ACKNOWLEDGEMENTS

The Organisational Traineeship Segment (OTS) provided us with a unique opportunity of

working with an organisation. The organisation understanding component (OU) gave us an idea
about the working of the organisation, organisation action component gave us a first hand
experience of project handling and problem solving. I would like to thank IRMA and our OTS
Co-ordinator, Prof. Jayant Negi, for providing us with this opportunity.
We would also like to thank our host organisation H M Patel Center for Medical Care and
Education, Karamsad for giving me this wonderful opportunity to work with them and also for
providing us all the needed support.
We would like to mention special gratitude towards our reporting officer r Pagnesh Gor and his
entire KRUPA team for their support and guidance throughout the training. Also we would like
to mention the efforts of the general manager Mr Dilip Jose who was always there with his
valuable inputs and comments which made us think on the issues at hand from different
dimensions.
We extend our gratitude to the Doctors, Residents, Interns, Students, and other staff of the
different OPDs, Medical Records and MIS of the hospital for their invaluable cooperation and
support.
We owe a lot to the private practioners who allowed us to extend the study into their respective
institutions and thereby see certain latent issues. Our special thanks to Dr Dharmendra Patel
(Khushbu ENT Surgical Hospital), Dr Sujay Joshi (ENT Surgical Hospital), Dr Deepa J Bhatt
(Haley Dental Hospital), Dr R M Wadwana (Dermatology and Venerology), Dr Anita Singh
(Akshar Deep Hospital and maternity home), Darpan Laboratory and Y K laboratory.
We are highly indebted to our faculty guide, Prof. Jayant Negi for providing his valuable advices
and insights on the topic.
To them and to all who have directly and indirectly contributed to this study, we shall remain
forever grateful.
Rupanwita Dash (24030)
Kumar Rakesh Ranjan (24051)

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 EXECUTIVE SUMMARY

I. Title: Time And Motion Study for Out Patients of shree Krishna Hospital.
II. Organisation: Shree Krishna Hospital and Medical College
III. Reporting Officer: Er. Pragnesh Gor
IV. Faculty Guide: Prof. Jayant Negi
V. Students’ Name: Rupanwita Dash & Kumar Rakesh Ranjan

Objectives:
1. To measure and assess the average time taken by an out door patient during each visit in
various OPDs and to find out areas where delay takes place.
2. To study the patients’ perception regarding delay/ waiting in the hospital and its
subsequent impact on the customer base of the hospital.
3. To suggest measures to reduce the waiting time and delays at various steps of treatment
of the outdoor patients.

Scope of the study: The study was done on the outpatients of Shree Krishna Hospital in the
morning OPD hours i.e. 9 am to 1.30 pm. Also patients of private clinics in Anand were studied
for comparison.

Methodology: Time study was conducted for 180 patients to find out the time taken at various
service centres for treatment. The same procedure was repeated for the private clinics and
comparison was made using statistical tools like mean, standard deviation and test of difference
of means. Patients’ psychological response to delay and its impact on service quality of the
hospital was taken through survey. Also process and layout analysis was carried out to find the
areas of delay. Doctors, students and patients at SKH were surveyed to explore various
dimensions of the waiting and delay problem.

Sources of data: Primary data collection was done through the Time and Motion study, and the
survey of Doctors, students and patients. The MIS department provided some of the secondary
data.

Major findings:
• The time taken for treatment at SKH at all the OPDs is higher than that of the private
clinics. However the difference is statistically significant for department of medicine and
gynaecology. Also pharmacy and pathology were other areas of major delay.
• The patients feel that major delay takes place due to transportation followed by waiting in
queue at various service centres. However time study shows the time taken in
transportation is only 7% of the total time taken. Also absent or non responsive staff and
slow service at some departments are other reasons of delay.
• For the patients choice of a hospital is not on the basis of time factor alone but the service
quality plays an important role there. The importance given to time by them in service
quality study was third to reliability and empathy issues.

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 • The process analysis shows there are many non value adding steps in the entire process
which are to be eliminated. Also the present layout and lack of proper information puts
the patients into inconvenience and thus the perceived delay is more.
• In the opinion of the doctors and students the services in this hospital are prompt or very
prompt whereas the patients feel the contrary. This could be a reason for the staff being
non responsive.

