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Gap analysis of Out Patient

Department at Metro Multispeciality


Hospital, Noida

A Project Report

Presented To:

Submitted By:
Taniya Bhattacharjee
I.D.- M090710034

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ACKNOWLEDGEMENT

The author wishes to express her sincere gratitude to many


people who have been associated with her throughout the project
period.

The author acknowledges Mr.Ashok Chitkara, Chairman of


Chitkara University and Mr.Rajesh Shrivastava ,General Manager ;
Metro Multispeciality Hospital for making it possible to conduct
the project in hospital premises.

The author wishes to thank , Dr.Sonika Bakshi, Student


coordinator, for taking a great interest to motivate, encourage
and constantly guiding throughout the course of research project.
She has been a great source of inspiration.

The author humbly acknowledges Ms.Natasha Bansal; Assistant


Administrator; Metro Multispecialty Hospital for her constant
support,motivation and guidance throughout the project. A
sincere expression of gratitude is extended towards the
respected panel of experts Ms.Jaya(OPD Incharge),Ms.Kanika
(Medical Superintendent)and Mr.Rajneesh (Administrator) for
their valuable suggestions and support.

The author is thankful to Dr. Pooja for explaining the research


process and making the project easier.

In the end, the author is highly thankful from the core of her heart
to her beloved parents who supported her throughout the course
of study. Last but not the least, the author is thankful to all the
colleagues for their help and cooperation.

TANIYA BHATTACHARJEE

MBA(HEALTHCARE MANAGEMENT)
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DECLARATION

This is to certify that the Project Report titled


“Gap analysis of Out Patient Department at
Metro Multispeciality Hospital,Noida”
submitted by me , A Student of MBA
(Healthcare Management) of Chitkara
University,Chandigarh comprises only my
original work and due acknowledgement has
been made in the text to all other material
used.

Date:

[Taniya Bhattacharjee]

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TABLE OF CONTENTS
Chapter Content Page
No. No.
Executive Summary vii-
viii
1. Introduction 1-8
1.1.0 Introduction of
organization.

1.2.0 Introduction of topic

1.3.0 Problem statement

1.4.0 Research objectives

1.5.0 Operational definitions

2. Review Of Literature 9-11

3 Research Methodology 12-15


.
3.1.0 Research Methodology

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3.1.1 Research objectives

3.2.0 Methodology

3.3.0 Research design

3.3.1 Type of study

3.3.2 Population

3.3.3 Sampling technique

3.4.0 Data collection

3.4.1 Primary data

3.4.2 Secondary data

3.5.0 Tools for analysis

3.6.0 Data entry

3.7.0 Need and significance of


study

4. Research Findings 16-33


4.1.0 Research Findings

4.1.1 Findings for objective


no. 1

4.1.2 Findings for objective


no. 2

4.1.3 Findings for objective


no. 3

5. Summary, Conclusion and 34-39


Recommendations

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6. Implications and Future 40
Research
References ix

Annexure
Annexure I:OPD SCHEDULE

Annexure II: REGISTERATION


FORM

Annexure III: Patient Satisfaction


form

Annexure IV:Bill reciept

Annexure V: Metro Dental


implant brochure

Annexure VI:Waiting time track


sheet

Annexure VII:Excel sheet

Annexure VIII: Location

Annexure IX: Signage Location

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TABLE OF GRAPHS

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S.No Content Page No.
1. Graph 4.1: 23
Occupancy
level of
Monday
2. Graph 4.2: 24
Occupancy
level of
Tuesday
3. Graph 4.3: 24
Occupancy
level of
Wednesday
4. Graph 4.4: 25
Occupancy
level of
Thursday
5. Graph 4.5: 25
Occupancy
level of Friday
6. Graph 4.6: 26
Occupancy
level of
Saturday
7. Graph 4.7: 27
Waiting time in
queue
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EXECUTIVE SUMMARY
Increasing competition in health care sector has made it necessary to improve
satisfaction of patients and staff, and the Out Patient Department (OPD) often

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called "shop window" becomes a key area which can made or marr the reputation
of the hospital. The research study titled “GAP ANALYSIS OF OUT PATIENT
DEPARTMENT”was conducted from 4.9.10-2.9.10 at Metro Multispeciality
Hospital,Noida.
Research objectives were:
• To study and analyze the process flow of various activities done at “Out
Patient Department”
• To analyze prevalent arrival and departure time of patients and calculate the
waiting time for each activity.
• To identify process lacunas/gaps present in the system and suggest
recommendations for the same.
The researcher conducted an observational study(Time and motion study) and the
procedure of systematic sampling was used to select patients visiting OPD. With
the help of observation,the researcher made the process flow of various activities
and identified the gaps present in the system.Primary data regarding the waiting
time analysis was collected with the help of WAITING TIME TRACKING
SHEET developed by the researcher. The tracking sheet consisted information
about the arrival time of patients in OPD. This was followed by a detailed analysis
of their waiting time for each activity which includes queuing time (Qt),billing
time(Bt),Waiting for consultation time(Wt) and Consultation time ( Ct).
Based on the results, it was found that Monday and Saturday are the days which
have the highest occupancy levels in OPD close to around 70 patients during peak
hours.The occupancy levels were a linear function of time.As the time increased
from 9:30 to 10:00 to 11:00 the occupancy levels also increased touching a peak of
50-60 patients during peak hours of 11:00 to 11:30.Waiting time analysis suggests
maximum waiting time of 15 minutes in queue for billing and maximum queue
length of 25 patients during peak hours.As far as waiting for consultation of
general physician is concerned. The maximum waiting time of 67 minutes was
seen around10:05 to 10:10.This was mainly attributed to increased load in OPD as
a result of Dengue outbreak in Delhi.
Major gaps in the system include prolonged waiting time as a result of Dengue
epidemic and lax attitude on the part of doctors among other reasons explained in
research findings.Also included in the gaps is the dissatisfaction with quality of

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services being provided,dissatisfaction with basic amenities,no proper maintenance
of OPD records,no public addresal system and high number of refunds.
From the findings it was concluded that despite the hospital having good reputation
and nice patient inflow in OPD,it is not being able to manage the OPD operations
smoothly which often results in chaos and fights in OPD.Mismanagement can be
seen at every step from Doctors not being on time for OPD to Billing assistants not
opening cash counters on time which ultimately results in prolonged waiting
times.Hence ,the hospital should solve the problem of increased dissatisfaction
among patients by adopting a holistic approach towards it.These problems if
neglected can have a cascading effect .Hence, it is very important as smooth
functioning of OPD sends a positive signal to the patients about the hospital.

