisal
Staff Queries
Follow up with selected candidates
Issuing of appointment letters
Disciplinary Policy
Leaves sanctioning
14
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Payroll
Budgeting for departments
Doctors payout
Duty roster
Issuing of Experience letters
STORES
Layout -New Stores Block
Staff 4
Hierarchy
Stores Manager
Store Supervisor
Bio medical Engineer GDA
Records Maintained
Goods Receipt Note Quotations Purchase Requests Capital Sanctioned Record
WORK FLOW
Department in need of material
Through HIS Indentation
or Requisition slip
Store15
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Issue Note Return File Purchase Receipt Purchase Orders
Store checks for the required material and the quantity
YES NO
Material issued and recorded in Issue Register Entry into Shortage Register
Record of the material entered HIS ldquoPurchase Requestrdquo is filled in HIS
Duties of Store In charge
Forecasting requirement Budgetary requirement Inventory control Stock verification Communicate the purchase
department about requirement Minimize pilferage
INFORMATION TECHNOLOGY (IT) DEPARTMENT
Layout -Ground Floor Main Building
Staff 3
Functions and responsibilities
To keep the servers alive
To keep the network alive
To keep internet connection alive
To take care of all the desktops amp laptops in the organization
To track the records of all the desktops
To keep an eye on the employees desktops
To resolve the complaints of the employees
Training of the other staff for the HIS
Major Work Areas General Administration amp HIS
16
Bin card maintained At a time 2800 items maintained in
the stores Random sample check to ensure the
genuinity and authenticity of product Disposal of surplus obsolete
Material Distribution
I) General Administration
Servers
Anti virus server Database server Application server Archive server
II) HIS (Hospital Information System)
Application by Avanttec
Billing Ward management Laboratory services Discharges + Medical Records Housekeeping Pharmacy Payroll Medical equipment
Access to Information
o User specific access according to their roles
HIS Backup
Done once a day Centralized database Internal backups
MEDICAL RECORD DEPARTMENT
Layout -MRD Block
Staff 3
Infrastructure
Desktop 1
Printer 1
Organogram Medical Records Officer Statistician
Medical Records Technician
17
Functions of MRD
To ensure that the Shija Hospital has complete amp accurate medical record for every
patient
Public dealings with respect to Bill verification MLC cases and dealing with
Summons to the doctors hospital
To maintain high level of confidentiality as far as patientrsquos records are concerned
To ensure that the records are Identified and stored safely to prevent unauthorized
changes and easily retrieved whenever required
Issuing Emergency Medical Birth amp Death certificates
To generate Bed Occupancy reports ALOS and other hospital statistics (daily amp
monthly)
Record Retention Periods
IP Record 05 years
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patient
CLINICAL NUTRITION amp DIETICS DEPARTMENT
Layout -Ground floor OPD Block
Head Dietician Ms Bimota
Functions
Catering to Inpatients Diet counseling Education Smooth provision of laid out diets to the patients To check the patient food for quality preparation presentation and packing Coordinating closely with the Nursing shift in charges for changes in the patientrsquos
diet or new admissions etc
Records Maintained
Diet order sheet Meal count register Store register Diet Sheets
18
Counseling Register
Type of Diet Diet Card Color
Normal White
Diabetes Mellitus Yellow
Chronic Renal Failure Blue
Liquid Diet Pink
Flowchart of Dietician and Inpatient Interaction
The Dietician takes details of new patients such as name UHID doctorrsquos name diagnosis and diet prescribed Then Dietician takes a detailed round wherein she meets every patient and determines patientsrsquo actual intake Dietician then provides nutritional counseling and education ensures patientsrsquo compliance to recommended diet She also recognizes personal eating and food preferences
Afterwards the dietician does nutritional screening in order to know about patientsrsquo clinical condition appetite and tolerance to food and acceptance to hospital diet personal preferences disliking and food allergies if any
After the rounds detailed food summary sheets are planned and prepared for every patient keeping in mind medical history and preferences of patient as well
SECURITY
Own security force not outsourced since 2009
Area of Operation (Present)
To deal with 3 ldquoMrdquo- Man Material amp Machinery
Visitorrsquos check Entry restriction at ICU gate Security for doctors and nurse quarter Surveillance of hospital through CCTVrsquos Theft Burglary Violence Material movements in amp out of the hospital Handling visitorrsquos pass In case of patientrsquos death handling emotional chaos of attendants Parking management and traffic control
19
HOUSEKEEPING
Status Own
Department Manager Mr Arju
FUNCTIONS
bull Clean Floor Wall Ceiling
bull Discharge Cleaning
bull Remove Garbage
bull Replace Supplies In Utility Rooms
bull Clean Housekeeping Equipments
bull Clean Room Wards Reception OT ICU Etc
bull Infection Control
bull Pest amp Rodent Control
bull Odour Control
LAUNDRY- Own
Department in charge- MsUmajini
Functions
Segregation of soiled and clean linen Traffic flow of linen before 8am Carrying the linen around the hospital Registered linen and purpose System of collection
o Colored bins
Infected linen handled separately- soaked in sodium hyperchloride Register maintained ndash separate for infected and un-infected linen Floor wise collection Different registers for each type of linen Separate people for ironing and drying from those who collect and wash
20
bull Environment Hygiene
bull Sanitation Hygiene
bull Checking Cleanliness Of All Areas
bull Control amp Reporting Of All
Maintenance Works
bull Hospital Waste Disposal
bull In-Service Training
bull Cooperation with Other Depts
Shared responsibility with nurses in charge Report- washing record submitted to HR dept Due list of linen- expected on Monday
GAPS IDENTIFIED IN STORES MANAGEMENT
No forecasting of requirement done ie Reorder Levels not defined
No analysis like ABC VED done for inventory control
Codification of items still in progress
HIS for Stores still not completely streamlined
AMC amp CMC not maintained for all
Some departments go beyond the indent allowance
Repair and Maintenance of equipments There are instruments which are not used at all
o Non-functionalo Repair requiredo Condemned
For Quality assurance o Quality calibration o Annual Maintenance Contracto Complete Maintenance Contract
Instruments go for regular servicing or they are serviced and examined regularly- Some machines are serviced in the hospital- eg computers printers patient
monitor BP instrument Alternative arrangements are available during that period of time- Patient
monitors from other wards are managedo No back up stock available
Shortage during repair period Patient monitor ndash completely mobile thus record maintenance difficult-
communication gap between the material managers 3 total staff
GAPS IDENTIFIED IN HMIS
Avanttec is a Chennai Based HIS system hence immediate access to providers not available
Strong foundation but HIS is still not fully streamlined Personnel shortage in the department No staff at night
21
GAPS IDENTIFIED IN LAUNDRY DEPARTMENT
6 Set rule per patient not followed Presently only 2 sets per patient No weighing scale No sewing machine for repair No supervision over measured use of detergent and other chemicals
PROJECT ndash 1
A Study on Discharge Procedure with Special Emphasis
on In-Patient Feedback
22
INTRODUCTION
The study was carried out in Shija Hospitals and Research Institute which is a 180 bedded hospital located in Manipur The Hospital is well known for its high end technology and services in the region The Hospital looks forward to continually develop its services and improve the facilities available in order to become a well known health service provider in the South East Asian region in the future The operations management had identified the discharge procedure as an area where there was a scope for improvement Hence the hospital had assigned the project to study the discharge procedure
Discharging a patient is an activity common to every hospital - small large community inner-city teaching or non-teaching The discharge process can have an impact on numerous factors such as patient satisfaction bed availability timely tests and procedures needed for discharge transportation and nursing home arrangements No matter what type of patient is being discharged (maternity medicine orthopedic neurologic) numerous activities must be completed for each before the patient can be released This work toward discharge day should begin upon admission
As part of a progress towards NABH accreditation at Shija Hospital the discharge process is one of the many process improvement projects The discharge process at this hospital also incorporates obtaining feedback from the in-patient regarding the services at the time of discharge Due to inappropriate management the hospital was facing an acute shortage in the feedback response from the patients
The management at the hospital realizes the need and importance of patient satisfaction and a need of a measurable index through feedback analysis In all service industries customer retention is a vital issue Hence the management wanted to do all that they could to obtain feedback from the patients at the time of discharge and make the discharge procedure as smooth as it can get
The objective of this study was to study the process of discharge and find out the probable reasons for the failure to attain feedback from the patients at the time of discharge
23
STUDY METHODOLOGY
AIM
To study the discharge procedure practiced at Shija Hospitals with special emphasis on
analyzing the reasons for the short-fall of In-Patient Feedback
OBJECTIVE
1 To find the steps followed during discharge of an in-patient2 To find the total time taken for a discharge of a single patient3 To find the contributing reasons for the short fall of in-patient feedback
received in the wards
RATIONALE
The discharge of a patient is a very important component of in-patient service and needs to be smooth and efficient On the other hand in-patient feedback is equally important as it provides the performance standards of the hospital which needs to be continually enhanced
METHODOLOGY
Study design-
Area- Shija Hospitals and Research Institute Manipur
Duration- From 11-04-2011 to 30-04-2011
Type of study- Observational and Survey study
Sample size-120 in-patients and the following hospital staff
Nurse Superintendant
RMOs on duty
Staff nurse
Front office executives
Service entry staff
Sampling Method-Convenience sampling
Study tool Questionnaire and personal interviews
24
Type of Data collected -
Interviewer guided questionnaires collected from patients by visiting the different wards
Personal interview of various hospital staff and officials involved in discharge procedure
DISCHARGE PROCESS
25
Doctor prescribes the discharge
Nurse informs the patient about the time of discharge
26
Staff nurse starts discharge formalities by
Asking the Resident Medical Officer Concerned Physician to
make discharge summary
Informing Dietician to make discharge diet report for patient
Counseling of the patient by the dietician and physiotherapist (if
physiotherapy is going on for patient)
Asking the service entry assistants to enter all the details regarding the
patients starting from the no of consultant visits to medicines
consumed
Sending to Pharmacy Daily Billing Activity Sheet
Daily Pharmacy BillsDischarge medication detailsMedicines left unconsumed
In Pharmacy Summary of Pharmacy Bill is prepared
Daily Billing Activity Sheet
Summarized Pharmacy Bill
Giving the feedback form to the patient attendants
Fig1 Communication channels during the discharge procedure
27
Billing department finalizes the bill
Payment taken by billing department from attendants
IPD Billing informs at the nursing station about the clearance of bill
Discharge Summary completion by Medical Transcriptionist
Nurse informs the patient amp patient changes clothes
Nurse checks the checklist given for discharge of patient
All medications + Investigations reports + Patientrsquos file given to the patient
Patient given amp explained about how to take the medications + any special instruction + follow up schedule
Patient Discharged
Collects the filled up feedback form from the patient attendants
There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays
Fig 2 A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital
020406080
100120
82
28 39
102
Compliance to discharge procedure
No
of p
atien
ts
Table1 Duration of various parameters related to discharge
28
DoctorNurseService ward boysBillingofficePatient
Various other departments of the hospital
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
Payroll
Budgeting for departments
Doctors payout
Duty roster
Issuing of Experience letters
STORES
Layout -New Stores Block
Staff 4
Hierarchy
Stores Manager
Store Supervisor
Bio medical Engineer GDA
Records Maintained
Goods Receipt Note Quotations Purchase Requests Capital Sanctioned Record
WORK FLOW
Department in need of material
Through HIS Indentation
or Requisition slip
Store15
Finger print report checking
Manpower planning
Dispatch of salaries
Pre recruitment calls
Organizing interviews
Preliminary interviews
Joining formalities
Leave record maintenance
Issuing of I-Cards
Salary statement
Full and final settlement
Induction and orientation
Investigation of staff grievances
Issue Note Return File Purchase Receipt Purchase Orders
Store checks for the required material and the quantity
YES NO
Material issued and recorded in Issue Register Entry into Shortage Register
Record of the material entered HIS ldquoPurchase Requestrdquo is filled in HIS
Duties of Store In charge
Forecasting requirement Budgetary requirement Inventory control Stock verification Communicate the purchase
department about requirement Minimize pilferage
INFORMATION TECHNOLOGY (IT) DEPARTMENT
Layout -Ground Floor Main Building
Staff 3
Functions and responsibilities
To keep the servers alive
To keep the network alive
To keep internet connection alive
To take care of all the desktops amp laptops in the organization
To track the records of all the desktops
To keep an eye on the employees desktops
To resolve the complaints of the employees
Training of the other staff for the HIS
Major Work Areas General Administration amp HIS
16
Bin card maintained At a time 2800 items maintained in
the stores Random sample check to ensure the
genuinity and authenticity of product Disposal of surplus obsolete
Material Distribution
I) General Administration
Servers
Anti virus server Database server Application server Archive server
II) HIS (Hospital Information System)
Application by Avanttec
Billing Ward management Laboratory services Discharges + Medical Records Housekeeping Pharmacy Payroll Medical equipment
Access to Information
o User specific access according to their roles
HIS Backup
Done once a day Centralized database Internal backups
MEDICAL RECORD DEPARTMENT
Layout -MRD Block
Staff 3
Infrastructure
Desktop 1
Printer 1
Organogram Medical Records Officer Statistician
Medical Records Technician
17
Functions of MRD
To ensure that the Shija Hospital has complete amp accurate medical record for every
patient
Public dealings with respect to Bill verification MLC cases and dealing with
Summons to the doctors hospital
To maintain high level of confidentiality as far as patientrsquos records are concerned
To ensure that the records are Identified and stored safely to prevent unauthorized
changes and easily retrieved whenever required
