SUMMER TRAINING

(April 2nd-31st May, 2012)

In

INDIAN SPINAL INJURY CENTRE

A REPORT

On

“OPD PATIENT SATISFACTION”

BY

PULKIT KATHURIA

Post-graduate Diploma in Hospital and Health Management (2011-13)

INTERNATIONAL INSTITUTE OF HEALTH MANAGEMENT AND RESEARCH,

DELHI

1

ACKNOWLEDGEMENT

I am extremely indebted to all the professionals at Indian Spinal Injury Centre for sharing

generously their knowledge and precious time which inspired me to do best during summer

training. I owe a great debt to Major H.P.S Ahluwalia (Chairman) and Dr. H.S. Chhabra

(Medical Director) for giving me an opportunity to undergo training in their prestigious institute.

Also I express gratitude to Ms. Sugandh Ahluwalia (deputy director strategy) and Dr. P.H

Mishra (Medical superintendent) 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 hospital.

The data collection and my learning would have not been possible without in depth discussions

with marketing team (Mr Abhishek Srivastava, Mr Debashish Mukherjee and Ms. Shivika

Kansotia). I thank them for providing timely guidance, assistance & kind support during our

study. I would also like to thank Mr Alok Rawat for his valuable inputs in our study.

I am highly grateful to all the departmental heads and staff for giving me time in spite of their

hectic schedule. Without their active cooperation and participation it would not have been

possible to accomplish my task.

Most importantly I would like to thank my mentor Dr. Pawan Taneja for her unconditional

support, guidance and motivation throughout the study period.

2

TABLE OF CONTENTS

S.No Chapters Page no

1. Abbreviations 4

2. Reflection of Course on Summer Training 6

3. Hospital Profile 8

OPD PATIENT SATISFACTION PROJECT

4. Abstract 11

5. Rationale of Study and Introduction 12

6. OPD Process Flow 14

7. Objectives and Review of Literature 15

8. Methodology 16

9. Study Findings 17

10. Conclusion 25

11. Recommendations 26

12. Limitations 27

13. Special Case Study I- Review of various hospital

departments.

28

14. References 38

15. Annexure 39

3

ABBREVIATIONS

AHU - Air Handling Units

4

AC - Air Conditioner

AMC- Annual Maintenance Contract

BTL- Below the Line

C.G.H.S- Central Government Health Scheme

CRM- Customer Relationship Management

CSSD - Central Sterile and Supply Department

DG- Director General

D/S - Discharge Summary

ECG - Electro Cardiogram

ENT - Ear Nose Throat

ESIS- Employ State Insurance Scheme

ETO - Ethylene Oxide

HIS - Hospital Information System

HIV- HUMAN IMMUNO DEFICIENCY VIRUS

HOD - Head of Department

IPD - Inpatient Department

ICU - Intensive care Unit

IT - Information Technology

MD - Managing Director

MLC - Medico Legal case

MRD - Medical Records department

MTP - Medical Termination of Pregnancy

NICU - Neonatal Intensive Care unit

OPD - Out patient Department

OT - Operation Theatre

5

PET/CT - Positron Emission Tomography/ Computerized Tomography

PNDT - Pre Natal Determination Test

REHAB - Rehabilitation

RMO - Resident medical Officer

TPA - Third Party Administrator

USP - Unique Selling Product

UHID - Unique Health Identification Number

REFLECTION OF THE COURSES LEARNT ON THE SUMMER TRAINING PROJECT

6

As a part of my summer training, I was interning at The Indian Spinal Injury Centre for duration

of eight weeks starting from April 2nd - May 31st 2012. With the exposure and my training at the

hospital, I can now incorporate my learning’s from the two modules - Hospital Planning and

Strategic Management to my project.

Hospital planning comprises of Planning, Designing, Equipping and Commissioning all such

buildings and facilities where healthcare is delivered. When designing a hospital, it must be

always kept in mind that the hospital is used not only by the in-patients, but also, by all kinds of

people that come in touch with the organisational facilities - starting from the community, to

casual visitor, nurse, clinician etc. The design decisions have to incorporate a variety of

parameters to suit them all. Moreover spaces in a hospital should be comforting and provide

order to its increasingly complex and chaotic schedules.

Hospital buildings are always complex because they impact the building as a whole including the

zoning plan, provision of air handling equipment, design to provide viewing galleries. The site of

the hospital should be such that it has access to alternate hospital, easy road access, availability

of public transport, enough sign postings, emergency disaster plan, enough car parking spaces

and provision of solar water heaters, water conservations etc. In addition, there should be enough

signages which should be illuminated such as room and bed numbers and provision of speakers

for making the announcements.

As per my observations at the hospital, there were signages at all the mandatory places and more.

There was easy access to public transport and also to alternate hospital that is “Fortis Rajan

Dhall”, Vasant Kunj.

As far as hospital infrastructure is concerned the car parking space was sufficiently available.

Illuminated signages, emergency disaster plan, solar water heaters, speakers for making

announcements were also present in adequate amount. The hospital has been designed in a user

friendly way. Since it is spinal injury hospital, adequate amount of wheelchairs were available

with the provision of assistive technology.

Bringing the focus to the Strategic Management, it is a field that deals with the major initiatives

taken by general managers on behalf of owners, involving utilization of resources, enhancement

of the performance of the firms with respect to their external environments. It entails specifying

7

the organization's mission, vision and objectives, developing policies, plans, often in terms of

projects and programs, which are designed to achieve these objectives, and then allocating

resources to implement the policies, plans, projects and programs.

In this regard ISIC has defined its mission, vision and values attributed for its overall

development, along with the specific goals defined for each department paving a way for the

achievement of the organizational goal. For example: The Marketing departments decides the

next year goals on prior basis and then decide which camps should be conducted in which month

both in house and out house along with advertisements.

Organizational Profile

As an integral part of the PGDHM course, the summer training helps us in understanding the

overall functioning of the hospitals from a managerial point of view. Keeping this factor in view,

8

we tried to visit different hospital departments of Indian Spinal Injuries Centre (ISIC) with a

special focus on understanding the various procedures in place. I visited different departments,

met the department In-charge and interacted with the doctors, nurses and other staff.