CHAPTER 1: INTRODUCTION

1.1.0 INTRODUCTION ABOUT ORGANISATION

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Metro Hospitals & Heart Institute is a chain of 13 Hospitals including 3 satellite
centers, is an ISO 9001:2000 approved Hospitals. With a vision to provide the
utmost level of healthcare to the common man, at the most affordable cost, a group
of NRI physicians led by Dr. Purshotam Lal (Padma Vibhushan, Padma
Bhushan and Dr. B.C. Roy National awardee), a pioneer of Interventional
Cardiology in India, founded Metro Hospitals & Heart Institute. The first hospital
was set up in Noida in June 1997 by the name of Metro Hospitals & Heart
Institute.

Immediately after foraying into the heart care segment, Multispeciality wing was
started in September 1998, followed by Metro Centre for Liver & Digestive
Diseases, Metro Center for Respiratory Diseases, Metro Heart Institutes at Meerut,
Faridabad; Lajpat Nagar, Patel Nagar, Preet Vihar at Delhi and Metro Hospital &
Research Centre at Vadodara.
Metro hospital and heart institute is a pioneer in the technological revolution in
health care, rendering services to thousands of patients from across the globe to get
them cured, in the presence of world class facilities.

Since 1997, they have helped to enhance the lives of thousands of people who have
chosen us for quality healthcare services.
They have developed the concept of ‘Metro Coronary Screening’ whereby an
angiography can be done with the use of minimal dye from the arc. The procedure
reduces the cost of an angiography. This procedure takes only 5 minutes and the
individual can go back to home / work in less than an hours time.

Technological advancements aside, they continue to be a leader in the industry for


the personal approach they take with every patient. Their professional team
provides exceptional service and employs the highest standards of patient care.
Many hospitals across the country refer their most difficult cases to Metro
Hospital. This is a true testimony to the skill and knowledge of Dr. P Lal and his
professional team.
Dr. Purshottam Lal (Padma Vibhushan, Padma Bhushan and Dr. B.C. Roy
National awardee), a pioneer of Interventional Cardiology in India, founded Metro
Hospitals & Heart Institute. Dr. Purshottam Lal is an internationally acclaimed
interventional cardiologist who epitomizes the best in professional excellence and
service to the humanity, especially the poor and the needy. Dr. Lal has the unique
distinction of introducing the largest number of procedures in the field of
interventional Cardiology for the first time. He has been listed several times in the
Limca book of world records.

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VISION & MISSION
Their vision is to achieve excellence in Healthcare services by offering unique
expertise, state of the art technology & patient care. Metro Hospitals is committed
in providing world class health care services at an affordable cost, irrespective of
the person being literate or illiterate, caste, creed or social status and beliefs
followed by one and all, with complete dedication alike.

Their immediate agenda is to set up more such dedicated centres for providing
wholesome treatment to the patients from all over the country. They are committed
in continually serving the humanity at every needful hour with their state of the art
facilities and world's best professionals. They are motivated by the immense faith
that their patients have kept in them, they will stand by their principles and policies
and will pursue the same with full dedication in future as well.

The specialities which are provided in their hospitals are Cardiology, ENT,
Critical Care Medicine, Anesthesiology, Ophthalmology, Urology, Interventional
Radiology, Pediatrics, Obstetrics and Gynaecology, Nephrology and Renal
transplant, General surgery, Gastro surgery, Oncology and Onco surgery,
Dentistry, Neurology and Neurosurgery, Pulmonology and Orthopaedics.

Metro hospitals and heart institute is a pioneer in the technological revolution in


health care, rendering services to thousands of patients from across the globe to get
them cured, in the presence of world class facilities.

Metro Hospital has been empanelled by eminent and prestigious organizations like
CGHS, NHPC, NDPL, MTNL, NTPC, PGCIL, PFCL, GAIL, HUDCO, RBI,
SAIL, ITI, SBI etc. They are providing health insurance facility to all clients round
the clock. They are one of the pioneers in providing health insurance and cashless
facility in India with all types of medical insurance from all companies engaged in
the health insurance / medical insurance / medi claim business in the India. They
accept all "cashless" cards for providing best facility and medical treatment, health
check-up plans to their clients and patients.(Metro Hospitals)1

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1.2.0 INTRODUCTION ABOUT RESEARCH TOPIC
The concept of OPD-originated in mid 17th century by Sir George clark. Modern
OPD services emerged in 1850 in USA from frame work of dispensaries.
OUT PATIENT DEPARTMENT
Out patient department is that section of the hospital which is staffed and equipped
and has scheduled working hours to provide diagnostic,therapeutic,preventive and
rehabilitative care to those patients who are not registered as inpatients while
receiving the services ( S.K Joshi)2
OUTPATIENT
Outpatient is person given diagnostic, therapeutic or preventive service through the
hospitals facilities and who at the time is not registered as an inpatient in the hospital.
Outpatients can be grouped under the following three categories.
1)Emergency Outpatients

A person given emergency care as a result of sudden illness or accident.

2)Referred Outpatients
A person referred to the outpatient department by a private practitioner or other
physician from one clinical discipline to other, for specific diagnostic or treatment
procedures or pinion and who will return to the referring physician for further care
and disposal.

3)General Outpatients/walk-inns
A person who is not referred and comes to the hospital on the account of his
illness.