Issuing Emergency Medical Birth amp Death certificates
To generate Bed Occupancy reports ALOS and other hospital statistics (daily amp
monthly)
Record Retention Periods
IP Record 05 years
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patient
CLINICAL NUTRITION amp DIETICS DEPARTMENT
Layout -Ground floor OPD Block
Head Dietician Ms Bimota
Functions
Catering to Inpatients Diet counseling Education Smooth provision of laid out diets to the patients To check the patient food for quality preparation presentation and packing Coordinating closely with the Nursing shift in charges for changes in the patientrsquos
diet or new admissions etc
Records Maintained
Diet order sheet Meal count register Store register Diet Sheets
18
Counseling Register
Type of Diet Diet Card Color
Normal White
Diabetes Mellitus Yellow
Chronic Renal Failure Blue
Liquid Diet Pink
Flowchart of Dietician and Inpatient Interaction
The Dietician takes details of new patients such as name UHID doctorrsquos name diagnosis and diet prescribed Then Dietician takes a detailed round wherein she meets every patient and determines patientsrsquo actual intake Dietician then provides nutritional counseling and education ensures patientsrsquo compliance to recommended diet She also recognizes personal eating and food preferences
Afterwards the dietician does nutritional screening in order to know about patientsrsquo clinical condition appetite and tolerance to food and acceptance to hospital diet personal preferences disliking and food allergies if any
After the rounds detailed food summary sheets are planned and prepared for every patient keeping in mind medical history and preferences of patient as well
SECURITY
Own security force not outsourced since 2009
Area of Operation (Present)
To deal with 3 ldquoMrdquo- Man Material amp Machinery
Visitorrsquos check Entry restriction at ICU gate Security for doctors and nurse quarter Surveillance of hospital through CCTVrsquos Theft Burglary Violence Material movements in amp out of the hospital Handling visitorrsquos pass In case of patientrsquos death handling emotional chaos of attendants Parking management and traffic control
19
HOUSEKEEPING
Status Own
Department Manager Mr Arju
FUNCTIONS
bull Clean Floor Wall Ceiling
bull Discharge Cleaning
bull Remove Garbage
bull Replace Supplies In Utility Rooms
bull Clean Housekeeping Equipments
bull Clean Room Wards Reception OT ICU Etc
bull Infection Control
bull Pest amp Rodent Control
bull Odour Control
LAUNDRY- Own
Department in charge- MsUmajini
Functions
Segregation of soiled and clean linen Traffic flow of linen before 8am Carrying the linen around the hospital Registered linen and purpose System of collection
o Colored bins
Infected linen handled separately- soaked in sodium hyperchloride Register maintained ndash separate for infected and un-infected linen Floor wise collection Different registers for each type of linen Separate people for ironing and drying from those who collect and wash
20
bull Environment Hygiene
bull Sanitation Hygiene
bull Checking Cleanliness Of All Areas
bull Control amp Reporting Of All
Maintenance Works
bull Hospital Waste Disposal
bull In-Service Training
bull Cooperation with Other Depts
Shared responsibility with nurses in charge Report- washing record submitted to HR dept Due list of linen- expected on Monday
GAPS IDENTIFIED IN STORES MANAGEMENT
No forecasting of requirement done ie Reorder Levels not defined
No analysis like ABC VED done for inventory control
Codification of items still in progress
HIS for Stores still not completely streamlined
AMC amp CMC not maintained for all
Some departments go beyond the indent allowance
Repair and Maintenance of equipments There are instruments which are not used at all
o Non-functionalo Repair requiredo Condemned
For Quality assurance o Quality calibration o Annual Maintenance Contracto Complete Maintenance Contract
Instruments go for regular servicing or they are serviced and examined regularly- Some machines are serviced in the hospital- eg computers printers patient
monitor BP instrument Alternative arrangements are available during that period of time- Patient
monitors from other wards are managedo No back up stock available
Shortage during repair period Patient monitor ndash completely mobile thus record maintenance difficult-
communication gap between the material managers 3 total staff
GAPS IDENTIFIED IN HMIS
Avanttec is a Chennai Based HIS system hence immediate access to providers not available
Strong foundation but HIS is still not fully streamlined Personnel shortage in the department No staff at night
21
GAPS IDENTIFIED IN LAUNDRY DEPARTMENT
6 Set rule per patient not followed Presently only 2 sets per patient No weighing scale No sewing machine for repair No supervision over measured use of detergent and other chemicals
PROJECT ndash 1
A Study on Discharge Procedure with Special Emphasis
on In-Patient Feedback
22
INTRODUCTION
The study was carried out in Shija Hospitals and Research Institute which is a 180 bedded hospital located in Manipur The Hospital is well known for its high end technology and services in the region The Hospital looks forward to continually develop its services and improve the facilities available in order to become a well known health service provider in the South East Asian region in the future The operations management had identified the discharge procedure as an area where there was a scope for improvement Hence the hospital had assigned the project to study the discharge procedure
Discharging a patient is an activity common to every hospital - small large community inner-city teaching or non-teaching The discharge process can have an impact on numerous factors such as patient satisfaction bed availability timely tests and procedures needed for discharge transportation and nursing home arrangements No matter what type of patient is being discharged (maternity medicine orthopedic neurologic) numerous activities must be completed for each before the patient can be released This work toward discharge day should begin upon admission
As part of a progress towards NABH accreditation at Shija Hospital the discharge process is one of the many process improvement projects The discharge process at this hospital also incorporates obtaining feedback from the in-patient regarding the services at the time of discharge Due to inappropriate management the hospital was facing an acute shortage in the feedback response from the patients
The management at the hospital realizes the need and importance of patient satisfaction and a need of a measurable index through feedback analysis In all service industries customer retention is a vital issue Hence the management wanted to do all that they could to obtain feedback from the patients at the time of discharge and make the discharge procedure as smooth as it can get
The objective of this study was to study the process of discharge and find out the probable reasons for the failure to attain feedback from the patients at the time of discharge
23
STUDY METHODOLOGY
AIM
To study the discharge procedure practiced at Shija Hospitals with special emphasis on
analyzing the reasons for the short-fall of In-Patient Feedback
OBJECTIVE
1 To find the steps followed during discharge of an in-patient2 To find the total time taken for a discharge of a single patient3 To find the contributing reasons for the short fall of in-patient feedback
received in the wards
RATIONALE
The discharge of a patient is a very important component of in-patient service and needs to be smooth and efficient On the other hand in-patient feedback is equally important as it provides the performance standards of the hospital which needs to be continually enhanced
METHODOLOGY
Study design-
Area- Shija Hospitals and Research Institute Manipur
Duration- From 11-04-2011 to 30-04-2011
Type of study- Observational and Survey study
Sample size-120 in-patients and the following hospital staff
Nurse Superintendant
RMOs on duty
Staff nurse
Front office executives
Service entry staff
Sampling Method-Convenience sampling
Study tool Questionnaire and personal interviews
24
Type of Data collected -
Interviewer guided questionnaires collected from patients by visiting the different wards
Personal interview of various hospital staff and officials involved in discharge procedure
DISCHARGE PROCESS
25
Doctor prescribes the discharge
Nurse informs the patient about the time of discharge
26
Staff nurse starts discharge formalities by
Asking the Resident Medical Officer Concerned Physician to
make discharge summary
Informing Dietician to make discharge diet report for patient
Counseling of the patient by the dietician and physiotherapist (if
physiotherapy is going on for patient)
Asking the service entry assistants to enter all the details regarding the
patients starting from the no of consultant visits to medicines
consumed
Sending to Pharmacy Daily Billing Activity Sheet
Daily Pharmacy BillsDischarge medication detailsMedicines left unconsumed
In Pharmacy Summary of Pharmacy Bill is prepared
Daily Billing Activity Sheet
Summarized Pharmacy Bill
Giving the feedback form to the patient attendants
Fig1 Communication channels during the discharge procedure
27
Billing department finalizes the bill
Payment taken by billing department from attendants
IPD Billing informs at the nursing station about the clearance of bill
Discharge Summary completion by Medical Transcriptionist
Nurse informs the patient amp patient changes clothes
Nurse checks the checklist given for discharge of patient
All medications + Investigations reports + Patientrsquos file given to the patient
Patient given amp explained about how to take the medications + any special instruction + follow up schedule
Patient Discharged
Collects the filled up feedback form from the patient attendants
There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays
Fig 2 A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital
020406080
100120
82
28 39
102
Compliance to discharge procedure
No
of p
atien
ts
Table1 Duration of various parameters related to discharge
28
DoctorNurseService ward boysBillingofficePatient
Various other departments of the hospital
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
Store checks for the required material and the quantity
YES NO
Material issued and recorded in Issue Register Entry into Shortage Register
Record of the material entered HIS ldquoPurchase Requestrdquo is filled in HIS
Duties of Store In charge
Forecasting requirement Budgetary requirement Inventory control Stock verification Communicate the purchase
department about requirement Minimize pilferage
INFORMATION TECHNOLOGY (IT) DEPARTMENT
Layout -Ground Floor Main Building
Staff 3
Functions and responsibilities
To keep the servers alive
To keep the network alive
To keep internet connection alive
To take care of all the desktops amp laptops in the organization
To track the records of all the desktops
To keep an eye on the employees desktops
To resolve the complaints of the employees
Training of the other staff for the HIS
Major Work Areas General Administration amp HIS
16
Bin card maintained At a time 2800 items maintained in
the stores Random sample check to ensure the
genuinity and authenticity of product Disposal of surplus obsolete
Material Distribution
I) General Administration
Servers
Anti virus server Database server Application server Archive server
II) HIS (Hospital Information System)
Application by Avanttec
Billing Ward management Laboratory services Discharges + Medical Records Housekeeping Pharmacy Payroll Medical equipment
Access to Information
o User specific access according to their roles
HIS Backup
Done once a day Centralized database Internal backups
MEDICAL RECORD DEPARTMENT
Layout -MRD Block
Staff 3
Infrastructure
Desktop 1
Printer 1
Organogram Medical Records Officer Statistician
Medical Records Technician
17
Functions of MRD
To ensure that the Shija Hospital has complete amp accurate medical record for every
patient
Public dealings with respect to Bill verification MLC cases and dealing with
Summons to the doctors hospital
To maintain high level of confidentiality as far as patientrsquos records are concerned
To ensure that the records are Identified and stored safely to prevent unauthorized
changes and easily retrieved whenever required
Issuing Emergency Medical Birth amp Death certificates
To generate Bed Occupancy reports ALOS and other hospital statistics (daily amp
monthly)
Record Retention Periods
IP Record 05 years
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patient
CLINICAL NUTRITION amp DIETICS DEPARTMENT
Layout -Ground floor OPD Block
Head Dietician Ms Bimota
Functions
Catering to Inpatients Diet counseling Education Smooth provision of laid out diets to the patients To check the patient food for quality preparation presentation and packing Coordinating closely with the Nursing shift in charges for changes in the patientrsquos
diet or new admissions etc
Records Maintained
Diet order sheet Meal count register Store register Diet Sheets
18
Counseling Register
Type of Diet Diet Card Color
Normal White
Diabetes Mellitus Yellow
Chronic Renal Failure Blue
Liquid Diet Pink
Flowchart of Dietician and Inpatient Interaction
The Dietician takes details of new patients such as name UHID doctorrsquos name diagnosis and diet prescribed Then Dietician takes a detailed round wherein she meets every patient and determines patientsrsquo actual intake Dietician then provides nutritional counseling and education ensures patientsrsquo compliance to recommended diet She also recognizes personal eating and food preferences
Afterwards the dietician does nutritional screening in order to know about patientsrsquo clinical condition appetite and tolerance to food and acceptance to hospital diet personal preferences disliking and food allergies if any
After the rounds detailed food summary sheets are planned and prepared for every patient keeping in mind medical history and preferences of patient as well
SECURITY
Own security force not outsourced since 2009
Area of Operation (Present)
To deal with 3 ldquoMrdquo- Man Material amp Machinery
Visitorrsquos check Entry restriction at ICU gate Security for doctors and nurse quarter Surveillance of hospital through CCTVrsquos Theft Burglary Violence Material movements in amp out of the hospital Handling visitorrsquos pass In case of patientrsquos death handling emotional chaos of attendants Parking management and traffic control
19
HOUSEKEEPING
Status Own
Department Manager Mr Arju
FUNCTIONS
bull Clean Floor Wall Ceiling
bull Discharge Cleaning
bull Remove Garbage
bull Replace Supplies In Utility Rooms
bull Clean Housekeeping Equipments
bull Clean Room Wards Reception OT ICU Etc
bull Infection Control
bull Pest amp Rodent Control
bull Odour Control
LAUNDRY- Own
Department in charge- MsUmajini
Functions
Segregation of soiled and clean linen Traffic flow of linen before 8am Carrying the linen around the hospital Registered linen and purpose System of collection
o Colored bins
Infected linen handled separately- soaked in sodium hyperchloride Register maintained ndash separate for infected and un-infected linen Floor wise collection Different registers for each type of linen Separate people for ironing and drying from those who collect and wash
20
bull Environment Hygiene
bull Sanitation Hygiene
bull Checking Cleanliness Of All Areas
bull Control amp Reporting Of All
Maintenance Works
bull Hospital Waste Disposal
bull In-Service Training
bull Cooperation with Other Depts
Shared responsibility with nurses in charge Report- washing record submitted to HR dept Due list of linen- expected on Monday
GAPS IDENTIFIED IN STORES MANAGEMENT
No forecasting of requirement done ie Reorder Levels not defined
No analysis like ABC VED done for inventory control
Codification of items still in progress