The story of the Indian Spinal Injuries Centre is really the story of one man’s journey of faith of

accomplishing an almost impossible mission of completely dedicating his life to others. ISIC,

brainchild of Major Ahluwalia is a 145 bedded hospital (with 14 beds reserved for poor)

sprawled across 12 acres of lush green lawns and citrus fruit trees in the heart of South Delhi,

successfully running for the past 12 years. It is perhaps, the only hospital designed by a patient

for a patient, providing everything that a spinal injured patient would need under one roof. It is

the only hospital in India that is completely barrier free since the architects had a unique insight

into the possible impediments that a spinal injured patient can face, therefore endowing a homely

and easier to relate to atmosphere. The Indian Spinal Injuries Centre (ISIC) was a true landmark,

not only in India, but in the whole of Asia.

ISIC is India’s most advanced Spine, Orthopaedic and Neuromuscular Surgical centre with all

the latest diagnostics and surgical equipment and a highly qualified team of internationally

recognized specialists who have been trained in leading institutes of India and abroad. It has a

team of dedicated, internationally trained & acclaimed spine surgeons providing cutting edge

medical & surgical technology. The spine service provides comprehensive management of spinal

injury, back pain, spinal deformities, tumors, osteoporosis etc. In addition the hospital hopes to

consolidate on provision of super specialty service in the field of Spine Surgery, Orthopaedics,

Rheumatology, Neurology, Rehabilitation, Urology, and Plastic Surgery. 

The rehabilitation department is considered to be a vital core element of the hospital. It offers

complete facilities of physiotherapy, occupational therapy which provides guidance for patients

to lead a productive, self-reliant life followed by vocational training which offers the ISIC

patients with a new hope and confidence of running their households in a specific vocational

area.

ISIC is much more than a hospital, it is also considered a training institute and teaching hospital

affiliated to a leading university of the country. One the most coveted courses include Masters of

9

Prosthetics and Orthotics. ISIC Rehabilitation (Rehab) Centre has the latest medical technology

available so that the patients derive maximum benefit from their treatment.

Mission of ISIC

At Indian Spinal Injuries Centre, our aim is to restore hope and joy in the heart of every patient

with unrelenting attention to clinical excellence, patient safety and an unparalleled dedication to

assure exemplary physical, emotional and spiritual care.

Vision OF ISIC

To strive to become the first choice as a spinal and orthopaedic healthcare provider in

New Delhi.

To foster a culture of education in all of our activities and supporting exemplary health

sciences research and development in an environment which is both ethical and respectful

of others

Utmost dedication to providing quality, value driven health care to all we serve through

education, outreach, and other innovative services in spine and other spinal ailments.

To strengthen our relationships through affiliation with renowned institutions of higher

learning; offering technological advances and modern facilities.

To reach the lives of thousands of newly spinal injured every year by providing medical

excellence through both scientific expertise and compassionate therapy.

ISIC Core Values & Commitments:

To strive to bring awareness in the field of disability and lobby with policy makers to

introduce suitable legislation for prevention of disability and enforcement of the equal

opportunity bill.

We will continue to put strong emphasis on man power development through education

programs with a focus on graduate and post-graduate courses in Rehabilitation Sciences.

WHAT SETS ISIC APART/USP OF ISIC: REHABILITATION

10

Figure 1: Overview of Rehabilitative Services at ISIC

One of most advanced technology so that patients can derive maximum benefits from

the treatment

USP of ISIC

Only hospital to have separate Department of Assistive Technology

Not only provides physical and mental rehabilitation but also provides emotional and

community rehabilitation.

Multidisciplinary approach followed for the rehabilitation of the patient.

“OPD PATIENT SATISFACTION AT ISIC”

11

Abstract

The objective of this study was to find out the level of satisfaction among the appointment and

walk-in OPD patients at ISIC. Patient satisfaction depends upon many factors such as quality of

clinical services provided, availability of medicine, behavior of doctors and other health staff,

cost of services, hospital infrastructure, physical comfort, and respect for patient preferences.

Mismatch between patient expectation and the service received is related to decrease patient

satisfaction.

The methodology adopted was purposive sampling and study design was cross sectional

descriptive study. The sample size for the study was 70 OPD patients. The sampling universe

was Indian Spinal Injury Centre, Vasant Kunj.

The key findings from the study were that the level of satisfaction regarding overall quality and

consultant service was high. On the other hand, most of the patients were dissatisfied with the

waiting time and cost of services. The other key finding was that the factor which influences the

most the choice of hospital was word of mouth followed by referral from doctors.

Figure 2: Patient Satisfaction

Rationale of Study

12

Since this is the age of consumerism; the patient dictates what is, and what is not, acceptable or

exceptional. So from a managerial perspective, patient satisfaction will always remain a

fundamental requirement for clinical and financial success of any organization.

Patient satisfaction measurement not only predicts about the financial success of organization

but also adds important information on system performance, thus contributing to organization’s

total quality management.

So the study on OPD patient satisfaction was done to find out the level of patient satisfaction

among the appointment and walk in patients at ISIC and suggest areas of improvement.

Introduction

The OPD is defined as the hospital's department where patients undergo diagnoses and/or

treatment but do not stay overnight. It is a hospital facility where non-urgent ambulatory medical

care is provided.

OPD acts as a show window to the hospital services and a patient’s impression of the hospital

services begins at the OPD. The patients who need indoor care are advised admissions through

the OPD and thus OPD also acts as a filter for indoor admissions. Besides the curative services,

certain preventive services like immunization; promotive services like dietary counseling and

rehabilitative services like physiotherapy and occupation therapy are also provided in OPD.

Among all departments in a hospital, the OPD caters to maximum number of patients. It is

generally the first point of contact of patients and their attendants with a hospital, and thus

creates first impression about the hospital services. Therefore, it has wider implications on the

reputation and brand image of the hospital. Although OPD is not a major profit center of

hospitals, it generates revenues indirectly through diagnostic services and admissions.