TYPES OF OPD SERVICES


TWO TYPES OF OPD SERVICES

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• CENTRALIZED OUTPATIENT SERVICES : All services are provided
in a compact area which includes all diagnostic and therapeutics facilities
being provided in the same place.
• DECENTRALIZED OUTPATIENT SERVICES : Services are provided
in the respective departments.
All patient get his or her first impression of the hospital from the OPD. It has been
described as the first point of contact between the hospital and the community and
which in many instances can make or mar the reputation of the hospital. Therefore it
is the SHOP WINDOW of hospital.
The importance of OPD lies in;
• First point of contact

• It is the shop window of hospital

• Makes or mars the hospital image

• A good OPD service can reduce the load on in-patient services

• It is a place for implementing preventive & promotive health activities.

• Facilitates teaching

• It acts as a filter for inpatient admission, ensuring that only those patients are
admitted who are most likely to benefit from such case.
• About twice the in-patients attend OPD every day

FUNCTIONS OF OPD
• Early diagnosis, curative, preventive & rehabilitative care on ambulatory
basis
• Effective treatment on ambulatory basis
• Screening for admission to hospital
• Follow up care & care after discharge
• Promotion of health by health education

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• Rendering of preventive health care
• Promotion of health through health education
• Training of medical / nursing students
• Keeping up to date records for future treatment, medical education,
epidemiological & social research
PREVENTIVE HEALTH ACTIVITIES
• Well baby clinics
• ANC, marriage counseling, planned parenthood etc
• School health clinic.
• Control of communicable diseases
• Early diagnosis & detection of chronic diseases like Cancer, TB, RHD etc.
• Health education & nutritional advice
• Rehabilitation & prevention of disabilities & handicaps

PHYSICAL FACILTIES AND LAYOUT


• Should be located adjacent to vital services
• Should be separate from inpatient wards and other department.
• OPD of all specialties should be in the same building.
• Should be near the main road and close to main entrance.
PRINCIPLES OF PLANNING AND LAYOUT
• Patient flow should be in one direction
• Able to share support services with inpatient department
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• Amenable to expansion without serious dislocation of work.
SIZE
• Bureau of Indian Standards has recommended the following space:
○ 2 sq m per bed for entrance zone

○ 10 sq m per bed for ambulatory zone

○ 6 sq m per bed for diagnostic zone out of total of 60 sq m per bed for
total hospital area(M S Gihony )3

IMPORTANCE OF GAP ANALYSIS


Increasing competition in health care sector has made it necessary to improve
satisfaction of patients and staff, and the Out Patient Department (OPD) often
called "shop window" becomes a key area which can made or mar the reputation of
the hospital.
In today's fast growing world, customer is looking for hassle free and quick
services. Meeting the customer requirements by the medical institutes with its
limited resources is the challenge.In most Indian hospitals, patients come to the
OPD without prior appointment and patients need to wait for hours before doctors
could see them. The situation would be especially worse for the elderly who have
to queue up, even when they are not well. Long waiting time in any hospital is
considered as an indicator of poor quality and needs improvement. Managing
waiting lines create a great dilemma for managers seeking to improve the return on

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investment of their operations. On the one hand, customers dislike waiting
intensely. If they feel they are waiting too long at hospital for service, they will
either leave the line prematurely or not return to hospital the next time they need
service. This will reduce customer demand and eventually revenue and profit.
Furthermore, longer waiting times increase costs because longer waiting times
equal more customers in a building. Hence, it will need more space for the
customers to wait in, which increases rent.(Satyaveer Singh)4

In the light of the above statements, we can say thus the gap analysis of out patient
department of any hospital is very important from managerial perspective. Because
of it being the busiest part of the hospital. And also the fact that a major chunk of
patients converge on the OPD at the same time in the early hours in order to avoid
waiting in the long queues. For full satisfaction of patients and proper utilization of
resources , the quality of service delivery in OPD should be of highest order which
can only be achieve by carefully scrutinizing the gaps present in the system and
correcting them.

1.3.0 PROBLEM STATEMENT


To identify and analyze the gaps present in the processes carried out at the Out
Patient Department and suggest recommendations for same.
1.4.0 RESEARCH OBJECTIVES
• To study and analyze the process flow of various activities done at “Out
Patient Department”
• To analyze prevalent arrival and departure time of patients and calculate the
waiting time for each activity.
• To identify process lacunas/gaps present in the system and suggest
recommendations for the same.
1.5.0 OPERATIONAL DEFINITIONS:

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1.ARRIVAL TIME, (At):
The time at which patient arrives at the hospital OPD.(At)
2.QUEUING TIME,(Qt):
It is the time spent by the patient standing in the queue.
3.BILLING TIME,(Bt):
It is the time taken by the patient at the billing counter
4.WAITING FOR CONSULTATION TIME ,(Wt):
It is the time spent by the patient for waiting for his consultation in the
waiting area.
5.CONSULTATION TIME ,(Ct):
It is the time spent by the doctor on the patient while giving consultation.

CHAPTER NUMBER 2:REVIEW OF LITERATURE

2.1.0
Satyaveer Singh in the year 2005 conducted a study on waiting time in OPD in Air
force Central dental Establishment (AFCDE). The study was done over the period
of 5 weeks. It included studying and observing the OPD for a period of 02 weeks
during which it was studied what was the general trends in all the OPD, how was
patients registered, how they move about once they were registered etc. After that
for one week collection of material was done which included referring the institute
library, searching material on Internet and books on hospital management. After
that for a period of one week reading were taking in OPD. During which the time
of arrival of patients and the time they entered the consultant were noted. This was
done three days in OPD. After that collated the collected material, readings and
drawing conclusions from them.
From the readings and the Waiting Time graphs for Dental department, it was
found that the initial waiting time was very high.These problems or features in
medical science need to be dealt properly, a solution proposed in this report was to
appoint some other consultant or duty doctor for the period of initial one or two

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hours, as per the requirement of each department in the OPD so that all are
benefit. That is to say that all the patients who are already ill are not further
irritated by long waiting time and could be relieved early and can go home and
rest.
Reception of AFIDS dealing with the patients with various dental problems where
receptionists need to be very active so that long queue can be avoided by
registering the name at the time of arrival of the patient.
Similar to the above suggestion for reducing waiting time several other suggestions
are drawn from the study of the nature of the OPD, arrival and departure pattern
and the various graphs of data collected from OPD. These suggestions were
presented as a part of recommendations for OPD in “Observation, Discussion and
Recommendations”. To sum up some of the key suggestions were:
a. Appoint additional doctor during the initial hour of OPD.
b. Use appointment system to avoid sudden influx of patients(Satyaveer )5