HIS for Stores still not completely streamlined
AMC amp CMC not maintained for all
Some departments go beyond the indent allowance
Repair and Maintenance of equipments There are instruments which are not used at all
o Non-functionalo Repair requiredo Condemned
For Quality assurance o Quality calibration o Annual Maintenance Contracto Complete Maintenance Contract
Instruments go for regular servicing or they are serviced and examined regularly- Some machines are serviced in the hospital- eg computers printers patient
monitor BP instrument Alternative arrangements are available during that period of time- Patient
monitors from other wards are managedo No back up stock available
Shortage during repair period Patient monitor ndash completely mobile thus record maintenance difficult-
communication gap between the material managers 3 total staff
GAPS IDENTIFIED IN HMIS
Avanttec is a Chennai Based HIS system hence immediate access to providers not available
Strong foundation but HIS is still not fully streamlined Personnel shortage in the department No staff at night
21
GAPS IDENTIFIED IN LAUNDRY DEPARTMENT
6 Set rule per patient not followed Presently only 2 sets per patient No weighing scale No sewing machine for repair No supervision over measured use of detergent and other chemicals
PROJECT ndash 1
A Study on Discharge Procedure with Special Emphasis
on In-Patient Feedback
22
INTRODUCTION
The study was carried out in Shija Hospitals and Research Institute which is a 180 bedded hospital located in Manipur The Hospital is well known for its high end technology and services in the region The Hospital looks forward to continually develop its services and improve the facilities available in order to become a well known health service provider in the South East Asian region in the future The operations management had identified the discharge procedure as an area where there was a scope for improvement Hence the hospital had assigned the project to study the discharge procedure
Discharging a patient is an activity common to every hospital - small large community inner-city teaching or non-teaching The discharge process can have an impact on numerous factors such as patient satisfaction bed availability timely tests and procedures needed for discharge transportation and nursing home arrangements No matter what type of patient is being discharged (maternity medicine orthopedic neurologic) numerous activities must be completed for each before the patient can be released This work toward discharge day should begin upon admission
As part of a progress towards NABH accreditation at Shija Hospital the discharge process is one of the many process improvement projects The discharge process at this hospital also incorporates obtaining feedback from the in-patient regarding the services at the time of discharge Due to inappropriate management the hospital was facing an acute shortage in the feedback response from the patients
The management at the hospital realizes the need and importance of patient satisfaction and a need of a measurable index through feedback analysis In all service industries customer retention is a vital issue Hence the management wanted to do all that they could to obtain feedback from the patients at the time of discharge and make the discharge procedure as smooth as it can get
The objective of this study was to study the process of discharge and find out the probable reasons for the failure to attain feedback from the patients at the time of discharge
23
STUDY METHODOLOGY
AIM
To study the discharge procedure practiced at Shija Hospitals with special emphasis on
analyzing the reasons for the short-fall of In-Patient Feedback
OBJECTIVE
1 To find the steps followed during discharge of an in-patient2 To find the total time taken for a discharge of a single patient3 To find the contributing reasons for the short fall of in-patient feedback
received in the wards
RATIONALE
The discharge of a patient is a very important component of in-patient service and needs to be smooth and efficient On the other hand in-patient feedback is equally important as it provides the performance standards of the hospital which needs to be continually enhanced
METHODOLOGY
Study design-
Area- Shija Hospitals and Research Institute Manipur
Duration- From 11-04-2011 to 30-04-2011
Type of study- Observational and Survey study
Sample size-120 in-patients and the following hospital staff
Nurse Superintendant
RMOs on duty
Staff nurse
Front office executives
Service entry staff
Sampling Method-Convenience sampling
Study tool Questionnaire and personal interviews
24
Type of Data collected -
Interviewer guided questionnaires collected from patients by visiting the different wards
Personal interview of various hospital staff and officials involved in discharge procedure
DISCHARGE PROCESS
25
Doctor prescribes the discharge
Nurse informs the patient about the time of discharge
26
Staff nurse starts discharge formalities by
Asking the Resident Medical Officer Concerned Physician to
make discharge summary
Informing Dietician to make discharge diet report for patient
Counseling of the patient by the dietician and physiotherapist (if
physiotherapy is going on for patient)
Asking the service entry assistants to enter all the details regarding the
patients starting from the no of consultant visits to medicines
consumed
Sending to Pharmacy Daily Billing Activity Sheet
Daily Pharmacy BillsDischarge medication detailsMedicines left unconsumed
In Pharmacy Summary of Pharmacy Bill is prepared
Daily Billing Activity Sheet
Summarized Pharmacy Bill
Giving the feedback form to the patient attendants
Fig1 Communication channels during the discharge procedure
27
Billing department finalizes the bill
Payment taken by billing department from attendants
IPD Billing informs at the nursing station about the clearance of bill
Discharge Summary completion by Medical Transcriptionist
Nurse informs the patient amp patient changes clothes
Nurse checks the checklist given for discharge of patient
All medications + Investigations reports + Patientrsquos file given to the patient
Patient given amp explained about how to take the medications + any special instruction + follow up schedule
Patient Discharged
Collects the filled up feedback form from the patient attendants
There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays
Fig 2 A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital
020406080
100120
82
28 39
102
Compliance to discharge procedure
No
of p
atien
ts
Table1 Duration of various parameters related to discharge
28
DoctorNurseService ward boysBillingofficePatient
Various other departments of the hospital
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
I) General Administration
Servers
Anti virus server Database server Application server Archive server
II) HIS (Hospital Information System)
Application by Avanttec
Billing Ward management Laboratory services Discharges + Medical Records Housekeeping Pharmacy Payroll Medical equipment
Access to Information
o User specific access according to their roles
HIS Backup
Done once a day Centralized database Internal backups
MEDICAL RECORD DEPARTMENT
Layout -MRD Block
Staff 3
Infrastructure
Desktop 1
Printer 1
Organogram Medical Records Officer Statistician
Medical Records Technician
17
Functions of MRD
To ensure that the Shija Hospital has complete amp accurate medical record for every
patient
Public dealings with respect to Bill verification MLC cases and dealing with
Summons to the doctors hospital
To maintain high level of confidentiality as far as patientrsquos records are concerned
To ensure that the records are Identified and stored safely to prevent unauthorized
changes and easily retrieved whenever required
Issuing Emergency Medical Birth amp Death certificates
To generate Bed Occupancy reports ALOS and other hospital statistics (daily amp
monthly)
Record Retention Periods
IP Record 05 years
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patient
CLINICAL NUTRITION amp DIETICS DEPARTMENT
Layout -Ground floor OPD Block
Head Dietician Ms Bimota
Functions
Catering to Inpatients Diet counseling Education Smooth provision of laid out diets to the patients To check the patient food for quality preparation presentation and packing Coordinating closely with the Nursing shift in charges for changes in the patientrsquos
diet or new admissions etc
Records Maintained
Diet order sheet Meal count register Store register Diet Sheets
18
Counseling Register
Type of Diet Diet Card Color
Normal White
Diabetes Mellitus Yellow
Chronic Renal Failure Blue
Liquid Diet Pink
Flowchart of Dietician and Inpatient Interaction
The Dietician takes details of new patients such as name UHID doctorrsquos name diagnosis and diet prescribed Then Dietician takes a detailed round wherein she meets every patient and determines patientsrsquo actual intake Dietician then provides nutritional counseling and education ensures patientsrsquo compliance to recommended diet She also recognizes personal eating and food preferences
Afterwards the dietician does nutritional screening in order to know about patientsrsquo clinical condition appetite and tolerance to food and acceptance to hospital diet personal preferences disliking and food allergies if any
After the rounds detailed food summary sheets are planned and prepared for every patient keeping in mind medical history and preferences of patient as well
SECURITY
Own security force not outsourced since 2009
Area of Operation (Present)
To deal with 3 ldquoMrdquo- Man Material amp Machinery
Visitorrsquos check Entry restriction at ICU gate Security for doctors and nurse quarter Surveillance of hospital through CCTVrsquos Theft Burglary Violence Material movements in amp out of the hospital Handling visitorrsquos pass In case of patientrsquos death handling emotional chaos of attendants Parking management and traffic control
19
HOUSEKEEPING
Status Own
Department Manager Mr Arju
FUNCTIONS
bull Clean Floor Wall Ceiling
bull Discharge Cleaning
bull Remove Garbage
bull Replace Supplies In Utility Rooms
bull Clean Housekeeping Equipments
bull Clean Room Wards Reception OT ICU Etc
bull Infection Control
bull Pest amp Rodent Control
bull Odour Control
LAUNDRY- Own
Department in charge- MsUmajini
Functions
Segregation of soiled and clean linen Traffic flow of linen before 8am Carrying the linen around the hospital Registered linen and purpose System of collection
o Colored bins
Infected linen handled separately- soaked in sodium hyperchloride Register maintained ndash separate for infected and un-infected linen Floor wise collection Different registers for each type of linen Separate people for ironing and drying from those who collect and wash
20
bull Environment Hygiene
bull Sanitation Hygiene
bull Checking Cleanliness Of All Areas
bull Control amp Reporting Of All
Maintenance Works
bull Hospital Waste Disposal
bull In-Service Training
bull Cooperation with Other Depts
Shared responsibility with nurses in charge Report- washing record submitted to HR dept Due list of linen- expected on Monday
GAPS IDENTIFIED IN STORES MANAGEMENT
No forecasting of requirement done ie Reorder Levels not defined
No analysis like ABC VED done for inventory control
Codification of items still in progress
HIS for Stores still not completely streamlined
AMC amp CMC not maintained for all
Some departments go beyond the indent allowance
Repair and Maintenance of equipments There are instruments which are not used at all
o Non-functionalo Repair requiredo Condemned
For Quality assurance o Quality calibration o Annual Maintenance Contracto Complete Maintenance Contract
Instruments go for regular servicing or they are serviced and examined regularly- Some machines are serviced in the hospital- eg computers printers patient
monitor BP instrument Alternative arrangements are available during that period of time- Patient
monitors from other wards are managedo No back up stock available
Shortage during repair period Patient monitor ndash completely mobile thus record maintenance difficult-
communication gap between the material managers 3 total staff
GAPS IDENTIFIED IN HMIS
Avanttec is a Chennai Based HIS system hence immediate access to providers not available
Strong foundation but HIS is still not fully streamlined Personnel shortage in the department No staff at night
21
GAPS IDENTIFIED IN LAUNDRY DEPARTMENT
6 Set rule per patient not followed Presently only 2 sets per patient No weighing scale No sewing machine for repair No supervision over measured use of detergent and other chemicals
PROJECT ndash 1
A Study on Discharge Procedure with Special Emphasis
on In-Patient Feedback
22
INTRODUCTION
The study was carried out in Shija Hospitals and Research Institute which is a 180 bedded hospital located in Manipur The Hospital is well known for its high end technology and services in the region The Hospital looks forward to continually develop its services and improve the facilities available in order to become a well known health service provider in the South East Asian region in the future The operations management had identified the discharge procedure as an area where there was a scope for improvement Hence the hospital had assigned the project to study the discharge procedure
Discharging a patient is an activity common to every hospital - small large community inner-city teaching or non-teaching The discharge process can have an impact on numerous factors such as patient satisfaction bed availability timely tests and procedures needed for discharge transportation and nursing home arrangements No matter what type of patient is being discharged (maternity medicine orthopedic neurologic) numerous activities must be completed for each before the patient can be released This work toward discharge day should begin upon admission
As part of a progress towards NABH accreditation at Shija Hospital the discharge process is one of the many process improvement projects The discharge process at this hospital also incorporates obtaining feedback from the in-patient regarding the services at the time of discharge Due to inappropriate management the hospital was facing an acute shortage in the feedback response from the patients
The management at the hospital realizes the need and importance of patient satisfaction and a need of a measurable index through feedback analysis In all service industries customer retention is a vital issue Hence the management wanted to do all that they could to obtain feedback from the patients at the time of discharge and make the discharge procedure as smooth as it can get
The objective of this study was to study the process of discharge and find out the probable reasons for the failure to attain feedback from the patients at the time of discharge
23
STUDY METHODOLOGY
AIM
To study the discharge procedure practiced at Shija Hospitals with special emphasis on
analyzing the reasons for the short-fall of In-Patient Feedback
OBJECTIVE
1 To find the steps followed during discharge of an in-patient2 To find the total time taken for a discharge of a single patient3 To find the contributing reasons for the short fall of in-patient feedback
received in the wards
RATIONALE
The discharge of a patient is a very important component of in-patient service and needs to be smooth and efficient On the other hand in-patient feedback is equally important as it provides the performance standards of the hospital which needs to be continually enhanced
METHODOLOGY
Study design-
Area- Shija Hospitals and Research Institute Manipur
Duration- From 11-04-2011 to 30-04-2011
Type of study- Observational and Survey study
Sample size-120 in-patients and the following hospital staff
Nurse Superintendant
RMOs on duty
Staff nurse
Front office executives
Service entry staff
Sampling Method-Convenience sampling