The care in OPD indicates the quality of services of a hospital and is reflected by patient’s

satisfaction. The OPD should be

13

Easily accessible from the main road and the main entrance of the hospital.

It is ideally located on ground floor with a separate wide entrance.

All outpatient clinics should preferably be clustered in one block for the convenience of

clients and management.

The outpatient department of ISIC works on a daily basis for six days in a week except Sundays.

The area has main entrance close to road with a car parking area. Near the entrance is the

reception counters for registration. The doctor’s consultation rooms are associated with sub-

waiting areas adequate enough to accommodate the patients and attendants waiting for

consultation.

Out Patient Department Facilities available at Indian Spinal Injuries Centre

Figure 3: Chart Showing OPD Facilities at ISIC

Process Flow

14

Spinal Disorders & SurgeryOrthopaedics

Alternative MedicineAnesthesia

CardiologyChest & Respiratory MedicineDentalDermatology

Emergency (24*7)ENT (Ear/Nose/Throat)

Executive Health Check-upFoot Care Clinic (Podiatry)

GastroenterologyGynecology

Internal MedicineJoint Disease Services

(Rheumatology)

NeurologyNeurosurgery

Nephrology & DialysisOphthalmology

Obesity andweight management,

Pain clinic, Pediatrics

Plastic surgeryPsychiatry

Psychology and stress management Rehabilitation

Radiology & imaging services Surgery

Speech therapy Urology

Patient comes to the billing section of O.P.D

Objectives of Study

General objective:

15

Billing Executive asks whether 1st time Patient or Follow up Patient

Follow up Patient

2-3 Minutes

1st Time Patient

5-7 minutes

Patient fills up Registration Form and O.P.D Card Patient asked 2-3 predefined search parameters like phone number etc to get details.

Unique UHID is generated Details retrieved, new entry done

and Billing is done.

Card is given to Ward Boy, which he then numbers on first come basis. No segregation of new, follow up and walk in patients done. 1St 20 patients are appointment, followed by 1st come 1st serve basis for

numbering.

Patient in most of the cases is asked to go for an investigation and then again seen by the consultant for diagnosis.

Time taken for investigation depending upon crowd varies from 20min-1hour.

2nd Consultation has waiting of 20min-1 hr depending on the crowd.

Patient Exits the O.P.D

To determine the level of satisfaction among the walk in/ pre- appointment patients with major

aspects of service delivery

Specific objective:

To identify the factors which influence patient satisfaction

To define the parameters of the patient satisfaction in terms of quality of care and value

for money

To suggest how can the patient satisfaction level be improved

Review of Literature

(1) A study was conducted to measure the satisfaction of OPD (Outpatient Department) patients

in public health facilities of Madhya Pradesh (eight districts) in India. A total of 561 OPD

patients were included in the study to know their perceptions towards the public health facilities,

choosing health facility, registration process, basic amenities, perception towards doctors and

other staff, perception towards pharmacy and dressing room services.

It was found that most of the respondents were youth and having low level of education. The

major reason of choosing the public health facility was inexpensiveness, infrastructure, and

proximity of health facility. The patients were more satisfied with the basic amenities at higher

health facilities compared to lower level facilities. It was also observed that the patients were

more satisfied with the behavior of doctors and staff at lower health facilities compared to higher

level facilities.

(2) Another study was conducted among 200 patients attending OPD of Sree Chitra Tirunal

Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India. it was found

that majority of the patients are satisfied with the services provided. They were satisfied with the

guidance, logistic arrangements, support services, nursing care, Doctors consultation etc.

wherever there is delay in consultation; it is to be explored that where it can be improved.. It is

worthwhile to note that there is scope for improvement of the Out Patient Department Services.

Therefore it can be concluded that the OPD services form an important component of Hospital

services and feedback of patients are vital in quality improvement.

16

Methodology

Study design-

Area- Indian spinal injury centre, Vasant Kunj

Duration- From 09-04-2012 to 28-04-2012

Type of study- Cross sectional Descriptive study

Sample size- 70 OPD patients at ISIC (As per decision of management)

Sampling Method- Purposive Sampling Method.

OPD patients of following 4 departments were surveyed- Spine, Orthopedics, Neurology and

Rheumatology. The average footfall of these four departments is 90 patients/day.

Type of Data collected -

Primary data collected by visiting the different departments.

Both types of observations –participative and non participative were used in learning the

function and working of the OPD.

Non Participative observation was used mainly to learn the general things about the hospital like

waiting time of the patient, availability of the ward boys/attendants.

Study Findings

Table No 1: Demographic Profile of Patients

17

Demographic ProfileNumber in Paranthesis(70)

Gender Male 29(41.43)Female 41(58.57) Age 20-35 28(40%)36-50 21(30%)51-65 17(24%)Above 65 4(6%)

The study of demographic profile of the OPD patients helps in knowing consumer market

characteristics such as age, sex, income and disabilities. These demographic statistics can help to

predict the types of services people are using and what the target population is. The table shows

that out of the total patient surveyed 58.57% were females and the rest were 41.43% patients

were males Moreover maximum number of respondents (40%) belonged to the age group of 20-

35 years and minimum respondents (5.71%) belonged to above 66 year age group.

1. Is this your first visit to hospital?

Figure 4- Number of New/ Follow up Cases

(See figure no-4)The patient coming to hospital may be a new or a follow up case. It was found

that maximum number of patients were old patients 64 (91%) i.e. it was not there first visit while

only a few (6) were new patients .So it can be concluded that around 90% patients do come back

which can be attributed either to the specialized treatment provided or the quality of care.

2. Accessibility to hospital.

18

Ease of Location Enough Signages50

52

54

56

58

60

62

64

66

68

70

68

60

No

Of P

atien

ts

Figure 5 -: Factors Affecting Accessibility to Hospital

Access is an important part of quality of care. A crucial aspect for patient satisfaction is their

comfort levels with the facility itself i.e. a person’s ease in navigating a facility, and the

timeliness in receiving care. In addition to that Signs are so commonplace that their importance

can be taken for granted. As an entrepreneur, though, one should know that your sign can be

vitally important to your bottom line. The best signs are designed well enough to attract business,

while at the same time enhancing the area where they are meant to work. The above chart

illustrates that 68 patients out of 70 were easily able to locate the organization. In addition to that

the presence of signages always provides an easy accessibility to the hospital, Out of these 68

patients, 60 agreed that there were enough signages present which help to locate the

organization.