2.1.1
Akilan Arunkumar.A, Research Scholar, Tata Institute of Social Sciences,
Mumbai in the year 2006 conducted a research on the “Process time of patients
visitingOPD.Objeciveswere: To determine the flow of patients and the time spent
in the Hospital through arrival and service characteristics, To study the utilization
of various servers, To understand the bottlenecks in the patient flow,To propose
alternatives to make the patient flow process efficient.
Methodology
Therefore a study based on queueing principles was designed to know the arrival
pattern of patients, the time taken to provide the service (service rate), and the
utilization of ophthalmologists, optometrists and other staff involved in the OPD.
1413 samples were studied through this study. The response time was calculated
from finding the difference between the entry and exit time. Data analysis was
done using “QM for Windows” software. It was followed by Bottleneck Analysis.
A bottleneck is the node(s) in the queueing network that has the highest utilisation.
In other words it is a place where patients struck-up. Hence, when performing a
bottleneck analysis for the different activities (nodes), they tried to find the
utilisation values for each node and ensure that this value never exceeds its
capacity. If it does, then they looked at varying the parameters of this node namely
the service rate and the number of servers (staffs) and see the effect that this
change has on the overall response time of the system.

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They recommemded that since Reception centre being the primary bottleneck of
the system, by increasing another server here, the system may be made to work in
steady state. The possibility of clubbing function of Reception centre with the
registration may also be explored since this could cut down one additional node
and a total process time of 10 minutes approximately for each patient.
However it was evidently proved through the simulations that having a single
refraction chamber with 8 or even 6 technicians, the hospital could reduce waiting
time up to 25 percent, as well as better utilization of resources.
(Akilan)6

2.1.2
Vijaya Bharat, Bijoya Mohanty and N.K Das conducted a research on “ Waiting
time reduction in Out Patient Services in the cardiology section at Tata Main
Hospital,Jamshedpur in the year 1998.Cardiology section of the hospital shared
some commonailty with chronic congestive heart failure on account of “volume
overload” and “insufficient disposal” in both the situation.Therefore the principle
of congestive heart failure therapy was applied to solve the problem.Waiting time
was calculated in 258 patiensts.Crowding due to all the patients coming at the
same time was overcome by giving appointment to chronic patients on regular
basis.Efficiency was improved by improving the availability of doctors and
introduction of practice guidelines.Scheduling elective procedures after the OPD
and starting a pacemaker clinic led to better time management.After two months of
implementing these measure the average waiting time for consultation reduced
from 58.6 minutes to 7.7 minutes without any additional manpower and resources.
(Vijaya Bharat)7

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CHAPTER NUMBER 3:RESEARCH METHODOLOGY

3.1.0 RESEARCH METHODOLOGY


3.1.1 RESEARCH OBJECTIVES:
i. To study and analyze the process flow of various activities
done at “Out Patient Department”
ii. To analyze prevalent arrival and departure time of patients
and calculate the waiting time for each activity.
iii. To identify process lacunas/gaps present in the system and
suggest recommendations for the same.
3.2.0 METHODOLOGY
The research was aimed at meeting the above stated objectives with
the help of different methodologies.
3.2.1 RESEARCH OBJECTIVE NO.:1
For meeting objective no.1, secondary data was collected
from the hospital “OPD INCHARGE”. Data was also
collected from the OPD ATTENDENT ’s on duty and
substantiated by personal observation by the researcher.

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3.2.2 RESEARCH OBJECTIVE NO.:2
For meeting objective no. 2, primary data was collected with
the help of “WAITING TIME TRACKING SHEET”(Refer to
Annexure VI ) developed by the researcher. The tracking sheet
consisted information about the arrival time of patients in OPD.
This was followed by a detailed analysis of their waiting time
for each activity which includes queuing time (Qt),billing
time(Bt),Waiting for consultation time(Wt) and Consultation
time. This was followed by calculations of average waiting
time. The tracking sheet was filled with the help of careful
observation by the researcher.
This OBSERVATIONAL STUDY(TIME AND MOTION
STUDY) was conducted during OPD timings.
3.2.3 RESEARCH OBJECTIVE NO.:3
For meeting objective no.3, primary data was analyzed so as to
know the core problem/gap areas.The researcher also interacted
with CONSULTANTS, OPD INCHARGES AND PATIENTS.

3.3.0 RESEARCH DESIGN


3.3.1 TYPE OF STUDY
The researcher conducted an observational study(Time and Motion
study) of OPD for understanding the process flow of activities and
various gaps/lacunas halting the system. The observation was taken
with the help of Waiting time tracking sheet developed by the
researcher. This sheet was administered in OPD.

3.3.2 POPULATION
The patients visiting the OPD were taken into consideration for the
research purpose. This included patients visiting various specialities

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Category of patients include general,walk-in,and emergency patients
visiting OPD.

3.3.3 SAMPLING TECHNIQUE


The procedure of SYSTEMATIC SAMPLING was used.Out of all the
patients visiting OPD,every 4th patient was taken in for research
observation.This was taken in regard to overcrowding in the OPD
during peak hours.
3.3.4 SAMPLE SIZE
A sample of 75 patients was taken for the research purpose.

3.4.0 DATA COLLECTION TECHNIQUE


3.4.1 COLLECTION OF PRIMARY DATA
Primary data regarding the waiting time analysis was collected with
the help of WAITING TIME TRACKING SHEET developed by the
researcher. The data was collected from the OPD by administering the
tool. The tracking sheet consisted information about the arrival time
of patients in OPD. This was followed by a detailed analysis of their
waiting time for each activity which includes queuing time
(Qt),billing time(Bt),Waiting for consultation time(Wt) and
Consultation time (Ct). This was followed by calculations of average
waiting time..
3.4.2 COLLECTION OF SECONDARY DATA
Secondary data was collected from the hospital “OPD INCHARGE”,
“OPD SCHEDULE”. Data was also collected from the OPD
ATTENDENT ’s on duty and OPD TECHNICIANS.