Study tool Questionnaire and personal interviews
24
Type of Data collected -
Interviewer guided questionnaires collected from patients by visiting the different wards
Personal interview of various hospital staff and officials involved in discharge procedure
DISCHARGE PROCESS
25
Doctor prescribes the discharge
Nurse informs the patient about the time of discharge
26
Staff nurse starts discharge formalities by
Asking the Resident Medical Officer Concerned Physician to
make discharge summary
Informing Dietician to make discharge diet report for patient
Counseling of the patient by the dietician and physiotherapist (if
physiotherapy is going on for patient)
Asking the service entry assistants to enter all the details regarding the
patients starting from the no of consultant visits to medicines
consumed
Sending to Pharmacy Daily Billing Activity Sheet
Daily Pharmacy BillsDischarge medication detailsMedicines left unconsumed
In Pharmacy Summary of Pharmacy Bill is prepared
Daily Billing Activity Sheet
Summarized Pharmacy Bill
Giving the feedback form to the patient attendants
Fig1 Communication channels during the discharge procedure
27
Billing department finalizes the bill
Payment taken by billing department from attendants
IPD Billing informs at the nursing station about the clearance of bill
Discharge Summary completion by Medical Transcriptionist
Nurse informs the patient amp patient changes clothes
Nurse checks the checklist given for discharge of patient
All medications + Investigations reports + Patientrsquos file given to the patient
Patient given amp explained about how to take the medications + any special instruction + follow up schedule
Patient Discharged
Collects the filled up feedback form from the patient attendants
There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays
Fig 2 A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital
020406080
100120
82
28 39
102
Compliance to discharge procedure
No
of p
atien
ts
Table1 Duration of various parameters related to discharge
28
DoctorNurseService ward boysBillingofficePatient
Various other departments of the hospital
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
Functions of MRD
To ensure that the Shija Hospital has complete amp accurate medical record for every
patient
Public dealings with respect to Bill verification MLC cases and dealing with
Summons to the doctors hospital
To maintain high level of confidentiality as far as patientrsquos records are concerned
To ensure that the records are Identified and stored safely to prevent unauthorized
changes and easily retrieved whenever required
Issuing Emergency Medical Birth amp Death certificates
To generate Bed Occupancy reports ALOS and other hospital statistics (daily amp
monthly)
Record Retention Periods
IP Record 05 years
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patient
CLINICAL NUTRITION amp DIETICS DEPARTMENT
Layout -Ground floor OPD Block
Head Dietician Ms Bimota
Functions
Catering to Inpatients Diet counseling Education Smooth provision of laid out diets to the patients To check the patient food for quality preparation presentation and packing Coordinating closely with the Nursing shift in charges for changes in the patientrsquos
diet or new admissions etc
Records Maintained
Diet order sheet Meal count register Store register Diet Sheets
18
Counseling Register
Type of Diet Diet Card Color
Normal White
Diabetes Mellitus Yellow
Chronic Renal Failure Blue
Liquid Diet Pink
Flowchart of Dietician and Inpatient Interaction
The Dietician takes details of new patients such as name UHID doctorrsquos name diagnosis and diet prescribed Then Dietician takes a detailed round wherein she meets every patient and determines patientsrsquo actual intake Dietician then provides nutritional counseling and education ensures patientsrsquo compliance to recommended diet She also recognizes personal eating and food preferences
Afterwards the dietician does nutritional screening in order to know about patientsrsquo clinical condition appetite and tolerance to food and acceptance to hospital diet personal preferences disliking and food allergies if any
After the rounds detailed food summary sheets are planned and prepared for every patient keeping in mind medical history and preferences of patient as well
SECURITY
Own security force not outsourced since 2009
Area of Operation (Present)
To deal with 3 ldquoMrdquo- Man Material amp Machinery
Visitorrsquos check Entry restriction at ICU gate Security for doctors and nurse quarter Surveillance of hospital through CCTVrsquos Theft Burglary Violence Material movements in amp out of the hospital Handling visitorrsquos pass In case of patientrsquos death handling emotional chaos of attendants Parking management and traffic control
19
HOUSEKEEPING
Status Own
Department Manager Mr Arju
FUNCTIONS
bull Clean Floor Wall Ceiling
bull Discharge Cleaning
bull Remove Garbage
bull Replace Supplies In Utility Rooms
bull Clean Housekeeping Equipments
bull Clean Room Wards Reception OT ICU Etc
bull Infection Control
bull Pest amp Rodent Control
bull Odour Control
LAUNDRY- Own
Department in charge- MsUmajini
Functions
Segregation of soiled and clean linen Traffic flow of linen before 8am Carrying the linen around the hospital Registered linen and purpose System of collection
o Colored bins
Infected linen handled separately- soaked in sodium hyperchloride Register maintained ndash separate for infected and un-infected linen Floor wise collection Different registers for each type of linen Separate people for ironing and drying from those who collect and wash
20
bull Environment Hygiene
bull Sanitation Hygiene
bull Checking Cleanliness Of All Areas
bull Control amp Reporting Of All
Maintenance Works
bull Hospital Waste Disposal
bull In-Service Training
bull Cooperation with Other Depts
Shared responsibility with nurses in charge Report- washing record submitted to HR dept Due list of linen- expected on Monday
GAPS IDENTIFIED IN STORES MANAGEMENT
No forecasting of requirement done ie Reorder Levels not defined
No analysis like ABC VED done for inventory control
Codification of items still in progress
HIS for Stores still not completely streamlined
AMC amp CMC not maintained for all
Some departments go beyond the indent allowance
Repair and Maintenance of equipments There are instruments which are not used at all
o Non-functionalo Repair requiredo Condemned
For Quality assurance o Quality calibration o Annual Maintenance Contracto Complete Maintenance Contract
Instruments go for regular servicing or they are serviced and examined regularly- Some machines are serviced in the hospital- eg computers printers patient
monitor BP instrument Alternative arrangements are available during that period of time- Patient
monitors from other wards are managedo No back up stock available
Shortage during repair period Patient monitor ndash completely mobile thus record maintenance difficult-
communication gap between the material managers 3 total staff
GAPS IDENTIFIED IN HMIS
Avanttec is a Chennai Based HIS system hence immediate access to providers not available
Strong foundation but HIS is still not fully streamlined Personnel shortage in the department No staff at night
21
GAPS IDENTIFIED IN LAUNDRY DEPARTMENT
6 Set rule per patient not followed Presently only 2 sets per patient No weighing scale No sewing machine for repair No supervision over measured use of detergent and other chemicals
PROJECT ndash 1
A Study on Discharge Procedure with Special Emphasis
on In-Patient Feedback
22
INTRODUCTION
The study was carried out in Shija Hospitals and Research Institute which is a 180 bedded hospital located in Manipur The Hospital is well known for its high end technology and services in the region The Hospital looks forward to continually develop its services and improve the facilities available in order to become a well known health service provider in the South East Asian region in the future The operations management had identified the discharge procedure as an area where there was a scope for improvement Hence the hospital had assigned the project to study the discharge procedure
Discharging a patient is an activity common to every hospital - small large community inner-city teaching or non-teaching The discharge process can have an impact on numerous factors such as patient satisfaction bed availability timely tests and procedures needed for discharge transportation and nursing home arrangements No matter what type of patient is being discharged (maternity medicine orthopedic neurologic) numerous activities must be completed for each before the patient can be released This work toward discharge day should begin upon admission
As part of a progress towards NABH accreditation at Shija Hospital the discharge process is one of the many process improvement projects The discharge process at this hospital also incorporates obtaining feedback from the in-patient regarding the services at the time of discharge Due to inappropriate management the hospital was facing an acute shortage in the feedback response from the patients
The management at the hospital realizes the need and importance of patient satisfaction and a need of a measurable index through feedback analysis In all service industries customer retention is a vital issue Hence the management wanted to do all that they could to obtain feedback from the patients at the time of discharge and make the discharge procedure as smooth as it can get
The objective of this study was to study the process of discharge and find out the probable reasons for the failure to attain feedback from the patients at the time of discharge
23
STUDY METHODOLOGY
AIM
To study the discharge procedure practiced at Shija Hospitals with special emphasis on
analyzing the reasons for the short-fall of In-Patient Feedback
OBJECTIVE
1 To find the steps followed during discharge of an in-patient2 To find the total time taken for a discharge of a single patient3 To find the contributing reasons for the short fall of in-patient feedback
received in the wards
RATIONALE
The discharge of a patient is a very important component of in-patient service and needs to be smooth and efficient On the other hand in-patient feedback is equally important as it provides the performance standards of the hospital which needs to be continually enhanced
METHODOLOGY
Study design-
Area- Shija Hospitals and Research Institute Manipur
Duration- From 11-04-2011 to 30-04-2011
Type of study- Observational and Survey study
Sample size-120 in-patients and the following hospital staff
Nurse Superintendant
RMOs on duty
Staff nurse
Front office executives
Service entry staff
Sampling Method-Convenience sampling
Study tool Questionnaire and personal interviews
24
Type of Data collected -
Interviewer guided questionnaires collected from patients by visiting the different wards
Personal interview of various hospital staff and officials involved in discharge procedure
DISCHARGE PROCESS
25
Doctor prescribes the discharge
Nurse informs the patient about the time of discharge
26
Staff nurse starts discharge formalities by
Asking the Resident Medical Officer Concerned Physician to
make discharge summary
Informing Dietician to make discharge diet report for patient
Counseling of the patient by the dietician and physiotherapist (if
physiotherapy is going on for patient)
Asking the service entry assistants to enter all the details regarding the
patients starting from the no of consultant visits to medicines
consumed
Sending to Pharmacy Daily Billing Activity Sheet
Daily Pharmacy BillsDischarge medication detailsMedicines left unconsumed
In Pharmacy Summary of Pharmacy Bill is prepared
Daily Billing Activity Sheet
Summarized Pharmacy Bill
Giving the feedback form to the patient attendants
Fig1 Communication channels during the discharge procedure
27
Billing department finalizes the bill
Payment taken by billing department from attendants
IPD Billing informs at the nursing station about the clearance of bill
Discharge Summary completion by Medical Transcriptionist
Nurse informs the patient amp patient changes clothes
Nurse checks the checklist given for discharge of patient
All medications + Investigations reports + Patientrsquos file given to the patient
Patient given amp explained about how to take the medications + any special instruction + follow up schedule
Patient Discharged
Collects the filled up feedback form from the patient attendants
There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays
Fig 2 A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital
020406080
100120
82
28 39
102
Compliance to discharge procedure
No
of p
atien
ts
Table1 Duration of various parameters related to discharge
28
DoctorNurseService ward boysBillingofficePatient
Various other departments of the hospital
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
Counseling Register
Type of Diet Diet Card Color
Normal White
Diabetes Mellitus Yellow
Chronic Renal Failure Blue
Liquid Diet Pink
Flowchart of Dietician and Inpatient Interaction
The Dietician takes details of new patients such as name UHID doctorrsquos name diagnosis and diet prescribed Then Dietician takes a detailed round wherein she meets every patient and determines patientsrsquo actual intake Dietician then provides nutritional counseling and education ensures patientsrsquo compliance to recommended diet She also recognizes personal eating and food preferences
Afterwards the dietician does nutritional screening in order to know about patientsrsquo clinical condition appetite and tolerance to food and acceptance to hospital diet personal preferences disliking and food allergies if any
After the rounds detailed food summary sheets are planned and prepared for every patient keeping in mind medical history and preferences of patient as well
SECURITY
Own security force not outsourced since 2009
Area of Operation (Present)
To deal with 3 ldquoMrdquo- Man Material amp Machinery
Visitorrsquos check Entry restriction at ICU gate Security for doctors and nurse quarter Surveillance of hospital through CCTVrsquos Theft Burglary Violence Material movements in amp out of the hospital Handling visitorrsquos pass In case of patientrsquos death handling emotional chaos of attendants Parking management and traffic control
19
HOUSEKEEPING
Status Own
Department Manager Mr Arju
FUNCTIONS
bull Clean Floor Wall Ceiling
bull Discharge Cleaning
bull Remove Garbage
bull Replace Supplies In Utility Rooms
bull Clean Housekeeping Equipments
bull Clean Room Wards Reception OT ICU Etc
bull Infection Control
bull Pest amp Rodent Control
bull Odour Control
LAUNDRY- Own
Department in charge- MsUmajini
Functions
Segregation of soiled and clean linen Traffic flow of linen before 8am Carrying the linen around the hospital Registered linen and purpose System of collection
o Colored bins
Infected linen handled separately- soaked in sodium hyperchloride Register maintained ndash separate for infected and un-infected linen Floor wise collection Different registers for each type of linen Separate people for ironing and drying from those who collect and wash
20
bull Environment Hygiene
bull Sanitation Hygiene
bull Checking Cleanliness Of All Areas
bull Control amp Reporting Of All
Maintenance Works
bull Hospital Waste Disposal
bull In-Service Training
bull Cooperation with Other Depts
Shared responsibility with nurses in charge Report- washing record submitted to HR dept Due list of linen- expected on Monday
GAPS IDENTIFIED IN STORES MANAGEMENT
No forecasting of requirement done ie Reorder Levels not defined
No analysis like ABC VED done for inventory control
Codification of items still in progress
HIS for Stores still not completely streamlined
AMC amp CMC not maintained for all
Some departments go beyond the indent allowance
Repair and Maintenance of equipments There are instruments which are not used at all