3. What influenced you to come to the hospital?

It is always important to know that what influenced the patient to choose the organization as it

influences knowledge attitude behavior of patients and marketing strategies of hospital. Word of

mouth and referral from doctor were the most cited reasons followed by internet (to a lesser

extent) for the influence on choice of hospital. On the other hand, none of the patients said that

their choice was influenced by newspaper/magazine or any other advertisement (see figure-6)

19

45.71

4.29

38.57

2.86 8.57

Main Influence

WORD OF MOUTHNEWSPAPER/MAGZINEADVERTISEMENTINTERNETREFFERAL FROM DOCTORBOTH (WORD OF MOUTH & IN-TERNET)BOTH (WORD OF MOUTH & REFFERAL)

Figure 6 -: Reasons for choosing Health Facility

4. Average waiting Time for Appointment/Walk in Patients

Waiting time is one of the major aspect from which patient satisfaction can be measured. And

according to the study of (Mike Hart, (1995) "Improving out-patient clinic waiting times:

methodological and substantive issues",) all patients who attend out-patient clinics should be

seen within 30 minutes of their appointment time. The study revealed that the average waiting

time was 36 minutes for appointment patients and it was as long as 82.8 minutes for walk-in

patients [see figure -7]

20

Appointment Patients

Walk In Patients0

10

20

30

40

50

60

70

80

90

36

82.8

Tim

e ( I

n M

inut

es)

Figure 7: Waiting Time for Appointment/Walk in Patient

5. Pre Arrival Satisfaction Level

Satisfied with telephonic conversation prior to visit:

Yes: those who were satisfied No: those who were not satisfied

N = 57

YES NO0

10

20

30

40

50

60

49

8

No.

Of P

atien

ts

Figure 8: Satisfaction level With Pre arrival Telephonic Conversation

"The patient experience is more than what just happens within the four walls of the hospital.

Hospitals must think about the interactions that occur before the patient arrives and after he or

21

she leaves. Pre- Telephonic conversation refers to when the patient calls for appoint before

reaching the health facility which is equally important. The above chart [see figure-8] shows the

pre arrival patient satisfaction level. It was found that 49 of patients were satisfied with the

telephonic conversation prior to their visit while 8 patients did not agree with the above fact.

6. Satisfaction on Arrival

VALUE INTERPRETATION5 EXCELLENT4 GOOD3 FAIR2 POOR1 NOT APPLICABLE

Guidance

to Suita

ble Consulta

nt

Greeting o

n Arriva

l

Promptness

of Attnen

tion

Waiting R

oom Comfort

Consulta

nt Serv

ices

1

1.5

2

2.5

3

3.5

4

4.5

5

3.9 3.9 3.7 3.64.3

Mea

n Sc

ore

Figure 9: Factors Related to Post Arrival Satisfaction

Every patient does not know that which consultant he should see for his ailment and moreover,

the level of patient satisfaction is judged by consultant services along with factors such as

waiting room area comfort, greeting on arrival and promptness of attention. It can be observed

that maximum number of patient was satisfied with guidance to suitable consultant and greeting

22

on arrival while waiting room comfort served obstacle with the mean score of 3.6 and needs to

be improved.

Moreover a patient comes with an expectation that he/she will be treated in best possible way. It

was found that maximum patients (mean score-4.3) were satisfied with the consultant services

and rated them as good and also said that the doctor spent adequate time with them.

7. Whether the Prescribed Medicines available in Pharmacy?

N= 53

YES NO0

5

10

15

20

25

30

35

40

38

15

No.

Of P

atien

ts

Figure 10: Availability of Prescribed Medicines in Pharmacy

Pharmacy is one of the departments that generate huge revenue for a healthcare organization.

Out of 70 patients, 53 availed the pharmacy facility. Data reveals that out of these 53 patients, 38

patients got the prescribed medicines from the pharmacy itself, while 15 patients told that

medicines were not available in the pharmacy. The patients who fall under the category of N/A

are those who preferred to take it from outside.

8. Whether the Prescribed Diagnostic Test available in Hospital?

All though OPD caters to large number of patients, it is generally not a profit centre for hospital.

The major profits come from investigations, pharmacy and admissions that are advised by the

consultants in the OPD. With regard to the availability of diagnostic test, majority (75.71 %) of

23

the patients told that diagnostic tests were available in the hospital while 22.86 % of the patients

preferred to get their tests done from outside. (See figure 11)

N=54

YES NO0

10

20

30

40

50

60

53

1

No.

Of P

atien

ts

Figure 11: Availability of Prescribed Diagnostic Tests

9. Overall Financial Satisfaction

ASSISTA

NCE WITH

FINANCIAL Q

UERIES

EXPLA

NATION O

F THE P

AYMEN

T PROCED

URE

ESTIM

ATION O

F THE C

OST12345

3.8 3.9 3.5

Financial Administration

PARAMETERS

MEA

N S

CORE

Figure 12: Financial Satisfaction

24

Financial administration refers to that set of activities which are related to making to various

branches of organization to enable it to carrying out its objectives. Moreover it also adds to level

of satisfaction Maximum people rated financial administration with a mean score of 3.5-3.9

which is near to satisfactory aspect and further on measures can be taken to make it more

consumer oriented to increase the satisfaction levels. (See figure 12)

10. Overall Rating of Basic Amenities

TOILET FACILITIES FACILITIES FOR DISABLED

CAFETERIA1

1.5

2

2.5

3

3.5

4

4.5

5

3.9 3.7 3.5

Basic Amenities

PARAMETER

MEA

N S

CORE

Figure 13: Rating of Basic Amenities

Apart from the basic healthcare services, other facilities like toilet facilities, facilities for

disabled and cafeteria also contribute in affecting the patient satisfaction level. ISIC being a

spinal hospital needs to have all the basic amenities which are user friendly for such people and

as per the observation it can be concluded that people found toilet facilities and facilities for

disabled near to satisfaction level while the judgment regarding the cafeteria was a bit low.