3.5.0 TOOL FOR ANALYSIS

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A “WAITING TIME TRACKING SHEET” was devised by the researcher
for observation purposes. The tracking sheet consisted information about the
arrival time of patients in OPD.This was followed by a detailed analysis of
their waiting time for each activity which includes Queing time (Qt),Billing
time(Bt),Waiting for consultation time(Wt) and Consultation time(Ct).Using
the the occupancy levels of OPD / day were found.Also,it was used to do the
Queue length analysis and Waiting time in queue analysis.

3.6.0 DATA ENTRY


The data was entered in Microsoft Excel. Excel sheet contained information
about patient arrival time, queuing time, billing time , waiting for
consultation and consultation time.( Refer to Annexure VII)
3.7.0 NEED AND SIGNIFICANCE OF STUDY
Out Patient Department is among the most important departments of the hospital.It
is the entry point into the hospital’s care delivery system and is the point of first
contact between the patients/their relatives and the hospital and therefore like a
shop window,it projects a certain image of the hospital.

Long waiting time in any hospital is considered as an indicator of poor quality and
needs improvement. Managing waiting lines create a great dilemma for managers
seeking to improve the return on investment of their operations. On the one hand,
customers dislike waiting intensely. If they feel they are waiting too long at
hospital for service, they will either leave the line prematurely or not return to
hospital the next time they need service. This will reduce customer demand and
eventually revenue and profit. Furthermore, longer waiting times increase costs
because longer waiting times equal more customers in a building. Hence, it will
need more space for the customers to wait in, which increases rent.
3.7.1 This study was aimed at addressing the following needs :
i. Help in understanding the process flow of various activities in OPD.
ii. Help in identifying the reasons responsible for delayed service
delivery.

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iii. Help in understanding the functioning of OPD during epidemic time
i.e the outbreak of dengue and viral in Delhi.

CHAPTER NUMBER 4: RESEARCH FINDINGS

4.1.0 RESEARCH FINDINGS


4.1.1 FINDINGS OF RESEARCH OBJECTIVE NO:- 1
To study and analyze the process flow of various activities done at
“Out Patient Department”
1) OPD SPECIALITIES IN METRO MULTI SPECIALITY
HOSPITAL ARE AS FOLLOWS: (Refer to Annexure I,II ,III,V )
• Medicine
• Gynecology
• Pediatrics
• Orthopaedics
• Eye
• Skin/Dermatology
• ENT
• Dentistry
• Psychiatry
• Nephrology
• Neurology
• Urology

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• Oncology
• Rheumatology
• Hematology
• Physiotherapy
• Neuro Surgery
• Pulmonology
• Gastroenterology
• Gastro Surgery
• Plastic Surgery
• Pediatrics Surgery

2) OPD TIMINGS: There are 2 shifts for OPD; Morning OPD and
evening OPD

MORNING OPD: 9:00A.M TO 3:00 P.M

EVENING OPD : 4:00P.M TO 8:00 P.M

3)AMENITIES PROVIDED IN OPD :


• 2 T.V sets in each OPD area(positive distraction)
• Centrally Air conditioned
• Drinking water facility
• Seating facility
• Suggestion Box/grievance facility
• Patient ushering services
• Wheel Chair services
• Investigation and Pharmacy services
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• Security Services
• OPD Attendants

4) OPD STAFFING:
OPD INCHARGE :1
OPD ATTENDENTS :2
PERSONAL ASSITANTS : 2
GDA/WARD BOY :1
BILLING ASSITANTS : 4( Refer to Annexure VIII)

5)EMPANELLED COMPANIES: ( Refer to Annexure IV)

• Many companies both private and public are on the empanelled list of the
hospital.
• Companies include
MTNL,DU,DTC,BPCL,ONGC,HUDCO,STC,GAIL,HCL,RBI,FCI,NDPL,
NSIC,SBI,PNB among others.

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PROCESS FLOW FOR APPOINTMENT IN OPD

START

PATIENT CALLS FOR


APPOINTMENT

ASKS FOR A SPECIFIC DOES NOT ASKS FOR A


DOCTOR SPECIFIC DOCTOR

DOCTOR SCHEDULE PATIENT TOLD ABOUT


CHECKED DOCTORS AND THEIR
SCHEDULES ,CHOOSES
THE DOCTOR IF HE WANTS

SLOT AVAILAIBLE
YE ASK PATIENT
S DETAILS

NO
PATIENT DETAILS
PATIENT NOTED
INFORMED ABOUT
ALTERNATE
TIMINGS/DOCTOR

APPOINTMENT
BOOKED

END

Fig 4.1: The above flow chart shows the process of appointment in OPD.

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7) PROCESS FLOW FOR BILLING AND CONSULTATION

EFERRAL,EMERGENCY,APPOINTMENT/WITHOUT APPOINTMENT) DIRECTED FOR BILLING FROM RECEPT

HEALTH
DIAGONO CONSULTA
CHECK &
STICS TION

ASK THE PATIENT IF HE HAS AVAILED SERVICES EARLIER

PATIENT UHID
REGISTER THE NEW
NO YES RETRIEVED
PATIENT

CREDIT LETTER OR CARD OF THE


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COMPANY IS SEEN IF PATIENT IS ON
EMPANNELLED COMPANIES LIST(GIVEN A
DISCOUNT)
GENERATION OF INVOICE AND TOKEN
NUMBER

NUMBER SUBMITTED TO OPD


ATTENDANTS AND PATIENT WAITS FOR
HIS TURN IN SITIING AREA

PATIENT DIRECTED TO APPROPRITE


CONSULTING CHAMBER WHEN HIS
TURN COMES

CONSULTATION BY DOCTOR

AFTER CONSULTATION ROUTES

DIRECTED TO:

EXIT DIAGNOS PHARMA FOLLO CROSS ADMISSI


TIC CY W-UP CONSULTA ON
TION

Fig 4.2: The above flow chart shows the processes involved in billing and
consulatation at OPD.