o Non-functionalo Repair requiredo Condemned
For Quality assurance o Quality calibration o Annual Maintenance Contracto Complete Maintenance Contract
Instruments go for regular servicing or they are serviced and examined regularly- Some machines are serviced in the hospital- eg computers printers patient
monitor BP instrument Alternative arrangements are available during that period of time- Patient
monitors from other wards are managedo No back up stock available
Shortage during repair period Patient monitor ndash completely mobile thus record maintenance difficult-
communication gap between the material managers 3 total staff
GAPS IDENTIFIED IN HMIS
Avanttec is a Chennai Based HIS system hence immediate access to providers not available
Strong foundation but HIS is still not fully streamlined Personnel shortage in the department No staff at night
21
GAPS IDENTIFIED IN LAUNDRY DEPARTMENT
6 Set rule per patient not followed Presently only 2 sets per patient No weighing scale No sewing machine for repair No supervision over measured use of detergent and other chemicals
PROJECT ndash 1
A Study on Discharge Procedure with Special Emphasis
on In-Patient Feedback
22
INTRODUCTION
The study was carried out in Shija Hospitals and Research Institute which is a 180 bedded hospital located in Manipur The Hospital is well known for its high end technology and services in the region The Hospital looks forward to continually develop its services and improve the facilities available in order to become a well known health service provider in the South East Asian region in the future The operations management had identified the discharge procedure as an area where there was a scope for improvement Hence the hospital had assigned the project to study the discharge procedure
Discharging a patient is an activity common to every hospital - small large community inner-city teaching or non-teaching The discharge process can have an impact on numerous factors such as patient satisfaction bed availability timely tests and procedures needed for discharge transportation and nursing home arrangements No matter what type of patient is being discharged (maternity medicine orthopedic neurologic) numerous activities must be completed for each before the patient can be released This work toward discharge day should begin upon admission
As part of a progress towards NABH accreditation at Shija Hospital the discharge process is one of the many process improvement projects The discharge process at this hospital also incorporates obtaining feedback from the in-patient regarding the services at the time of discharge Due to inappropriate management the hospital was facing an acute shortage in the feedback response from the patients
The management at the hospital realizes the need and importance of patient satisfaction and a need of a measurable index through feedback analysis In all service industries customer retention is a vital issue Hence the management wanted to do all that they could to obtain feedback from the patients at the time of discharge and make the discharge procedure as smooth as it can get
The objective of this study was to study the process of discharge and find out the probable reasons for the failure to attain feedback from the patients at the time of discharge
23
STUDY METHODOLOGY
AIM
To study the discharge procedure practiced at Shija Hospitals with special emphasis on
analyzing the reasons for the short-fall of In-Patient Feedback
OBJECTIVE
1 To find the steps followed during discharge of an in-patient2 To find the total time taken for a discharge of a single patient3 To find the contributing reasons for the short fall of in-patient feedback
received in the wards
RATIONALE
The discharge of a patient is a very important component of in-patient service and needs to be smooth and efficient On the other hand in-patient feedback is equally important as it provides the performance standards of the hospital which needs to be continually enhanced
METHODOLOGY
Study design-
Area- Shija Hospitals and Research Institute Manipur
Duration- From 11-04-2011 to 30-04-2011
Type of study- Observational and Survey study
Sample size-120 in-patients and the following hospital staff
Nurse Superintendant
RMOs on duty
Staff nurse
Front office executives
Service entry staff
Sampling Method-Convenience sampling
Study tool Questionnaire and personal interviews
24
Type of Data collected -
Interviewer guided questionnaires collected from patients by visiting the different wards
Personal interview of various hospital staff and officials involved in discharge procedure
DISCHARGE PROCESS
25
Doctor prescribes the discharge
Nurse informs the patient about the time of discharge
26
Staff nurse starts discharge formalities by
Asking the Resident Medical Officer Concerned Physician to
make discharge summary
Informing Dietician to make discharge diet report for patient
Counseling of the patient by the dietician and physiotherapist (if
physiotherapy is going on for patient)
Asking the service entry assistants to enter all the details regarding the
patients starting from the no of consultant visits to medicines
consumed
Sending to Pharmacy Daily Billing Activity Sheet
Daily Pharmacy BillsDischarge medication detailsMedicines left unconsumed
In Pharmacy Summary of Pharmacy Bill is prepared
Daily Billing Activity Sheet
Summarized Pharmacy Bill
Giving the feedback form to the patient attendants
Fig1 Communication channels during the discharge procedure
27
Billing department finalizes the bill
Payment taken by billing department from attendants
IPD Billing informs at the nursing station about the clearance of bill
Discharge Summary completion by Medical Transcriptionist
Nurse informs the patient amp patient changes clothes
Nurse checks the checklist given for discharge of patient
All medications + Investigations reports + Patientrsquos file given to the patient
Patient given amp explained about how to take the medications + any special instruction + follow up schedule
Patient Discharged
Collects the filled up feedback form from the patient attendants
There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays
Fig 2 A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital
020406080
100120
82
28 39
102
Compliance to discharge procedure
No
of p
atien
ts
Table1 Duration of various parameters related to discharge
28
DoctorNurseService ward boysBillingofficePatient
Various other departments of the hospital
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
HOUSEKEEPING
Status Own
Department Manager Mr Arju
FUNCTIONS
bull Clean Floor Wall Ceiling
bull Discharge Cleaning
bull Remove Garbage
bull Replace Supplies In Utility Rooms
bull Clean Housekeeping Equipments
bull Clean Room Wards Reception OT ICU Etc
bull Infection Control
bull Pest amp Rodent Control
bull Odour Control
LAUNDRY- Own
Department in charge- MsUmajini
Functions
Segregation of soiled and clean linen Traffic flow of linen before 8am Carrying the linen around the hospital Registered linen and purpose System of collection
o Colored bins
Infected linen handled separately- soaked in sodium hyperchloride Register maintained ndash separate for infected and un-infected linen Floor wise collection Different registers for each type of linen Separate people for ironing and drying from those who collect and wash
20
bull Environment Hygiene
bull Sanitation Hygiene
bull Checking Cleanliness Of All Areas
bull Control amp Reporting Of All
Maintenance Works
bull Hospital Waste Disposal
bull In-Service Training
bull Cooperation with Other Depts
Shared responsibility with nurses in charge Report- washing record submitted to HR dept Due list of linen- expected on Monday
GAPS IDENTIFIED IN STORES MANAGEMENT
No forecasting of requirement done ie Reorder Levels not defined
No analysis like ABC VED done for inventory control
Codification of items still in progress
HIS for Stores still not completely streamlined
AMC amp CMC not maintained for all
Some departments go beyond the indent allowance
Repair and Maintenance of equipments There are instruments which are not used at all
o Non-functionalo Repair requiredo Condemned
For Quality assurance o Quality calibration o Annual Maintenance Contracto Complete Maintenance Contract
Instruments go for regular servicing or they are serviced and examined regularly- Some machines are serviced in the hospital- eg computers printers patient
monitor BP instrument Alternative arrangements are available during that period of time- Patient
monitors from other wards are managedo No back up stock available
Shortage during repair period Patient monitor ndash completely mobile thus record maintenance difficult-
communication gap between the material managers 3 total staff
GAPS IDENTIFIED IN HMIS
Avanttec is a Chennai Based HIS system hence immediate access to providers not available
Strong foundation but HIS is still not fully streamlined Personnel shortage in the department No staff at night
21
GAPS IDENTIFIED IN LAUNDRY DEPARTMENT
6 Set rule per patient not followed Presently only 2 sets per patient No weighing scale No sewing machine for repair No supervision over measured use of detergent and other chemicals
PROJECT ndash 1
A Study on Discharge Procedure with Special Emphasis
on In-Patient Feedback
22
INTRODUCTION
The study was carried out in Shija Hospitals and Research Institute which is a 180 bedded hospital located in Manipur The Hospital is well known for its high end technology and services in the region The Hospital looks forward to continually develop its services and improve the facilities available in order to become a well known health service provider in the South East Asian region in the future The operations management had identified the discharge procedure as an area where there was a scope for improvement Hence the hospital had assigned the project to study the discharge procedure
Discharging a patient is an activity common to every hospital - small large community inner-city teaching or non-teaching The discharge process can have an impact on numerous factors such as patient satisfaction bed availability timely tests and procedures needed for discharge transportation and nursing home arrangements No matter what type of patient is being discharged (maternity medicine orthopedic neurologic) numerous activities must be completed for each before the patient can be released This work toward discharge day should begin upon admission
As part of a progress towards NABH accreditation at Shija Hospital the discharge process is one of the many process improvement projects The discharge process at this hospital also incorporates obtaining feedback from the in-patient regarding the services at the time of discharge Due to inappropriate management the hospital was facing an acute shortage in the feedback response from the patients
The management at the hospital realizes the need and importance of patient satisfaction and a need of a measurable index through feedback analysis In all service industries customer retention is a vital issue Hence the management wanted to do all that they could to obtain feedback from the patients at the time of discharge and make the discharge procedure as smooth as it can get
The objective of this study was to study the process of discharge and find out the probable reasons for the failure to attain feedback from the patients at the time of discharge
23
STUDY METHODOLOGY
AIM
To study the discharge procedure practiced at Shija Hospitals with special emphasis on
analyzing the reasons for the short-fall of In-Patient Feedback
OBJECTIVE
1 To find the steps followed during discharge of an in-patient2 To find the total time taken for a discharge of a single patient3 To find the contributing reasons for the short fall of in-patient feedback
received in the wards
RATIONALE
The discharge of a patient is a very important component of in-patient service and needs to be smooth and efficient On the other hand in-patient feedback is equally important as it provides the performance standards of the hospital which needs to be continually enhanced
METHODOLOGY
Study design-
Area- Shija Hospitals and Research Institute Manipur
Duration- From 11-04-2011 to 30-04-2011
Type of study- Observational and Survey study
Sample size-120 in-patients and the following hospital staff
Nurse Superintendant
RMOs on duty
Staff nurse
Front office executives
Service entry staff
Sampling Method-Convenience sampling
Study tool Questionnaire and personal interviews
24
Type of Data collected -
Interviewer guided questionnaires collected from patients by visiting the different wards
Personal interview of various hospital staff and officials involved in discharge procedure
DISCHARGE PROCESS
25
Doctor prescribes the discharge
Nurse informs the patient about the time of discharge
26
Staff nurse starts discharge formalities by
Asking the Resident Medical Officer Concerned Physician to
make discharge summary
Informing Dietician to make discharge diet report for patient
Counseling of the patient by the dietician and physiotherapist (if
physiotherapy is going on for patient)
Asking the service entry assistants to enter all the details regarding the
patients starting from the no of consultant visits to medicines
consumed
Sending to Pharmacy Daily Billing Activity Sheet
Daily Pharmacy BillsDischarge medication detailsMedicines left unconsumed
In Pharmacy Summary of Pharmacy Bill is prepared
Daily Billing Activity Sheet
Summarized Pharmacy Bill
Giving the feedback form to the patient attendants
Fig1 Communication channels during the discharge procedure
27
Billing department finalizes the bill
Payment taken by billing department from attendants
IPD Billing informs at the nursing station about the clearance of bill
Discharge Summary completion by Medical Transcriptionist
Nurse informs the patient amp patient changes clothes
Nurse checks the checklist given for discharge of patient
All medications + Investigations reports + Patientrsquos file given to the patient
Patient given amp explained about how to take the medications + any special instruction + follow up schedule
Patient Discharged
Collects the filled up feedback form from the patient attendants
There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays
Fig 2 A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital
020406080
100120
82
28 39
102
Compliance to discharge procedure
No
of p
atien
ts
Table1 Duration of various parameters related to discharge
28
DoctorNurseService ward boysBillingofficePatient
Various other departments of the hospital
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
Shared responsibility with nurses in charge Report- washing record submitted to HR dept Due list of linen- expected on Monday
GAPS IDENTIFIED IN STORES MANAGEMENT
No forecasting of requirement done ie Reorder Levels not defined
No analysis like ABC VED done for inventory control
Codification of items still in progress
HIS for Stores still not completely streamlined
AMC amp CMC not maintained for all
Some departments go beyond the indent allowance
Repair and Maintenance of equipments There are instruments which are not used at all
o Non-functionalo Repair requiredo Condemned
For Quality assurance o Quality calibration o Annual Maintenance Contracto Complete Maintenance Contract
Instruments go for regular servicing or they are serviced and examined regularly- Some machines are serviced in the hospital- eg computers printers patient
monitor BP instrument Alternative arrangements are available during that period of time- Patient
monitors from other wards are managedo No back up stock available
Shortage during repair period Patient monitor ndash completely mobile thus record maintenance difficult-
communication gap between the material managers 3 total staff
GAPS IDENTIFIED IN HMIS