11. Overall Rating of Quality of Care and Value for Money

ISIC being one of the hospitals dealing with spinal injury needs to tackle the patient not only for

the physical injury but also for emotional illness so care for ISIC, is not uni departmental but a

25

multidisciplinary facet and quality of care provided depicts the standards maintained by the

hospital management which according to the patient rating is termed excellent.

Being the only hospital dealing in spinal injuries patient generally found it expensive in

consecutive visits so the value for money was rated as low. (See figure-14)

QUALITY OF CARE VALUE FOR MONEY1

1.5

2

2.5

3

3.5

4

4.5

5

4.13.5

Mea

n Sc

ore

Figure 14: Overall Satisfaction

Conclusion

Patient satisfaction is a fundamental requirement for the clinical and financial success of any

organization that provides health care. The process of meeting or exceeding patient expectations,

serves as an antecedent to patient loyalty. One of the major challenges of the dynamic healthcare

environment is keeping up with constantly escalating patient expectations. This requires various

mechanisms in place for remaining in touch with, and responding to, those changing

expectations-an essential organizational commitment in today’s competitive health care

marketplace. Satisfied patients are more likely to be loyal, to refer others to the organization, and

26

to comply more with instructions, and will be less likely to complaint or worse, initiate a

malpractice suit.

Outpatient department of ISIC is one of the best OPD’s among the various hospitals of Delhi. It

caters to a patient population of roughly fifty eight thousand annually. This amounts to an

average OPD rush of about 150-200 patients per day and even more on weekends.

At ISIC, most of the patients are satisfied with the overall quality of care and consultant services.

One of the major concerns for the patients was value of money. Around 45% patients were

dissatisfied with the overall cost of the services. More below The Line (BTL) activities to be

pursued with round the year hoarding and visual marketing. CRM (Customer relationship

management) should be followed rigorously as 91% patients do comeback.

Recommendations

The findings of the present study can be utilized to improve the health services at ISIC resulting in the more satisfaction of patients availing the health facilities.

When the patients are waiting for the doctor, patient engaging materials such as news

paper/magazine should be present for the waiting patients.

Department OPD waiting time for seeing the doctor is long so the hospital

administration should try to manage the waiting time.

As most patients, whether new or old, prefer to come to the hospital in the

morning, so there is always a crowding of outpatients. Most patients also come

without appointments. The waiting time for appointment patients is not much

but it is very high for walk in patients.

There is large number of walk in patients in rheumatology, so waiting time is

the maximum in the rheumatology department. Consequently, an important area

to improve upon is the appointment and scheduling system.

At times, doctors do not use time slots appointed to them effectively, which

affects the productivity of the hospital. The appointment should be scheduled

with adequate time slot for each patient to be examined properly and less

waiting time for those following.

27

Some days when there are more patients in waiting area of OPD, then the seats are not

enough for patients in OPD. So, more chairs can be placed in the waiting area to

accommodate all waiting patients.

Well-groomed and efficient billing and front office staff is a key to the efficient

functioning of OPDs. Therefore imparting soft skills, customer focused and process

centric training to the OPD personnel and creating a culture of empathy and compassion

for patients in the OPD should be high on agenda. 

Some of the patients were not satisfied with the basic amenities being provided at the

hospital; hence, some strategies need to be adopted to improve the same.

Some of the patients informed that medicines were not available in the OPD pharmacy

and few didn’t even know about the existence of pharmacy, so management needs to

ensure that all medicines which are being prescribed should be procured on time and drug

formulary can be designed as it also helps in generating revenue. Moreover, efforts

should be made to increase the number of signages to direct towards pharmacy.

Subsequent repeat study may be conducted to know the satisfaction level.

Limitations

The study is subjected to the understanding, bias and prejudices of respondents.

Although participants were assured of confidentiality, it may still be possible that they

either over or underreported their level of satisfaction.

Low response rates: this was due to the fact that new patients visiting the organization

were reluctant to respond as they were less familiar with the services being provided at

the hospital, so most of the respondents were follow up cases as they were more familiar

with the services being offered.

Small sample size: most of the patients are in pain or other discomfort when they visit the

hospital, so very few of them respond to the survey. Also, it was important to take care of

patients and the survey being performed does not cause any discomfort to them. So, only

those people were surveyed who felt no discomfort responding to the questionnaire?

28

CASE STUDY

CRITICAL REVIEW OF VARIOUS HOSPITAL DEPARTMENTS

1. Radiology

Introduction-

Radiology is a medical specialty that employs the use of imaging to both diagnose and treat

disease visualized within the human body. Radiologists use an array of imaging technologies

(such as x-ray radiography, ultrasound, computed tomography (CT), nuclear medicine, positron

emission tomography (PET) and magnetic resonance imaging (MRI) to diagnose or treat

diseases. Interventional radiology is the performance of (usually minimally invasive) medical

procedures with the guidance of imaging technologies. The acquisition of medical imaging is

usually carried out by the radiographer or radiologic technologist.

Radiology Services at ISIC

Figure 15: Radiology Services at ISIC

29

SERVICES AT ISICCT SCAN

DEXA SCAN

MRI X-RAY

ULTRASOUND

DOPPLER STUDIES

MRI Department

Magnetic Resonance Imaging (MRI) is a safe and non-invasive test. It uses strong magnetic field

and pulses of radio waves which produces anatomical images (organs and soft tissues) of high

quality structures inside the human body. It is an application nuclear magnetic resonance.

As an MRI does not use ionizing radiation, it is the preferred imaging method for children and

pregnant women. It is primarily used in medical imaging to demonstrate pathological or other

physiological alterations of living tissues.

MRI is considered ideally suited for soft tissue problems-;

Diagnosing multiple sclerosis (MS)

Diagnosing brain tumours

Diagnosing spinal infections

Visualizing torn ligaments in the wrist, knee and ankle

Visualizing shoulder injuries

Evaluating bone tumours, and herniated discs in the spine

Diagnosing strokes in their earliest stages

MRI System at ISIC

The MRI at ISIC is of 1.5 T [SEIMENS MAGNETOM AVANTO]. It offers following

advantages-

Ultra Fast image acquisition

Strong gradients for high resolution and short scan times

For obese patients, it supports up to 250 kg (550 lbs), without table movement

restrictions.