2
8) OPD MANAGEMENT DURING INCREASING DENGUE/VIRAL
CASES(Refer to Annexure No X )

IFA
ACCOM

Fig 4.3: The above flow chart shows the management of OPD by Metro
Multispeciality hospital during Dengue outbreak in Delhi.
COUN
PATIE

PATIENT
ACCEPTS

REGISTERATION
4.1.2 FINDINGS OF RESEARCH OBJECTIVE NO.2:
To analyze prevalent arrival and departure time of patients and calculate
the waiting time for each activity.
The WAITING TIME Tracking sheet (Refer to Annexure No: )
Date wise excel sheets of waiting times for various activities and for
various departments(Refer to Annexure )

(a) DAY WISE OCCUPANY LEVEL OF OPD


MONDAY

Graph 4.1: The above graph shows the occupancy levels of OPD at different
timings on Monday. The OPD used to start at 9.30.The rush used to build up
gradually .The peak occupancy of 70 patients can be seen at 11:00 A.M. The major
reason for this was the availability of both the general physicians during this
timings. As there was a outbreak in the city ,the demand for general physician was
observed to be very high.
TUESDAY
Graph 4.2: The above graph shows the occupancy levels of OPD at different
timings on Tuesday. Maximum occupancy of 60 patients can be seen at 11:30
A.M.
WEDNESDAY

Graph 4.3: The above graph shows the occupancy levels of OPD at different
timings onWednesday. Maximum occupancy of 45 patients can be seen at 11:30
A.M.
THURSDAY

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Graph 4.4: The above graph shows the occupancy levels of OPD at different
timings onThursday. Maximum occupancy of 58 patients can be seen at 11:30
A.M.The increased number can be attributed to the patients of Rheumatology on
Thursday.
FRIDAY

Graph 4.5: The above graph shows the occupancy levels of OPD at different
timings on Friday. Maximum occupancy of 62 patients can be seen at 11:30 A.M.
SATURDAY

Graph 4.6: The above graph shows the occupancy levels of OPD at different
timings on Saturday. Maximum occupancy of 72 patients can be seen at 11:30
A.M.

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(b)WAITING TIME IN QUEUE
1. AVERAGE WAITING TIME IN QUEUE

Graph 4.7: The above graph shows the average waiting time of patients in queue.
The maximum waiting time of 15 minutes can be observed during the peak hours
between 11:00-11:30.The reason for this was that the second billing counter of
OPD did not use to open during peak.As a result of which crowd use to gather in
the OPD billing area.

2. QUEUE LENGTH ANALYSIS

Graph 4.8: The above graph shows the queue length analysis. It shows the
number of patients standing in queue at any given point of time.The
maximum number can be again seen at 11:00 A.M when 25 patients used to
standing in queue for billing.

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3. WAITING TIME FOR CONSULTATION (GENERAL MEDICINE
PHYSICIAN)

Graph 4.9:The above graph shows the waiting time for consultation of General
Physician during Dengue outbreak. As it can be seen from the graph the waiting
time for consultation used to almost increase linearly as the time and number of
patients increased. The maximum waiting time of 67 minutes was seen
around10:05 to 10:10.This was mainly attributed to increased load in OPD as a
result of epidemic.

4.AVERAGE TIME OF VARIOUS ACTIVITIES

Graph 4.10: The above graph shows the average timings of various activities in the
OPD process flow.The average time for Queuing is 6.07 minutes, for billing its
1.05 minutes,waiting for consultation is 23.33 minutes.The Average waiting time
comes out to be 30.45 minutes.

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4.1.3 FINDINGS OF RESEARCH OBJECTIVE NO: 3
“To identify process lacunas/gaps present in the system and suggest
recommendations for the same.”
The following gaps were identified in the system during the study
1)PROLONGED WAITING TIME
○ Too many patients in relation to doctors

○ Doctors are busy elsewhere in the hospital at the time of OPD

○ Doctors on rounds during OPD timings.

○ Doctors come late or are absent from OPD for prolonged duration.

○ Delay in registration and billing counter, collection of laboratory


specimens and report giving because of

• Dengue and viral fever epidemic in Delhi during the


study.

• Procedures not streamlined for efficiency.

• Lack of sufficient manpower during the peak hours.

• Patient referred by registration staff to wrong


consultant .

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• Patient referred by billing staff to consultants who are
absent.

• No UPS back up in case server goes down.

2)DISSATISFACTION WITH THE QUALITY OF SERVICE


○ Unfamiliarity with procedures to be followed to avail service,
especially to carry out laboratory and x-ray investigations after
consultation i.e poor patient ushering services.

○ Non-availability of any positive distractions like


Magazines ,Television was also not functional most of the times.

○ Queue jumping of Metro employees.

○ Extra activities for ex: Filling up of certificates, Panel forms,


discharge summary also had cascading effect on waiting time.
3)DISSATISFACTION WITH AMENITIES
○ No toilets in the OPD area

○ Lack of seating accommodation; seating arrangements not as per peak


hours.
○ Absence of female attendant when leading to examination by male
doctor.
○ Non-availability of wheelchairs for non-ambulatory patients
○ Dirty glasses in the drinking area.

4) NO PROPER MAINTAINANCE OF RECORDS


○ Records are not properly filled ,maintained and there is no
standardization of medical records

5) NO PUBLIC ADDRESAL SYSTEM IN OPD


OPD attendant used to collect the billing receipt which had a token number
and enter it into the register and distribute the receipts to doctor. He then
used to call patient one by one.

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○ Fights were frequent as each patient wished to go first and was
apprehensive about the transparency of the system.

○ Since there was no display system in the area, patients were clueless
regarding the duration of time for which they have to wait for
consultation.

○ Many patients left without consultation because of this.