Avanttec is a Chennai Based HIS system hence immediate access to providers not available
Strong foundation but HIS is still not fully streamlined Personnel shortage in the department No staff at night
21
GAPS IDENTIFIED IN LAUNDRY DEPARTMENT
6 Set rule per patient not followed Presently only 2 sets per patient No weighing scale No sewing machine for repair No supervision over measured use of detergent and other chemicals
PROJECT ndash 1
A Study on Discharge Procedure with Special Emphasis
on In-Patient Feedback
22
INTRODUCTION
The study was carried out in Shija Hospitals and Research Institute which is a 180 bedded hospital located in Manipur The Hospital is well known for its high end technology and services in the region The Hospital looks forward to continually develop its services and improve the facilities available in order to become a well known health service provider in the South East Asian region in the future The operations management had identified the discharge procedure as an area where there was a scope for improvement Hence the hospital had assigned the project to study the discharge procedure
Discharging a patient is an activity common to every hospital - small large community inner-city teaching or non-teaching The discharge process can have an impact on numerous factors such as patient satisfaction bed availability timely tests and procedures needed for discharge transportation and nursing home arrangements No matter what type of patient is being discharged (maternity medicine orthopedic neurologic) numerous activities must be completed for each before the patient can be released This work toward discharge day should begin upon admission
As part of a progress towards NABH accreditation at Shija Hospital the discharge process is one of the many process improvement projects The discharge process at this hospital also incorporates obtaining feedback from the in-patient regarding the services at the time of discharge Due to inappropriate management the hospital was facing an acute shortage in the feedback response from the patients
The management at the hospital realizes the need and importance of patient satisfaction and a need of a measurable index through feedback analysis In all service industries customer retention is a vital issue Hence the management wanted to do all that they could to obtain feedback from the patients at the time of discharge and make the discharge procedure as smooth as it can get
The objective of this study was to study the process of discharge and find out the probable reasons for the failure to attain feedback from the patients at the time of discharge
23
STUDY METHODOLOGY
AIM
To study the discharge procedure practiced at Shija Hospitals with special emphasis on
analyzing the reasons for the short-fall of In-Patient Feedback
OBJECTIVE
1 To find the steps followed during discharge of an in-patient2 To find the total time taken for a discharge of a single patient3 To find the contributing reasons for the short fall of in-patient feedback
received in the wards
RATIONALE
The discharge of a patient is a very important component of in-patient service and needs to be smooth and efficient On the other hand in-patient feedback is equally important as it provides the performance standards of the hospital which needs to be continually enhanced
METHODOLOGY
Study design-
Area- Shija Hospitals and Research Institute Manipur
Duration- From 11-04-2011 to 30-04-2011
Type of study- Observational and Survey study
Sample size-120 in-patients and the following hospital staff
Nurse Superintendant
RMOs on duty
Staff nurse
Front office executives
Service entry staff
Sampling Method-Convenience sampling
Study tool Questionnaire and personal interviews
24
Type of Data collected -
Interviewer guided questionnaires collected from patients by visiting the different wards
Personal interview of various hospital staff and officials involved in discharge procedure
DISCHARGE PROCESS
25
Doctor prescribes the discharge
Nurse informs the patient about the time of discharge
26
Staff nurse starts discharge formalities by
Asking the Resident Medical Officer Concerned Physician to
make discharge summary
Informing Dietician to make discharge diet report for patient
Counseling of the patient by the dietician and physiotherapist (if
physiotherapy is going on for patient)
Asking the service entry assistants to enter all the details regarding the
patients starting from the no of consultant visits to medicines
consumed
Sending to Pharmacy Daily Billing Activity Sheet
Daily Pharmacy BillsDischarge medication detailsMedicines left unconsumed
In Pharmacy Summary of Pharmacy Bill is prepared
Daily Billing Activity Sheet
Summarized Pharmacy Bill
Giving the feedback form to the patient attendants
Fig1 Communication channels during the discharge procedure
27
Billing department finalizes the bill
Payment taken by billing department from attendants
IPD Billing informs at the nursing station about the clearance of bill
Discharge Summary completion by Medical Transcriptionist
Nurse informs the patient amp patient changes clothes
Nurse checks the checklist given for discharge of patient
All medications + Investigations reports + Patientrsquos file given to the patient
Patient given amp explained about how to take the medications + any special instruction + follow up schedule
Patient Discharged
Collects the filled up feedback form from the patient attendants
There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays
Fig 2 A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital
020406080
100120
82
28 39
102
Compliance to discharge procedure
No
of p
atien
ts
Table1 Duration of various parameters related to discharge
28
DoctorNurseService ward boysBillingofficePatient
Various other departments of the hospital
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
GAPS IDENTIFIED IN LAUNDRY DEPARTMENT
6 Set rule per patient not followed Presently only 2 sets per patient No weighing scale No sewing machine for repair No supervision over measured use of detergent and other chemicals
PROJECT ndash 1
A Study on Discharge Procedure with Special Emphasis
on In-Patient Feedback
22
INTRODUCTION
The study was carried out in Shija Hospitals and Research Institute which is a 180 bedded hospital located in Manipur The Hospital is well known for its high end technology and services in the region The Hospital looks forward to continually develop its services and improve the facilities available in order to become a well known health service provider in the South East Asian region in the future The operations management had identified the discharge procedure as an area where there was a scope for improvement Hence the hospital had assigned the project to study the discharge procedure
Discharging a patient is an activity common to every hospital - small large community inner-city teaching or non-teaching The discharge process can have an impact on numerous factors such as patient satisfaction bed availability timely tests and procedures needed for discharge transportation and nursing home arrangements No matter what type of patient is being discharged (maternity medicine orthopedic neurologic) numerous activities must be completed for each before the patient can be released This work toward discharge day should begin upon admission
As part of a progress towards NABH accreditation at Shija Hospital the discharge process is one of the many process improvement projects The discharge process at this hospital also incorporates obtaining feedback from the in-patient regarding the services at the time of discharge Due to inappropriate management the hospital was facing an acute shortage in the feedback response from the patients
The management at the hospital realizes the need and importance of patient satisfaction and a need of a measurable index through feedback analysis In all service industries customer retention is a vital issue Hence the management wanted to do all that they could to obtain feedback from the patients at the time of discharge and make the discharge procedure as smooth as it can get
The objective of this study was to study the process of discharge and find out the probable reasons for the failure to attain feedback from the patients at the time of discharge
23
STUDY METHODOLOGY
AIM
To study the discharge procedure practiced at Shija Hospitals with special emphasis on
analyzing the reasons for the short-fall of In-Patient Feedback
OBJECTIVE
1 To find the steps followed during discharge of an in-patient2 To find the total time taken for a discharge of a single patient3 To find the contributing reasons for the short fall of in-patient feedback
received in the wards
RATIONALE
The discharge of a patient is a very important component of in-patient service and needs to be smooth and efficient On the other hand in-patient feedback is equally important as it provides the performance standards of the hospital which needs to be continually enhanced
METHODOLOGY
Study design-
Area- Shija Hospitals and Research Institute Manipur
Duration- From 11-04-2011 to 30-04-2011
Type of study- Observational and Survey study
Sample size-120 in-patients and the following hospital staff
Nurse Superintendant
RMOs on duty
Staff nurse
Front office executives
Service entry staff
Sampling Method-Convenience sampling
Study tool Questionnaire and personal interviews
24
Type of Data collected -
Interviewer guided questionnaires collected from patients by visiting the different wards
Personal interview of various hospital staff and officials involved in discharge procedure
DISCHARGE PROCESS
25
Doctor prescribes the discharge
Nurse informs the patient about the time of discharge
26
Staff nurse starts discharge formalities by
Asking the Resident Medical Officer Concerned Physician to
make discharge summary
Informing Dietician to make discharge diet report for patient
Counseling of the patient by the dietician and physiotherapist (if
physiotherapy is going on for patient)
Asking the service entry assistants to enter all the details regarding the
patients starting from the no of consultant visits to medicines
consumed
Sending to Pharmacy Daily Billing Activity Sheet
Daily Pharmacy BillsDischarge medication detailsMedicines left unconsumed
In Pharmacy Summary of Pharmacy Bill is prepared
Daily Billing Activity Sheet
Summarized Pharmacy Bill
Giving the feedback form to the patient attendants
Fig1 Communication channels during the discharge procedure
27
Billing department finalizes the bill
Payment taken by billing department from attendants
IPD Billing informs at the nursing station about the clearance of bill
Discharge Summary completion by Medical Transcriptionist
Nurse informs the patient amp patient changes clothes
Nurse checks the checklist given for discharge of patient
All medications + Investigations reports + Patientrsquos file given to the patient
Patient given amp explained about how to take the medications + any special instruction + follow up schedule
Patient Discharged
Collects the filled up feedback form from the patient attendants
There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays
Fig 2 A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital
020406080
100120
82
28 39
102
Compliance to discharge procedure
No
of p
atien
ts
Table1 Duration of various parameters related to discharge
28
DoctorNurseService ward boysBillingofficePatient
Various other departments of the hospital
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
INTRODUCTION
The study was carried out in Shija Hospitals and Research Institute which is a 180 bedded hospital located in Manipur The Hospital is well known for its high end technology and services in the region The Hospital looks forward to continually develop its services and improve the facilities available in order to become a well known health service provider in the South East Asian region in the future The operations management had identified the discharge procedure as an area where there was a scope for improvement Hence the hospital had assigned the project to study the discharge procedure
Discharging a patient is an activity common to every hospital - small large community inner-city teaching or non-teaching The discharge process can have an impact on numerous factors such as patient satisfaction bed availability timely tests and procedures needed for discharge transportation and nursing home arrangements No matter what type of patient is being discharged (maternity medicine orthopedic neurologic) numerous activities must be completed for each before the patient can be released This work toward discharge day should begin upon admission
As part of a progress towards NABH accreditation at Shija Hospital the discharge process is one of the many process improvement projects The discharge process at this hospital also incorporates obtaining feedback from the in-patient regarding the services at the time of discharge Due to inappropriate management the hospital was facing an acute shortage in the feedback response from the patients
The management at the hospital realizes the need and importance of patient satisfaction and a need of a measurable index through feedback analysis In all service industries customer retention is a vital issue Hence the management wanted to do all that they could to obtain feedback from the patients at the time of discharge and make the discharge procedure as smooth as it can get
The objective of this study was to study the process of discharge and find out the probable reasons for the failure to attain feedback from the patients at the time of discharge
23
STUDY METHODOLOGY
AIM
To study the discharge procedure practiced at Shija Hospitals with special emphasis on
analyzing the reasons for the short-fall of In-Patient Feedback
OBJECTIVE
1 To find the steps followed during discharge of an in-patient2 To find the total time taken for a discharge of a single patient3 To find the contributing reasons for the short fall of in-patient feedback
received in the wards
RATIONALE
The discharge of a patient is a very important component of in-patient service and needs to be smooth and efficient On the other hand in-patient feedback is equally important as it provides the performance standards of the hospital which needs to be continually enhanced
METHODOLOGY
Study design-
Area- Shija Hospitals and Research Institute Manipur
Duration- From 11-04-2011 to 30-04-2011
Type of study- Observational and Survey study
Sample size-120 in-patients and the following hospital staff
Nurse Superintendant
RMOs on duty
Staff nurse
Front office executives
Service entry staff
Sampling Method-Convenience sampling
Study tool Questionnaire and personal interviews
24
Type of Data collected -
Interviewer guided questionnaires collected from patients by visiting the different wards
Personal interview of various hospital staff and officials involved in discharge procedure
DISCHARGE PROCESS
25
Doctor prescribes the discharge
Nurse informs the patient about the time of discharge
26
Staff nurse starts discharge formalities by
Asking the Resident Medical Officer Concerned Physician to
make discharge summary
Informing Dietician to make discharge diet report for patient
Counseling of the patient by the dietician and physiotherapist (if
physiotherapy is going on for patient)
Asking the service entry assistants to enter all the details regarding the
patients starting from the no of consultant visits to medicines
consumed
Sending to Pharmacy Daily Billing Activity Sheet
Daily Pharmacy BillsDischarge medication detailsMedicines left unconsumed
In Pharmacy Summary of Pharmacy Bill is prepared
Daily Billing Activity Sheet
Summarized Pharmacy Bill
Giving the feedback form to the patient attendants
Fig1 Communication channels during the discharge procedure
27
Billing department finalizes the bill
Payment taken by billing department from attendants