Greater reduction in Noise by 97%

Lighter weight coils which makes it more comfortable especially for cardiac or oncology

patients.

Unparalleled flexibility, accuracy, and speed.

30

Low power and cooling requirements

Procedure of MRI Scan at ISIC

Patient is advised by the doctor for MRI Scan

Patient makes the payment at the respective counter and is directed to the MRI Room

Patient goes to the MRI room and entry for the patient is made in the records like (Name,

Age/Sex, Part to be scanned, time in and time out and referring doctor)

If patient load is large then the patient is advised to wait for some time in the waiting area

Before entering into the MRI room, patient needs to change his/her clothes and all metal

things e.g. jewellery, mobile etc should be kept out of the room.

Patient preparation in done on the MRI table and procedure is started

Following observations were made-:

The average time taken for each scan is 24 minutes. (40 patients were observed during

the study. The specific time taken for scan differs for each body part and also depends on

number of images required).

31

It was observed that for MRI scan of whole spine, the minimum time taken was 14

minutes in one patient, whereas the maximum time taken for whole spine in another

patient was thirty minutes. So, there is a difference of 16 minutes in time taken for the

same body part.

Similarly for another patient the time taken for brain scan was 14 minutes, and for

another patient 40 minutes were taken for the same. Here, 25 minutes more were taken

for the scan of same body part.

The minimum time taken for a scan was ten minutes and the maximum time was 65

minutes but for different body parts.

Shortcomings

Patient Shifting

When a patient comes from IPD for MRI scan, he has to be shifted from metallic stretcher to the

plastic sealed stretcher which is used in MRI room and then to the patient table of MRI machine.

This is due to the fact that metallic stretcher cannot be taken inside the MRI scan room because

of the magnetic field in the room.

The shifting of patient twice in MRI room creates discomfort for the IPD patient who is already

not fit enough and for other OPD patients as well which results in increase of the waiting time.

Ward boy availability

When the IPD patient is being shifted from the MRI stretcher to the MRI patient table,

sometimes the ward boy is unavailable to assist for the same. So, the technician who is

controlling the monitor has to go in MRI room for shifting or wait for ward boy to come. This

delays the procedure to start. For patient shifting (IPD pt.), 3 human resources are required.

In 4 out of 40 cases, it was observed that ward boy left the patient in MRI room before the scan

started. The technician had to leave his work and assist in patient shifting. Ideally, the ward boy

should stay till the scan starts and should return back on time to take patient back to ward.

32

Delay due to posture

Patient has to lie still during the MRI scan procedure. If a patient does any movement during the

scan, it takes longer than the usual time to complete the MRI. There is loss of time if a patient

moves during the scan, it might either be due to technician i.e. proper instructions not given or

due to patient i.e. instructions not followed.

In 3 out of 40 cases, patient did not follow the instructions and moved during scan which led to

delay in completion of scan.

Patient preparation

Magnetic coils need to be arranged around patient’s body part to be scanned. Sometimes, the

assistant is not available to arrange the coils. In such a case, the technician who controls the

monitor has to leave his seat and go for patient preparation. The technician otherwise can utilize

that time to enter the details of the patient in the monitor. Also, coils have to be arranged right

the first time.

In 5 out of 40 cases, magnetic coils had to be re-arranged during the scan which led to delay in

completion of scan. Also, in 6 cases assistant was not available.

Technical delay

MRI chillers are responsible for removing the heat from the MRI scanner. For MRI scanner to

work efficiently, the magnet has to be kept as cool as possible. There are two methods for

cooling available: air cooled chillers and water cooled chillers. Here in ISIC, water cooled

chillers are used. Sometimes these water cooled chillers do not work properly, because of which

the monitor and magnetic coils stop working for some time. The monitor takes a while to restart,

so time is lost during this period and the next MRI is delayed.

The monitor went off twice during the period of study. It took 15 minutes for the monitor to

restart.

33

Recommendations-:

MRI stretchers which are plastic sealed should be made available in the wards. This will

enable the staff to shift the patient from patient bed to MRI stretcher itself which will

reduce time as well as discomfort of the patient.

Whenever an IPD patient comes for MRI scan, a ward boy should be with him from the

time he leaves from ward till the time patient is shifted to the MRI table. The ward boy

should ask the technician about the duration of scan and should be back by the time the

scan finishes. This will reduce the time in shifting the patient back to the MRI stretcher

so that next scan can be started quickly.

Proper instructions should be given to the patient. If a patient is anxious before the scan,

he should be explained that the procedure is necessary and if he moves during the scan, it

will take longer to complete the scan.

The assistant should not leave the MRI room if patients are waiting for the scan. If he has

to go for some work outside, he should make sure that some other assistant is there to

help the technician.

The working of the water chillers should be checked on a regular basis to minimize the

technical errors.

Pharmacy at ISIC

Introduction-

Hospital pharmacists work in a hospital pharmacy service. They are experts in the field of

medicines and are not only responsible for the dispensing of prescriptions but also the purchase

and quality testing of all medicines used in a hospital. Pharmacists work closely with medical

and nursing staff to ensure that patients receive the best treatment. They also provide help and

advice to patients in all aspects of their medicines.

Typical activities may include:

Checking prescriptions to ensure that there are no errors and that they are appropriate and

safe for the individual patient;

Providing advice on the dosage of medicines and the most appropriate form of

medication, for example, tablet, injection, ointment or inhaler;

34

Participating in ward rounds, taking patient drug histories and involvement in decision-

making on appropriate treatments;

Ensuring medicines are stored appropriately and securely;

supervising the work of less experienced and less qualified staff;

Answering questions about medicines from within the hospital

Keeping up to date with, and contributing to, research and development;

Writing guidelines for drug use within the hospital and implementing hospital

regulations;

Providing information on expenditure on drugs;

Preparing and quality-checking sterile medications, for example, intravenous

medications;

General Observations

Substitution is only allowed in few cases ( not in high risk medicines and costly

medicines)

ABC Inventory method is followed, that is medicines are kept in Alphabetical Order

Narcotic drugs are kept in double lock and key shelf as per Schedule “X”.