6) NUMBER OF REFUNDS SEEN DURING THE STUDY PERIOD


Refunds were attributed to the presence of epidemic in Delhi during the month of
August-September.
They were because of:
• High waiting time
• Large number of patients as a result of Dengue outbreak
• Non-availability of Doctors

1
CHAPTER 5: SUMMARY, CONCLUSION AND
RECOMMENDATIONS

Increasing competition in health care sector has made it necessary to improve


satisfaction of patients and staff, and the Out Patient Department (OPD) often
called "shop window" becomes a key area which can made or marr the reputation
of the hospital. The research study titled “GAP ANALYSIS OF OUT PATIENT
DEPARTMENT”was conducted from 4.9.10-2.9.10 at Metro Multispeciality
Hospital,Noida.
Research objectives were:
• To study and analyze the process flow of various activities done at “Out
Patient Department”
• To analyze prevalent arrival and departure time of patients and calculate the
waiting time for each activity.
• To identify process lacunas/gaps present in the system and suggest
recommendations for the same.
The researcher conducted an observational study(Time and motion study) and the
procedure of systematic sampling was used to select patients visiting OPD. With
the help of observation,the researcher made the process flow of various activities
and identified the gaps present in the system.Primary data regarding the waiting
time analysis was collected with the help of WAITING TIME TRACKING
SHEET developed by the researcher. The tracking sheet consisted information
about the arrival time of patients in OPD. This was followed by a detailed analysis
of their waiting time for each activity which includes queuing time (Qt),billing
time(Bt),Waiting for consultation time(Wt) and Consultation time ( Ct).
Based on the results, it was found that Monday and Saturday are the days which
have the highest occupancy levels in OPD close to around 70 patients during peak
hours.The occupancy levels were a linear function of time.As the time increased
from 9:30 to 10:00 to 11:00 the occupancy levels also increased touching a peak of
50-60 patients during peak hours of 11:00 to 11:30.Waiting time analysis suggests

3
maximum waiting time of 15 minutes in queue for billing and maximum queue
length of 25 patients during peak hours.As far as waiting for consultation of
general physician is concerned. The maximum waiting time of 67 minutes was
seen around10:05 to 10:10.This was mainly attributed to increased load in OPD as
a result of Dengue outbreak in Delhi.The Average waiting time was 30.45 minutes.
Major gaps in the system include prolonged waiting time as a result of Dengue
epidemic and lax attitude on the part of doctors among other reasons explained in
research findings.Also included in the gaps is the dissatisfaction with quality of
services being provided,dissatisfaction with basic amenities,no proper maintenance
of OPD records,no public addresal system and high number of refunds.
From the findings it was concluded that despite the hospital having good reputation
and nice patient inflow in OPD,it is not being able to manage the OPD operations
smoothly which often results in chaos and fights in OPD.Mismanagement can be
seen at every step from Doctors not being on time for OPD to Billing assistants not
opening cash counters on time.Hence ,the hospital should solve the problem of
increased dissatisfaction among patients by adopting a holistic approach towards
it.These problems if neglected can have a cascading effect .Hence, it is very
important as smooth functioning of OPD sends a positive signal to the patients
about the hospital.
Recommendations:
On the Basis of the study the following recommendations are suggested by the
researcher:

(a) Introduction of Doctor’s checklist to ensure that Doctor’s come on time


It was found during the study that most of the times patients were told that
doctors are on rounds during the OPD timings..However on cross checking,it was
found that the doctors used to be late for OPD. Therefore a Doctors’s checklist
should be introduced which would contain information about Doctor’s time in and
time out in OPD.As a result of which the time wasted in patient waiting for doctor
to come would be substantially reduced.
STATUS OF THE RECOMMENDATION IN METRO HOSPITAL

This checklist has already been implemented in the hospital and is being taken care
of by OPD Incharge.
2
(b) Opening of second OPD billing counter ( which was non-functional
initially)
It was found during the observation that the hospital was not using their second
counter for OPD even during peak hours which resulted in chaos in the
passageway for the only operational cash counter.It was suggested that the second
billing counter should be opened so as to divert the rush during peak hours which
gets clogged in the first billing counter.
STATUS OF THE RECOMMENDATION IN METRO HOSPITAL

Implemented in the hospital.The counter opens sharp at 10:30 and is very much
instrumental in diverting the rush.
( c) Billing slots should be made in cash counters
It was observed during the study that billing slots were not present in the cash
drawers in billing counters.Cash was kept loose and there was no lock system on
the cash drawer.
Therefore billing slots should be made so as to have segregation of cash in the
drawer consequently the assistant does not have to search through the money to
find change for the patient thus saving time.
(d) Availabilty of change at the billing counter
It was observed that there was no money change present in the counter to give back
to patients.Assitants used to write the change patient has to be returned back on the
back of the billing receipt which created lots of confusion both for the patient and
assistants.
Therefore change of Rs.5000/- should be issued to the Billing counter so as to
avoid such situations.
(e)OPD schedule needs to be corrected for mistakes:
OPD schedule was found to have names of doctors who have already left the
organization,the names of certain specilities are also swapped.Therefore, it needs
to be corrected immediately as this source of information is given to patients for
referances.
STATUS OF RECOMMENDATION IN THE HOSPITAL

2
It’s still pending, the hospital is waiting for existing stock to finish and then order
new as communicated by the Medical superintendent.

(f) OPD wheelchairs should be there:


Two wheelchairs should be present in OPD so that this can be used for non-
ambulatory patients and the department does not have to waste time in searching
for wheelchairs in the hospital.

(g) Signage for second billing counter( Refer to Annexure IX)


Signage for the second billing counter should be properly displayed as many
patients do not know the presence of another counter.(Refer to Annexure for
location)

(h) Installation of Public Addresal system in OPD:


It is very important so as to have quicker and efficient service delivery.It would be
convenient for the hospital in a way that it will reduce manual work and most
convenient for the patients who would have an idea about their waiting time from
the token number given to them.Altercations would be less and system would
become smooth.
STATUS OF RECOMMENDATION IN THE HOSPITAL

It is under planning stage.They are planning to have a P.A system by year end.

(i) Availability of positive distractions


Availabilty of positive distractions like Television , Newspapers and Magazines so
as to reduce the anxiety level of patients.

(j) Ensure completion of medical records

1
It was found that most of the patient files were incomplete.The hospital should take
corrective measures to ensure completion as it is a very critical issue.Moreover,the
hospital is preparing for NABH, which makes completion even more significant.