Recommendations:
• Development of minor cross functional skills and sharing of one staff between
registration and pharmacy during peak load will help in hastening the services at
pharmacy.
• The operations at the OPDs should be revised especially in medicine and gynaecology.
The residents should do the routine jobs of recording the case history and taking B.P. etc
and the doctors will do the detail check up. The nurse and bens role will be well defined
to regulate the patient flow, inform the patients about procedures and routes and assist
doctors.
• Simple changes in layouts like shifting the waiting chairs, shift in nurse’s position,
separate seats for patients and their attendants etc. will make the operations smoother.
• The reduction in service time by the doctors by 10% will reduce the entire delay by more
than 50%. Also the staff should avoid being engaged in activities like talking on the
phone and gossiping that does not add value to patients’ treatment and increases delay
exponentially.
• Pull strategy in pathology combined with strong central control will reduce the delays to
a considerable extent. Also the focus should be to finish the treatment of a patient on the
same day itself.
• Shaping the demand by shifting it to the lean times from the peak hours and introducing
appointment system to a particular segment of patients will result in more uniform
capacity utilisation of the service providers across the entire working time instead of
accumulated load at some points of time thus make the services faster.
• Elaborate changes in signage will remove hassles and reduce the psychological unrest of
delay.
• Reducing the psychological waiting time by providing the facilities of television, reading
material etc and other things which would divert the patient’s attention, informing the
patients the reason, duration of wait and their serial number in the queue and making their
waiting comfortable by provision of basic amenities will help to a great extent in
pacifying the delay.
• Pleasing behaviour from the nurse and personal attention from the doctor will enhance
the perception of service quality and thus nullify the negative impacts of delay to a great
extent and builds a social relationship with the patients which add to the effective running
of the hospital in the long run.

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 TABLE OF CONTENTS

I. INTRODUCTION …………………………………………...………………………………..1
1.0 Background …………………………………...……………………………………………..1
1.1 Nature of the Problem ……………………………...………………………………………..1
1.2 Objective ………………………………………...…………………………………………..2
1.3 Scope of study………………………………………………………………………………..2
1.4 Hypothesis…………………………………………………………………………………....3
1.5 Definition of Terms …………………………………………………………………….........3
II. METHODOLOGY AND PROCEDURE ……………...……………………………….......5
2.0 Methodology…………………………..……………………………………….…………….5
2.0.0 Methods-engineering approach…………………………………………………….…………......5
2.0.1 Pareto’s 80/20 law………………………………………………………………….……………..5
2.0.2 Perceived service quality………………………………………………………………………….6
2.1 Sampling plan……………………………………………………………..…………………7
2.1.0. For time study of the patients…………………………………………………………………….7
2.1.1. For patients’ survey………………………………………………………………………………7
2.1.2. For doctors’ survey……………………………………………………………………………….8
2.1.3. For students’ survey………………………………………………………………………………8
2.2 Instruments and tools used………………………………………………..............................8
2.3 Procedure followed…………………………………….….…………………………………9
2.4 Assumptions ………………………………..…..…………….…………………………....10
2.5 Limitations …………………………………………………………………………….......11
III. FINDINGS AND CONCLUSIONS……………………………….………………………12
3.1 Process description……………………………………………………………………........12
3.2 Hospital Layout…………………………………………………………………………….15
3.3 Findings from objective study………………………………………………………...……18
3.3.1 Distribution of total time spent by a patient in availing any of the OPD service………………..19
3.3.2 Composition of the total service time……………………………………………..……………..20
3.3.3 Composition of total waiting time…………………………………………….…………………21
3.3.4 Distribution of transportation time ………………………………………….…………………..23

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 3.3.5 Delay in transportation……………………………………………………………….………….24
3.3.6 The cross departmental traffic……………………………………….…………………………..26
3.3.7 Study of SKH vis-à-vis private clinics……………………………………….………………… 28
3.4 Findings from subjective evaluation of waiting and delay…………………..…………….29
3.4.0 The identified factors for delay…………………………………………………………………29
3.4.1 Some qualitative response to waiting problems…………………………………………………32
3.5 Findings from doctors and students survey…………………………………..……………41
3.6 Prioritisation of areas of improvement……………………………………………..………43
IV. RECOMMENDATIONS……………………………………………………..…………...45
4.0 Department wise recommendation……………………………………..…………………..45
4.1 Medicine OPD…………………………………………………………..………………….45
4.1.0 Change in layout and operations…………………………………………………………………45
4.1.1 Reducing the hassles and service time (Monte Carlo simulation)…………………………….47
4.2 Department of OB & Gynaecology ……………………………………………..…………49
4.3 Department of Dentistry…………………………………………………..………………..51
4.4.1 Reducing service time through motion economy………………………………………………..51
4.4.2 Strategies to ensure effective Four-handed Dentistry……………………………………………52
4.4 Department of Ophthalmology……………………………………………..………………54
4.5 Pharmacy………………………………………………………………………...………….55
4.5.0 Change in lay out and operations………………………………………………………………..55
4.5.1 Strategic changes at pharmacy and registration………………………………………………….56
4.6 Department of Pathology…………………………………………………..……………….61
4.7 Registration Counter………………………………………………………..………………62
4.8 Improvement on signage and information…………………………………….……………63
4.9 Strategies to shape demand…………………………………………………..……………..65
4.9.1 Use of appointment system………………………………………………………………………65
4.9.2 Providing economic incentives for non peak demands…………………………………………..66
4.9.3 Staggered work staff schedule………………………………………………………...…………66
4.10 Reducing psychological waiting time………………………………..……………………66
4.11 Building social relationships…………………………………………….………………..68
4.12 Prioritisation of recommendations………………………………………….……………...69
V. REFERENCES……………………………………………………………….…………….73