High Risk Medicine are kept in are stored in separate shelf.

Roster is prepared one month in advance on 21st of every month.

Syrups, Eye/Ear/Nasal Drops, Powder is stored in separate shelves.

Surgical Goods are generally kept in bulk quantity and are stored in bulk.

Record of Daily temperature at Pharmacy is done as it is necessary to keep the

medicines at temperature less than 30. C.

Narcotic drugs are only issued in IPD Pharmacy, with a separate form which is DD12.

A separate form is meant for local purchase that is for those drugs which are not available

in the pharmacy and is required by the patient in the wards.

35

Recommendations

Refrigerator should be of large capacity; currently it is of 218L capacity which makes it

difficult to store all the medicines as out of total list of 70 medicines to be kept in the

refrigerator. 15 had to be kept in the ice boxes with the ice packs which make it difficult

to maintain the temperature ultimately affecting the viability of medicines.

Credit/Debit Card Machine should be made available as everyday 5-6 patients face

difficulty to make payment by cash and they had to run to the ATM to get cash.

There should be a separate counter for receiving the medicines through supplier as it

creates mess when medicines are supplied in bulk specially during the starting of each

month at the time of procurement of drugs.

The pharmacy department at ISIC faces the shortage of manpower so the management

should look into the same matter.

Lastly additional air conditioner should be installed in Pharmacy department as in the

month of May a dug lot of 700 capsules got damaged out of 1500 because of high

humidity resulting in loss of revenue.

Front Office

Introduction-

The front office should be located in a prominent place within the OPD block. It provides the

following services:

Reception/ Information/ Help desk

Registration

Billing

Medical records (for repeat outpatients)

Corporate & Insurance Assistance

36

It would be preferable to organize all these services clustered at one place that is convenient to

patients as well as to management.

Recommendations:

Wall clock should be placed at Main Reception Area.

STD/PCO facility should be provided in or around front office.

There should be a photocopy machine for convenience of patients

There should be more of LEDs placed in the waiting area for display of appointment

schedules in the waiting area

There should be more of patient’s and attendant’s engaging material like newspapers in

the waiting area.

Laundry Services

Introduction-

Laundry service is responsible for providing an adequate, clean and constant supply of linen to

all users. The basic tasks include: sorting, washing, extracting, drying, ironing, folding,

mending and delivery. A reliable laundry service is of utmost importance to the hospital. In

today’s medical care facilities, patients expect linen to be changed daily. An adequate supply of

clean linen is sufficient for the comfort and safety of the patient thus becomes essential.

The objective of hospital linen and laundry services is to ensure-:

Clean and adequate quantity of washed linen.

Supply to be made on regular basis.

Steps to be taken to prevent cross infection.

In acceptable quality and within a reasonable cost to hospital.

37

Figure 16: Flowchart of Laundry Department

Recommendations:

There should be barrier between soiled linen & infected linen.

There should be supervision for over measured use of detergent.

38

collecting soiled linen

transporting soiled linen

sorting of linen

loading washer

washing and

extraction

unloading/ loading dryers

finishing, storing

Redistribution

REFRENCES

1. http://isiconline.org/aboutus.aspx

2. Sonal Shukla’s article on “Streamlining OPD”, Express Healthcare, April 2008.

3. Dr. S. K. Jawahar’s, A study on out patient satisfaction at a super specialty hospital in

India”, Indian Journal of community Medical update, volume-2, Jul-Dec 2007

4. Preston M. Simmons “Managing a Hospital and the Role of the Hospital Pharmacist”,

February, 2006

5. http://www.prospects.ac.uk/hospital_pharmacist_job_description.htm

6. Dr. Hari Singh’s Article on “Out Patient Department”.

7. Presentation by John A. Armitstead’s “ The Role of Pharmacist in Hospital Setting”,

October, 2006

8. Prahlad Rai Sodani, Rajeev K Kumar, Jayati Srivastava,1 and Laxman Sharma’s,

Measuring Patient Satisfaction: A Case Study to Improve Quality of Care at Public

Health Facilities (Indian Journal of Community Medicine)

9. A. Deva, M. Haamid, patient satisfaction survey in outpatient department of a tertiary

care institute, 2010

10. Srilatha Sivalenka, Patient Satisfaction Surveys in Public Hospitals in Andhra Pradesh,

India, 1999-2000.

11. Dr. Bidhan Das, Ms. Pritindira Talwar, Ms. Pranita Jain’s, Journal of the Academy of

Hospital Administration, titled “Signage Program in Hospitals: A System for Quality

Improvement Through Patient Access and Convenience.”, Vol.16 No.1 2004-06.

12. http://www.whatsyoursignage.com/StepOne0.aspx

13. Mrs. Krishna Devi’s article on “ Laundry and Linen services in Hospital”

14. Dr. N.C Das, “Planning and Management of hospital Laundry”.

15. Rachel Field’s article on “The Importance of Patient Experience for Hospitals: Why it

Pays to Excel”, Beckers Hospital Review, July 11, 2011.

16. http://www.scribd.com/doc/41287299/Financial-Administration

17. Lecture (PowerPoint presentation) on “Medical Architecture” by Dr. Rajesh Bhalla.

39

18. Lecture (PowerPoint presentation) on “Strategic Management” by Mrs. Minakshi

Gautam.