(k)More storage area for keeping of OPD files


It was found the Patient’s Right to Privacy and Confidentiality was neglected in the
OPD as patient files use to be kept loose on the help desks and even more worse
,clogged in the dingy storage areas with no proper segregation.Therefore,poper
storage area should be there to keep the files and they should be duly sent to
Medical records department on time.

(l) Introduction of OPD checklist(Refer to annexure X )


It is said that whatever gets measured gets done. The checklist would ensure
accountability and transparency.This can be filled by the OPD incharge on daily
basis.

(m) Billing should be informed about the changes in consultant’s timings or


absence of any consultant for the day before starting with the billing
procedure so as to avoind cancellation of receipts.

(n) Extra activites such as filling of certificates,summaries ,panel forms should


not be done during OPD timings as it consumes time.

(o) Increasing seating capacity


The hospital should increase their seating capacity from present strength of 60
seats to 75 seats as the findings suggested maximum occupancy of around 70
1
patients during peak hours.Seating arrangements should be make like wise as in
India a patient does not come alone but comes with atleast one attendant.Proper
considerations should be given to these facts.

LIMITATIONS:
• Hawthorne effect:The study involved direct observation of OPD staff as a
result of which bias was introduced in the behavior of staff. This arose
because they knew the fact that they were being observed.

CHAPTER 6: IMPLICATIONS AND FUTURE RESEARCH

These findings have important implications as it will help in improving the


patient satisfaction by delivering care quickly and correctly. It will help in

2
understanding the process flow of various activities in OPD,help in identifying the
reasons responsible for delayed service delivery and also help in understanding the
functioning of OPD during epidemic time i.e the outbreak of dengue and viral in
Delhi.

Scope of future research


Future research can be done on finding the factors that motivate/demotivate a
patient towards the OPD services in the hospital and the importance of waiting
time from a patient’s point of view. Research can also be done by applying various
methods of operational research tools such as “Queuing models” to solve the
problems of increased queue length and waiting time for patients and making a
hassle free OPD model.

ANNEXURE VI

WAITING TIME TRACK SHEET

2
PATIE ARRIV QUEUI BILLI WAITING CONSULTA COMME
NT NO AL NG NG FOR TION TIME NTS
TIME TIME TIME CONSULTA
TION TIME

• Time is calculated in minutes.

1
ANNEXURE VIII

OPD ENTRANCE

2
WAITING AREA

SUGGESTION BOX

1
DOCTOR’S CHAMBERS

ANNEXURE IX

1
PROPOSED LOCATION FOR SIGNAGE OF SECOND
COUNTER

ANNEXURE X

3
Hospitals choke as Delhi battles dengue
DELHI: Patients suffering from dengue are finding it difficult to get
admission in city hospitals because of a sudden spurt in the
number of cases and limited beds at these medical facilities.

Three hospitals in the city - All India Institute of Medical Sciences,


Safdarjung Hospital and Ram Manohar Lohia Hospital - are taking
maximum burden of dengue patients, despite having limited beds
at their disposal thus choking the resources.

Premier medical institute AIIMS has reported the highest number


of admissions related to dengue fever till now. The city has
reported 550 dengue cases and one death this season.

"All wards are full. Nearly 50 patients including children are


admitted for dengue fever. Every day we get 10 to 15 new
admissions. Some are confirmed cases while others are suspected
cases. Those suspected are admitted for monitoring for sudden
fall in platelet count or some additional symptoms along with high
fever," a doctor with the Department of Medicine said.

Unlike in the year 2006, when a separate dengue ward was set up
to tackle influx of patients, there are no separate facilities this
time. All dengue patients are being admitted to the medicine
ward which has a total of 60 beds which are all occupied.

As a result, patients are being adjusted in corridors of the


hospitals as well. The authorities have managed to bring an
additional bed in the space between two beds. When the rush
increases, one bed is shared by two patients as well.

"It took us two days to finally get a bed in the ward. After
admission, my brother, who is a confirmed patient of dengue, was

3
made to lie in a bed in the corridor," Nitin, relative of a dengue
patient who was brought at AIIMS, said.

"AIIMS has all facilities and that is why even after being given a
bed in the corridor we continued treatment here. Doctors here are
not encouraging too much of hospital stay. If a patient shows
signs of improvement, doctors are immediately discharging
them," Nitin said.

Spokesperson of AIIMS Dr Y K Gupta said, "The medicine ward is


overcrowded and we have patients even in the corridors. If the
need arises we are referring cases to RML or Safdarjung. Not all
are being admitted. They are being monitored and if the need
arises, they are being admitted."

Another patient admitted in ward 11 of Medicine Department,


Safdarjung Hospital said, "I am admitted here since the last four
days and sharing my bed with another dengue patient since day
one. Doctors told us to adjust or else turn to private hospitals for
help."

Sadarjung hospital PRO Satyanarayan Makhwana said, "We have


a total of 12 beds dedicated to dengue patients and all are full.
This is a referral hospital and we cannot deny patients. As such
we have now adjusted two in one bed."

In the last four days there has been a sudden flow of patients
being referred from other hospitals.

"We have admitted both suspected and confirmed dengue fever


patients. Investigations are being conducted immediately and
unless necessary no admissions are happening. If the need arises,
we will have to create beds in the corridor or add more beds."

4
Meanwhile, the situation at RML hospital is relatively better.

Medical Superintendent, RML hospital, Dr T S Sidhu said, "We


have 60 beds in our ward that can be used for dengue
admissions. But have not yet heard any unit doctor complaining
of running short of bed. If there is any shortfall, we will make
arrangement in the floor or corridor or we will have to go for two
in one bed."

5
References:
1.Metro Hospitals;

http://www.metrohospitals.com/
2.S.K Joshi;Quality Management in Hospitals,3rd
Edition;Last modified 2009.

3. M.S Gihony ; Hospital Planning and Architecture; 5th


Edition.
4. Satyaveer Singh;e journal,Medvarsity;Last modified
2009’July.
5. Satyaveer Singh;e journal,Medvarsity;Last modified
2010’April.
6. Akhilan Arun Kumar;Journal of the Academy of Hospital
Administration;2006.

7.Vijaya Bharat ;Journal for healthcare research;2007.

7
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