IPD Billing informs at the nursing station about the clearance of bill
Discharge Summary completion by Medical Transcriptionist
Nurse informs the patient amp patient changes clothes
Nurse checks the checklist given for discharge of patient
All medications + Investigations reports + Patientrsquos file given to the patient
Patient given amp explained about how to take the medications + any special instruction + follow up schedule
Patient Discharged
Collects the filled up feedback form from the patient attendants
There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays
Fig 2 A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital
020406080
100120
82
28 39
102
Compliance to discharge procedure
No
of p
atien
ts
Table1 Duration of various parameters related to discharge
28
DoctorNurseService ward boysBillingofficePatient
Various other departments of the hospital
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
STUDY METHODOLOGY
AIM
To study the discharge procedure practiced at Shija Hospitals with special emphasis on
analyzing the reasons for the short-fall of In-Patient Feedback
OBJECTIVE
1 To find the steps followed during discharge of an in-patient2 To find the total time taken for a discharge of a single patient3 To find the contributing reasons for the short fall of in-patient feedback
received in the wards
RATIONALE
The discharge of a patient is a very important component of in-patient service and needs to be smooth and efficient On the other hand in-patient feedback is equally important as it provides the performance standards of the hospital which needs to be continually enhanced
METHODOLOGY
Study design-
Area- Shija Hospitals and Research Institute Manipur
Duration- From 11-04-2011 to 30-04-2011
Type of study- Observational and Survey study
Sample size-120 in-patients and the following hospital staff
Nurse Superintendant
RMOs on duty
Staff nurse
Front office executives
Service entry staff
Sampling Method-Convenience sampling
Study tool Questionnaire and personal interviews
24
Type of Data collected -
Interviewer guided questionnaires collected from patients by visiting the different wards
Personal interview of various hospital staff and officials involved in discharge procedure
DISCHARGE PROCESS
25
Doctor prescribes the discharge
Nurse informs the patient about the time of discharge
26
Staff nurse starts discharge formalities by
Asking the Resident Medical Officer Concerned Physician to
make discharge summary
Informing Dietician to make discharge diet report for patient
Counseling of the patient by the dietician and physiotherapist (if
physiotherapy is going on for patient)
Asking the service entry assistants to enter all the details regarding the
patients starting from the no of consultant visits to medicines
consumed
Sending to Pharmacy Daily Billing Activity Sheet
Daily Pharmacy BillsDischarge medication detailsMedicines left unconsumed
In Pharmacy Summary of Pharmacy Bill is prepared
Daily Billing Activity Sheet
Summarized Pharmacy Bill
Giving the feedback form to the patient attendants
Fig1 Communication channels during the discharge procedure
27
Billing department finalizes the bill
Payment taken by billing department from attendants
IPD Billing informs at the nursing station about the clearance of bill
Discharge Summary completion by Medical Transcriptionist
Nurse informs the patient amp patient changes clothes
Nurse checks the checklist given for discharge of patient
All medications + Investigations reports + Patientrsquos file given to the patient
Patient given amp explained about how to take the medications + any special instruction + follow up schedule
Patient Discharged
Collects the filled up feedback form from the patient attendants
There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays
Fig 2 A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital
020406080
100120
82
28 39
102
Compliance to discharge procedure
No
of p
atien
ts
Table1 Duration of various parameters related to discharge
28
DoctorNurseService ward boysBillingofficePatient
Various other departments of the hospital
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
Type of Data collected -
Interviewer guided questionnaires collected from patients by visiting the different wards
Personal interview of various hospital staff and officials involved in discharge procedure
DISCHARGE PROCESS
25
Doctor prescribes the discharge
Nurse informs the patient about the time of discharge
26
Staff nurse starts discharge formalities by
Asking the Resident Medical Officer Concerned Physician to
make discharge summary
Informing Dietician to make discharge diet report for patient
Counseling of the patient by the dietician and physiotherapist (if
physiotherapy is going on for patient)
Asking the service entry assistants to enter all the details regarding the
patients starting from the no of consultant visits to medicines
consumed
Sending to Pharmacy Daily Billing Activity Sheet
Daily Pharmacy BillsDischarge medication detailsMedicines left unconsumed
In Pharmacy Summary of Pharmacy Bill is prepared
Daily Billing Activity Sheet
Summarized Pharmacy Bill
Giving the feedback form to the patient attendants
Fig1 Communication channels during the discharge procedure
27
Billing department finalizes the bill
Payment taken by billing department from attendants
IPD Billing informs at the nursing station about the clearance of bill
Discharge Summary completion by Medical Transcriptionist
Nurse informs the patient amp patient changes clothes
Nurse checks the checklist given for discharge of patient
All medications + Investigations reports + Patientrsquos file given to the patient
Patient given amp explained about how to take the medications + any special instruction + follow up schedule
Patient Discharged
Collects the filled up feedback form from the patient attendants
There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays
Fig 2 A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital
020406080
100120
82
28 39
102
Compliance to discharge procedure
No
of p
atien
ts
Table1 Duration of various parameters related to discharge
28
DoctorNurseService ward boysBillingofficePatient
Various other departments of the hospital
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
26
Staff nurse starts discharge formalities by
Asking the Resident Medical Officer Concerned Physician to
make discharge summary
Informing Dietician to make discharge diet report for patient
Counseling of the patient by the dietician and physiotherapist (if
physiotherapy is going on for patient)
Asking the service entry assistants to enter all the details regarding the
patients starting from the no of consultant visits to medicines
consumed
Sending to Pharmacy Daily Billing Activity Sheet
Daily Pharmacy BillsDischarge medication detailsMedicines left unconsumed
In Pharmacy Summary of Pharmacy Bill is prepared
Daily Billing Activity Sheet
Summarized Pharmacy Bill
Giving the feedback form to the patient attendants
Fig1 Communication channels during the discharge procedure
27
Billing department finalizes the bill
Payment taken by billing department from attendants
IPD Billing informs at the nursing station about the clearance of bill
Discharge Summary completion by Medical Transcriptionist
Nurse informs the patient amp patient changes clothes
Nurse checks the checklist given for discharge of patient
All medications + Investigations reports + Patientrsquos file given to the patient
Patient given amp explained about how to take the medications + any special instruction + follow up schedule
Patient Discharged
Collects the filled up feedback form from the patient attendants
There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays
Fig 2 A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital
020406080
100120
82
28 39
102
Compliance to discharge procedure
No
of p
atien
ts
Table1 Duration of various parameters related to discharge
28
DoctorNurseService ward boysBillingofficePatient
Various other departments of the hospital
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
Fig1 Communication channels during the discharge procedure
27
Billing department finalizes the bill
Payment taken by billing department from attendants
IPD Billing informs at the nursing station about the clearance of bill
Discharge Summary completion by Medical Transcriptionist
Nurse informs the patient amp patient changes clothes
Nurse checks the checklist given for discharge of patient
All medications + Investigations reports + Patientrsquos file given to the patient
Patient given amp explained about how to take the medications + any special instruction + follow up schedule
Patient Discharged
Collects the filled up feedback form from the patient attendants
There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays
Fig 2 A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital
020406080
100120
82
28 39
102
Compliance to discharge procedure
No
of p
atien
ts
Table1 Duration of various parameters related to discharge
28
DoctorNurseService ward boysBillingofficePatient
Various other departments of the hospital
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays
Fig 2 A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital
020406080
100120
82
28 39
102
Compliance to discharge procedure
No
of p
atien
ts
Table1 Duration of various parameters related to discharge
28
DoctorNurseService ward boysBillingofficePatient
Various other departments of the hospital
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
Parameters Duration
Average Length of Stay 4-5 days
Average time taken for discharge 3 hours 42 min
Average time of the day when patients are discharged
1438 hrs
Average time of the day when the doctor confirms discharge
1030 hrs
Table2 Level of discharge related activities completed
Parameters Actual Percentage
No of feedback collected 82120 6833
Discharge confirmed before 24 hrs 28120 2333
Patients counseled regarding discharge 39120 3250
Information given to patients for care and medication
102120 85
Areas of Major delays
bull Preparation of the discharge summary by RMO
bull 1 Service entry in charge on each floor hence shortage during peak hours
bull Negotiation of the final bill at the Billing office by the attendants
bull Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes banks or ATMs(which are not available at the hospital)
bull Unexpected System failures 3
29
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
In Patient Feedback
Fig3 Process of collection of IP feedback
Reasons for low feedback
bull 27 case files arrived at wards without feedback forms inserted in them by the front office personnel
bull Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged
bull Negligence on the part of attendants on submitting the forms duly filled amounted to about 36
bull Feedback forms not a part of discharge checklistbull 9 of the patients and their attendants are worried about the way feedback is
going to be received by the hospital staff They think that the treatment of their next visit will be influenced by the feedback they give
bull 27 of them do not really believe that anything is going to be done about the feedback forms
General practices that can be implemented to make discharges effective The discharge planning process should begin as soon as is practical after the
patient is admitted to hospital No discharge should be considered lsquoroutinersquo All discharges have the potential to become complicated Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge
A discharge date should be set as early as possible although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change Discharge plans should be clearly documented in the patientrsquos medical and nursing records
Discharge documentation should be concise easy to use and most importantly relevant Staffs should familiarize themselves with documentation used in the
30
Feedback form inserted in the
case file from the front office
Distribution of the forms to the
patients to be discharged
Collected by the nurses or
submitted at the front office
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
discharge process and ensure they are competent in its completion Adequate on the job training can be provide for the same
Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital Most of the large hospitals such as Fortis follow the same
Use of software such as lsquopatient trackerrsquo which captures and sorts patient information easily and efficiently using palm top or computer during rounds or online is recommended for use Features include the ability to track patient data view patient lists and generate reports This software is being used by Johns Hopkins
Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors
Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to
reduce chances of error in the process
If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications
Table3 Analysis of threats and opportunities of streamlining discharge procedure
Threat(If we do not follow a standard process)
Opportunity(If we follow a standard process)
SHORT TERM
Continue to encounter difficulties admitting and discharging patients
Non compliance with medical care Inaccurate census staffing billing
room occupancy Dissatisfied customers
Turn around time of bed availability will improve
Decreased admission time Increase revenue Improved communication
among departments Increased patient satisfaction
LONG TERM
Less revenue per bed Potential for serious violations of
norms Billing issues
More revenue per bed More efficient operation Increased patient satisfaction
Ways to obtain more feedback
31
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the
patients and their attendants Introducing a new system such as Patient Welfare Department which will be a
dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge
All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members
Feedback based action The recommendations and suggestions must be seriously
looked upon and evaluate the feasibility to implement them Appreciations of nurses doctors or other service staff given by the patients and
attendants must be conveyed to them to encourage them in providing better service every time
32
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
Fortis Malar Hospital Chennai
(May 4- June 4 2011)
ACKNOWLEDGEMENT
33
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
I am extremely indebted to all the professionals at Fortis Malar Hospital Chennai for
sharing generously their knowledge and precious time which inspired me to do best
during summer training I owe a great debt to Mr Venkat SR (Head Human Resource)
Dr Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their
interest and sharing their valuable views in spite of their busy schedule It has been my
privilege to work under their dynamic supervision in the hospitals
The data collection and my learning would have not been possible without in depth
discussions with Ms Sheetal (Assistant Manager HR) Ms Ammu Ms Sravya
(Executives HR) Ms Hazel (Assistant Medical Administrator) Mr Egambaram
(Medical Records Officer) of Fortis Malar Hospital I thank them for providing timely
guidance assistance amp kind support during my study
Most importantly I would like to thank my mentor Dr Neetu Purohit for her
unconditional support guidance and motivation throughout the study period
Hospital Profile 34
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services Fortis Malar Hospital earlier known as Malar hospital was founded in 1992 under the leadership of DrRamamurthy The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has sky-rocketed With 180 beds the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology Cardiac surgery Neurology Neuro surgery Orthopedics Nephrology Gynecology Gastroenterology Pediatrics Diabetics and others
Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World The hospital provides medical expertise with the finest talents amongst doctors nurses technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through state-of-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care Enhanced by the warmth amp care of the professionally trained nurses and housekeeping staff Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls
Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental
Dermatology Diabetes
ampEndocrinology Emergency Medicine ENT Gastroenterology General Medicine
General Surgery GI Surgery Internal medicine Intervention
radiology Laboratory
Services Neonatology
35
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
36
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
PROJECT ndash 2
Medical Records Management and Protocol
Implementation
37
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
INTRODUCTION
The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located
in Chennai The Hospital is well known for its brand and the quality service that it
provides to its patients The business tag line of the hospital lsquoPatient Firstrsquo says it all
about their commitment to patient care service Maintaining and keeping records of the
patients is also a very important component of patient care The reason of its importance
is well elucidated in the study
The Medical Records Department is primarily concerned with documentation of patient
care It does not deal directly with reviews of actual treatment given or set standards of
care By ensuring that all personnel comply with regulations regarding documentation of
patient care the Medical Records department supports various medical staff committees
by providing data from medical records
Medical records play an important role in the functioning of any hospital in terms of
giving vital information for conducting research statistical data on utilization of hospital
services mortality and morbidity profiles and to evaluate performance of clinical
facilities It is beyond doubt that a well-organized and managed Medical Records
Department will go a long way in providing quality services to the patient
The objective of study was to study the medical records management and protocol
implementation practiced at Fortis Malar Hospital Chennai The study is a thorough
analysis of the structure process and outcome of the Medical records department
38
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
METHODOLOGY
Study design-
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Type of study- Observational study
Study tool Personal interviews
Type of Data collected -
o Personal interview of various hospital staff and officials involved in medical records
management
o Secondary data collected from the department
39
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
MEDICAL RECORD DEPARTMENT
Structure
Layout -6th floor
Staff 4
Infrastructure
Desktop 1
Printer 1
Wipro HIS used to maintain and share hospital data
Organogram
1 MRD officer
2 Medical Records Technicians 1 Office Assistant
3 offices in total
1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage
Job responsibilities
Technicians -2o Receiving files from various wards after a patient is dischargedo Assembling the fileso Deficiency check of the fileso Coding of the files according to ICD-10o Updating the Pending list for those patients who have been discharged
but the file has not arrived at the MRD officeo Birth Death nominal registerso Insurance related enquirieso Issuing wound certificate for MLC caseso Any information required by the MRO has to be assisted by the
technicians Office Assistant
o Daily update of statistics40
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
o Overall in charge for filing sending refilling files and cupboardso Department file clearance work
MROo Overall department functionso Death Birth Insuranceo Mediator between the department and higher authoritieso Statisticso Death audito Filing supervisoro Department manual maintenance o Dealing with police personnel related to death certificateo Assignment of duties and responsibilities o Representative for summons to court
Type of Discharge Files maintained
Death Files
Birth files
MLC cases
Recovered cases
Process
Admission amp Discharge Report generation
of previous day by MRD Officer
MRD Peon collects from each ward
Daily Floor Census
+
Discharge File of discharged patients
Assembling amp Deficiency check
Completion of Incomplete documents by the MRD Officer or concerned DoctorNurse
Daily Admission amp Discharge analysis
41
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
Coding (acc To ICD-10) amp Indexing
Filing
Sub process
Maintenance of files numbering and colour coding appropriately
Facilitation in claiming of insurance
Documents required for Reimbursement
Issue of Wound certificate to MLC related cases
Preparation of discharge pending list
Data entry for Out Patient In Patient total surgery admissions doctor-wise
account of all procedures such as- CT scan Ultra sonography TMT etc
Assembling coding and deficiency check of discharge files and filing
Census data collected from the nurses on duty on daily basis
o Manually
o Consult the concerned night duty nurses
Assembling
o Daily files submitted by the ward secretary to the MRD office
o Format of assembling order checklist is maintained
Assembling Order
1 Face sheet2 Patientrsquos Discharge Records3 Discharge sheet (Discharge DOR LAMA Death)4 Emergency amp OPD card5 History sheet6 Investigation flow chart7 Consultation form8 Informed consent9 Valuable handover form10 Undertaking for payment Primary ADHOC PTCA11 Angiography- Angioplasty Checklist12 Cardiac Anaesthetic Record13 Consultation for surgical amp medical treatment14 Pre-operative instruction checklist
42
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
15 Anaesthesia record16 Surgical safety checklist17 Operation note Delivery note18 Post operative evaluation form19 Labor chart20 Progress note21 Temperature chart22 Intake output chart23 Blood sugar24 Diabetic Monitoring chart25 Drug prescription amp Administration Record26 NICU Observation Chart27 Nurses Record28 ICU amp CCU Observation chart29 Medical Certificate cause of death30 Release of dead body certificate31 Final Bills (MLC case)32 Any other relevant document concerning to patient
Deficiency check
o Checklist maintained
o All files checked against the checklist to confirm the presence of all
required reports and forms
o Final Summary sheet prepared by the MRD comprising of all important
details- final diagnosis procedure etc
Coding
o Not done through the medical information system
o Has to be done manually with reference to WHO ICD-10 code book
Filing
o Filing is done manually and separate colour coding is done for MLC cases
Death and General categories
Census assembling and deficiency check done in the main office coding and filing
done in the separate office where all files are kept and maintained
43
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
Process of issuing Birth certificate
o A child is born in the hospital
o Birth report filled by patient or patient attendant
o Collection of birth report from Neonatal Intensive Care Unit by the MRD
staff
o Details of the child entered in the birth register
o Government issued form filled by MRD signed and approved by doctor
concerned
o Government issued form submitted to the municipality by the MRD staff
o Patient attendant go to the Municipal Corporation and collect the
certificate( Corporation of Chennai Zone-10 Adyar Office)
Claiming of insurance
Different insurance companies follow different policies and procedures There are three
categories of insurance as follows
o TPA
o Group
o Medical Assistance also known as Medicaid
However there are no insurance provisions for genetic related diseases or illnesses Once
admitted in the hospital pre-authorization form is submitted to billing office by the
patient Doctor billing persons fills the required forms The forms are then sent to the
company for approval Surgical procedure or treatment is carried out in the hospital
Investigator or claim analyst then comes to the MRD office to cross check all the details
of the procedure and asks for all procedures and file handed over to the investigator They
can see and verify and sign saying that they have verified They ask for some papers or
reports which are allowed to be given For the patients on a payment of Rs500 and
approved by the deputy Medical Superintendant papers can be obtained from the MRD
office
MLC related Casualty
These files are maintained separately for In Patients and Out Patients Casualty wards
maintain separate register for MLC cases These files are presented in case of request for
44
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
details from police stations Wound certificates are issued on approval by Casualty
Medical Officer in case of out patients and for admitted patients opinion is sought from
doctor concerned with the final diagnosis based on the surgery related to department The
details of the wound certificate are filled by MRD staff and three copies are made of the
same
MR requisition
Medical records can be obtained from the Medical records department by filling a
medical records requisition form The requisition form is available only to the internal
staff Detailed requisition form is to be filled by the person who is in need of the
concerned files For requirement of more than 5 files intimation has to be given before
two days
Statistical data of the following are received by the MRD from the respective
departments
o CATH Lab procedures
o Cardiac surgery
o General surgery
o Daily operation schedule
With reference to these mails data is entered in the existing format for MRD
Month end copy of the following statistical data submitted to higher authority
o Deputy Medical Superintendant
o Medical superintendant
o Zonal director
o Financial manager
o Delhi head office
Outcome
Generation of hospital related statistics such as Bed Occupancy Rate Average
Length Of Stay etc
Record Retention Periods
IP Record 05 years
45
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
Emergency Register 02 years
MLC Records Not to be destroyed
BirthDeath Register Not to be destroyed
OPD documents Handed over to the patients
Generation of Death Birth Certificates
Systemized and coded files for future reference
Gap analysis
Discharge files
o Incomplete nursersquos notes
o Patient details are missing
o Day to day notes with date and time is missing
o Sex details missing
o Admission slip is missing
o Discharge summary is missing in about 20 files
o Only 40 files are completely filled and gets through the checklist
o Consent form for procedure- left blank
o Patient Registration form missing
o No uniformity in admission forms various formats of admission forms
Birth certificates
Birth and death report filled incorrectly or later changes requested by the family In spite
of a 6 month long period of time given to decide the name there are still a high number of
cases where the parents come to change the names
Birth and death form to be actually filled by doctors but not followed
Insurance
o Investigator comes as a representation of the company but often fails to
bring a letter authorized by the patientrelatives
Coding ICD- 10 book not available at the MRD office
Insufficient space provided for MRD department according to 180 bedded
hospital
46
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
PROJECT ndash 3
Employee Joining Kit
47
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital
located in Chennai The management team at the hospital is a strongly dedicated team I
had an opportunity to work with the Human Resource management team of the hospital
During my training I have seen that they are continuously bringing out new ways and
means to delight their employees encourage them and aid them in performing their best
The Fortis Healthcare industry is known for its high retention rates of up to 95 It can be
said without doubt that the HR team has a role to play In the same spirit of delighting
their employees the HR team assigned me to design and prepare a comprehensive
employee joining kit to be given to the new employees
Joining a new organization is a moment filled with exhilaration excitement and curiosity
for the new employee At the same time the organization is eager to find out all about the
new employee their personal data health condition work experience etc The
organization also wants to acquaint the new employee with all the norms and customs of
the organization It is during the period of joining that the fresher is all eager to find out
all about the organization as well Hence it is the responsibility of the organization to
bridge the gap between the new employee and the organization by providing a
comprehensive and concise employee Joining kit which will contain the vision and values
of the organization guidelines for the layout use of canteen and other activities in the
organization
The objective ofthe assignment was to prepare a joining kit which will be a guide to the
new employee as well as a means of conveying the entire relevant and required message
to the fresher This would also serve as a booklet attached with all the mandatory as well
as non mandatory forms to be filled and submitted by the employee after they tear the
sheets attached with perforations
48
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
METHODOLOGY
Area- Fortis Malar Hospital Chennai
Duration- From 04-05-2011 to 04-06-2011
Study tool Personal interviews
Type of Data collected -
o Detailed personal interview of various hospital staff and officials
o Relevant and statutory forms collected from various departments
o Secondary data collected from the department of Human Resource Administration Food amp
Beverages Nursing etc
The Employee joining kit was successfully completed and approved by the management of the
staff The complete joining kit is attached as an annexure to give a more detailed comprehension
of the requirements of preparing an employee joining kit
49
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50
Annexure 1FORTIS MALAR HOSPITAL
ADYAR CHENNAI -20HOSPITAL STATISTICS FOR JAN TO DEC- 2011
SNO PARTICULARS JAN11 FEB11 MAR11 APR11 Total1 TOTAL OUTPATIENTS 8790 8533 9058 7749 3413000
CARDIOLOGY 789 812 861 756 3218002 DAILY AVERAGE OF OPD 284 305 292 258 1139243 TOTAL INPATIENTS ADMISSIONS 826 784 886 851 334700
CARDIOLOGY 253 807 871 760 2691004 DAILY AVERAGE OF ADMISSIONS 27 28 29 28 111955 TOTAL INPATIENTS DISCHARGES 795 794 905 824 3318006 DAILY AVERAGE OF DISCHARGES 26 28 29 27 111027 TOTAL INPATIENTS TREATED 3712 3399 3555 3184 1385000
CARDIAC CASES 1138 1218 1363 1094 4813008 DAILY AVERAGE OF INPATIENTS 120 121 115 106 462209 BED OCCUPANCY RATE 7044 6340 5975 5454 062
10 TOTAL SURGERIES 289 264 374 322 124900 MSOT 230 216 290 261 99700 CTOT 59 50 84 61 25400
11 TOTAL EMERGENCY CASES 1337 1181 1376 1145 503900 OP TREATED 1030 921 1071 850 387200
CASUALTY ADMISSIONS 307 269 310 285 117100
MLC CASES 97 81 117 95 39000
12 TOTAL DELIVERIES 38 35 39 36 14800
NORMAL 12 10 14 12 4800
LSCS 26 25 25 24 10000
FORCEPS 0 0 0 0 000
VACCUM EXTRACTOR 0 0 0 0 000
13 TOTAL CATH-LAB 157 162 175 170 66400
ANGIOGRAM 110 116 135 124 48500
PTCAOTHERS 47 23 40 46 15600
14 TOTAL ECG 649 637 952 608 284600
15 TOTAL ECHO 486 472 517 477 195200
16 TOTAL TREADMILL 150 187 175 129 6410017 TOTAL DIALYSIS 290 273 356 366 128500
18 TOTAL PHYSIOTHERAPHY 2027 1821 2153 1718 771900
OUT-PATIENTS 857 830 995 720 340200
IN-PATIENTS 1167 991 1158 985 430100
19 TOTAL NCV 43 37 46 36 16200
20 TOTAL EEG 26 33 38 37 13400
21AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) 466 380 347 337 1530
22 TOTAL DEATHS 22 29 23 8 8200 gt 24 HOURS 20 23 19 4 6600 lt 24 HOURS 2 6 4 4 1600 GROSS DEATH RATE ( ) 276 365 254 097 248 NET DEATH RATE ( ) 252 290 210 049 200
50