ANNEXURE

Annexure-A

QUESTIONNAIRE FOR OPD PATIENT SATISFACTION

Name Age/Sex

Address Contact No:

1. Name of consultant visited?

2. Is this your first visit to the hospital?YesNo

3. Accessibility to the hospital Yes No3a. Ease of location3b. Enough signages/hoardings

4. What was the main influence on your choice of hospital?Word of mouthNewspaper/magazineAdvertisement/hoardingInternetReferral (From Doctor)

5. Waiting time4a. What was your appointment time?4b. At what time did you arrive at hospital?4c. At what time you were seen by the doctor?4d. if delayed over 15 minutes, were you given explanation for the delay?YesNo4e. Were you satisfied with the explanation? YesNo

40

6. Pre arrivalWere you satisfied with the telephonic conversation prior to appointment?YesNo N/A- Not Applicable

7. On arrival Excellent Good Fair Poor Guidance on the suitable consultant Greeting on arrivalPromptness of attentionWaiting room/ area comfort

8. Consultant services:Explanation of line of treatment (procedure and next step in treatment)Excellent Good Fair Poor

9. How many minutes approximately the doctor spent with you?Less than 10 mins10-20 minsMore than 20 mins

10. Were the diagnostic tests and medicines prescribed by the consultant were available within the hospital or you had to go out?(Diagnostic Test) (Medicines Prescribed)Yes N/A Yes N/A No No

11. Financial administration Excellent Good Fair Poor8a. Assistance with financial queries8b. Explanation of payment procedure 8c. Estimation of Cost

12. Availability of amenities Excellent Good Fair Poor9a. Toilet facilities9b. Facilities for Disabled

41

9c. Cafeteria

13. Overall rating of quality of careExcellent Good Fair Poor

14. Overall rating of value for moneyExcellent Good Fair Poor

Annexure-B

List of various Hospital Departments visited

S.NO NAME OF THE DEPARTMENT

Date(s) of Visit

People met with Designation

1 Marketing 2nd April-4th May

Ms Sugandh Ahluwalia (Deputy Director Strategy)

2. Dialysis 7th May Mrs. Neetu Moetra(CNS)

3. CSSD 8th April Mr. Baban ( Manager-CSSD)

4. OT 9th May Mr. Santosh( Manager-OT)

6 Wards 14th May Mrs. Neetu Moetra(CNS)

7. Laundry 15th May Mr Hasan Agha( Manager – laundry)

8. Rehabilitation 16ST May Ms Chitra Kataria(HOD)

9.Pharmacy 17th -27th May Mr. Saurabh(Manager)

10. Biomedical Waste Management

28th May Mr Anant( Duty Administrator)

42

Annexure- C

Observation Table of MRI Study

S.NO NAME OF THE PATIENT

AGE/SEX OFTHE PATIENT

PART OF THE BODY SCANNED

REFERRINGDOCTOR

TIME TAKEN(In min.)

1 Mr. Lalji Chourasia

61/M Brain Dr. Bhushan 40

2 Mrs. Anju Borekar

55/F Lumbar and cervical spine

Dr. H.S Chabra

30

3 Ms. Tanya Khullar

26/F Lumbar Sacral n Whole Spine

Dr. K Das 10

4 Mr. Devendra Kumar

60/M Brain n Whole Spine

Dr. AK Sahani 20

5 Mrs. Shashi 56/F Whole Spine Dr. K Das 20

6 Mr. HP Sharma

72/M Head Dr. AK Sahani 15

7 Mrs. Kamlesh 47/F Whole Spine Dr. AK Sahani 23

8 Mrs. Sunita Reddy

42/F Lumbar Spine Self 22

9 Mrs. Sasmita Sahoo

34/F Rt. Shoulder Dr. B. Mahopattra

40

10. Mrs. Rekha Aggarwal

45/F Whole Spine Dr. Vikas Tondon

25

11 Mrs. Sultana Nazi

79/F Rt. Shoulder Dr. J Maheshwari

20

12 Mr. Gordham Dass

71/M Head Dr. AK Sahani 15

13 Mr. Prem Kumar (3)

38/M Head Dr. Sahani 40

14 Mr Sanjeev Kumar

47/M Dorso Lumbar Spine and Whole Spine

Dr. K Das 31

15 Mrs Upkar Kaur

70/F L.S Spine Dr. ML Bansal 18

16. Mr JK 70/M Brain Dr. Aparna 14

43

Aggarwal Gupta17. Mr. Jai Singh 58/M Lumbar Sacral

& Sacroiliac Joints

Dr. Chabra 23

18 Mrs. Razia Beg

58/F Whole Spine MMM Hospital 18

19 Mrs. Ishwari Dutt

91/F Brain and DWI

Dr. Sahani 28

20 Mr Suresh Chand

52/M Cervical Spine Dr. Aparna Gupta

14

21 Mr. Utpal Sen Gupta

78/M Cervical Spine, Brain and LS Spine

Dr. Chabra 65

22 MasterY 16/M Whole Spine Dr. Chabra 30

23 Mrs. Nasreen Shafi

46/M LS Spine Dr. Chabra 20

24. Mr. Rajendra Kr.

58/M LS SPINE Dr. Chabra 18

25 Mr. Dinesh Kr.

39/M Whole Spine Dr. S Tiwari 14

26 Mrs. Poonam 42/M Whole Spine Dr.Aparna 15

27. Mr. Jagdish Lohand

25/M Whole Spine Dr. K Das 14

28. Mr. Mohan Lal

81/M `Pelvis and Abdomen

Dr. Mihir Nyogi

45

29. Mrs. Sujata 55/F LS Spine Dr. Sahani 25

30. Mr. Raj Kumar

50/M Whole Spine Dr. AK Nanda 18

31 Khandaker Ilias

57/M LS n Whole Spine

Dr. Mahopattra 29

32 Mrs. Zohara 43/F Cervical n Dorsal Spine

Self 19

33 Ms. Apurva Singh

13/F Dorsal Spine Dr. HSC 12

34 Mr. BN Singh 64/M LS Spine Dr. Mahopattra 20

35 Mr. Hranthanguela

49/M Brain Dr. Aparna Gupta

18

36 Mrs. Kanta Devi

42/F Whole Spine Dr. Mahopattra 18

37 Mrs. Kamla Devi Narula

50/F D-L Spine Dr. Vineet 23

44

38 Master Khalid 17/M L- Spine Dr. Mahopattra 22

39 Mrs. Sushila Mehta

68/F W. Spine n Head

Dr. Sahani 35

40 Mr. Satya Prakash

73/M D-L Spine Dr. PK Sharma 22

45