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VI. ANNEXURES…………………………………………………………………..………….75
LIST OF TABLES

TABLE – 1 Departments studied ……………………………………………………………………...3

TABLE – 2 Sample for time study of patients…………………………………………………………7
TABLE – 3 Sample for students’ survey……………………………………………………………....8
TABLE - 4 Summary table of the time spent by a sample of patients in receiving OPD service….....18
TABLE – 5 Distribution of total time spent by a patient ………………………………………….….19
TABLE – 6 Distribution of the service time at different service centres... …………………………...20
TABLE – 7 Distribution of delay at different service centres ………………………………………..22
TABLE – 8 Distribution of transportation time among different service centres ……….……………23
TABLE – 9 Distribution of transportation time among different service centres ……….……………24
TABLE - 10 Delay in finding Departments ……………………………………………….………….25
TABLE – 11 Inter department traffic ………………………………………………………….……..26
TABLE – 12 Distribution of the total time spent by a patient …………………………….………….28
TABLE – 13 Test of difference of means …………………………………………………….……... 29
TABLE - 14 Factors for delay as perceived by the patients………………………………….………..30
TABLE - 15 Responses about promptness of services of hospital ………………………….………..32
TABLE –16 Before service and after service perceived time ……………………………….………..33
TABLE – 17 Difference in actual and anticipated time as perceived by the patients………….…….. 33
TABLE – 18 Reaction about delays in a hospital ……………………………………………….34
TABLE – 19 Responses about the fairness of the sequence in which patients are treated …….……..35
TABLE – 20 Information about cause and duration of wait ………………………………………… 36
TABLE – 21 Source of information to find routes …………………………………………………....37
TABLE – 22 Patient’s perception of the waiting atmosphere at SK hospital ………………………...37
TABLE – 23 Reaction about the time taken at various departments/counters ………………………. 38
TABLE –24 Intention of revisiting SK Hospital ……………………………………………………...39
TABLE – 25 Service quality of SKH along different dimensions as perceived by the patients ……...40
TABLE – 26 Perception of doctors and students ............................................................................…...42
TABLE- 27 Workload Indices………………………………………………………………………….43
TABLE - 28 Frequency distribution after reduction in service time by 1.45 min…………………..….48
TABLE – 29 Simulated service and arrival ……………………………………………………….…...48
TABLE - 30 Arrival and service rate frequency table from 3 days averaged values ……………….…57
TABLE –31 Monte Carlo simulations for 120 patients based on above frequency distribution………58
TABLE – 31 Match between requirements and recommendations…………………………………....70
TABLE – 32 Weighted scores of recommendations .............................................................…............71

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TABLE – 32 Correlation scores amongst recommendations…………………………………….....…72

LIST OF FIGURES

Figure – 1 Perceived service quality…………………………………………6

Figure – 2 Flow chart of patient’s movement……………………………….13
Figure – 3 Hospital layout…………………………………………………...15
Figure – 4 Inter departmental traffic……………….………………………...27
Figure – 5 The present layout of department of medicine…….……………..46
Figure – 6 The proposed layout of department of medicine…….…………...47
Figure – 7 OB and G Layout………………………………….…..................50
Figure – 8 Four handed dentistry……………………………….……………53
Figure – 9 Department of Ophthalmology…………………….………….….54
Figure – 10 Pharmacy existing layout………………………….…………….55
Figure – 11 Pharmacy proposed layout………………………….…….……..56
Figure – 12 The clinical Pathology Lab…………………………..…………..61

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 LIST OF ANNEXURES

Annexure 1…………………….Sample Process Chart

Annexure-2…………………….Time Study of Departments
Annexure-3…………………….Questionnaire for Patient Perception Test
Annexure-4…………………….Questionnaire for doctors
Annexure-5…………………….Questionnaire for Students/Interns/Residents
Annexure-6…………………….The SERVQUAL Instrument
Annexure-7………………….....Cause and Effect Diagram
Annexure 8...…………………. OPD Statistics for the Financial Year 2002-03
Annexure-9…………………… OPD Statistics for the Financial Year 2003-04
Annexure-10………………….. Average Number of Patients Being Treated By a Doctor per Day
in OPD in 2002-04
Annexure-11…………………..Factor Analysis to Segregate the Reasons for Delay as Perceived
By the Patients
Annexure-12…………………..Methods-Engineering Approach
Annexure-13………………… Show Cards
Annexure-14…………………. Principles of Motion Economy & Classification of Motion
Annexure-15 ………………….Colour Schemes of Departments and Sample signboards
Annexure-16…………………..Time taken for pathological tests in SKH vis-à-vis private labs.

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 ABBREVIATIONS USED

SKH Shree Krishna Hospital

OPD Out patient department
IPD In Patient Department
OB & G Department of Obstetrics and Gynaecology
ENT Department of Ear, Nose and Throat
BP Blood Pressure
Lab. Laboratory
OT Operation Theatre
Sec. Seconds
Min. Minutes
Hr. Hour
Std. Dev. Standard Deviation