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Summer Training

[April 11th April 30th, 2011] In

Shija Hospitals and Research Institute [May 4th June 4th, 2011] In

A Report By Anisha Khundongbam Post-graduate Diploma in Hospital and Health Management (2010-12)

Institute of Health Management Research, Jaipur 2010

PREFACE Summer training is an integral part of the course curriculum of PGDHM. As part of the course; students of first year are required to undergo summer placement at any reputed organization to get in depth exposure of various departments in the organization. During the period of summer training, I completed three projects which were carried out at two different Healthcare setups. The first study titled A Study on Discharge Procedure with Special Emphasis on InPatient Feedback, was carried out at Shija Hospitals and Research Institute, Manipur. The aim of the study was to understand the existing discharge procedure at the hospital and to analyze the probable reasons for low in-patient feedback ( which was a part of discharge procedure). The second study titled Medical Records Management and Protocol

Implementation was undertaken at Fortis Malar Hospital, Chennai to understand the structure, process outcome of the Medical Records Department at the Hospital. The third study titled Employee Joining Kit was also pursued at the Fortis Malar Hospital Chennai. This was a special project assigned by the HR department of the Hospital. The designing and preparation of the employee joining kit took many HR aspects into consideration as it had to be a comprehensive manual to be presented to the new employees at the time of joining. The Objectives of summer training were: To learn the daily operational management of the Organization and its various departments / areas. To study the salient and critical features about the functioning of these departments / areas. To identify issues / problems associated with some specific departments / areas. To undertake the projects / special tasks assigned to us.

TABLE OF CONTENTS

A. Profile of Shija Hospitals And Research Institute(Shri), Manipur.. 1 a) Introduction..3 b) Services available(Departments).3 c) Organization chart....5 d) Front office6 e) IPD department.8 f) Operation Theatre and ICU....10 g) Human Resource Department14 h) Stores ..15 i) Hospital management information system16 j) Medical records department..17 k) Clinical nutrition and dietetics department18 l) Security and Safety19 m) Housekeeping.19 n) Laundry .20 B. PROJECT 1- A Study on Discharge Procedure with Special Emphasis on In-Patient Feedback.22 C. Profile of Fortis Malar Hospital, Chennai..32 D. PROJECT STUDY 2- Medical Records Management and Protocol Implementation36 E. PROJECT STUDY 3- Employee Joining Kit.46 C. ANNEXURES a) b) c) d) e) f) Discharge checklist Feedback form Final Summary sheet Forms verification checklist Hospital statistics Record Employee joining kit

ABBREVIATIONS ALOS BOR CCTV CSSD DOR ECG ENT HIS Average Length of Stay Bed Occupancy Ratio Closed Circuit Television Central Sterile and Supply Department Discharge on Request Electro Cardiogram Ear Nose Throat Hospital Information System Human Resource Development International Classification of Diseases Intensive care Unit In Patient department Information Technology Medico Legal case Medical Records department Out patient Department Operation Theatre Resident medical Officer

HRD ICD ICU IPD IT -

MLC MRD OPD OT -

RMO -

Shija Hospitals and Research Institute [April 11th April 30th, 2011]

ACKNOWLEDGEMENT

I am extremely indebted to all the professionals at Shija Hospitals and Research Institute(SHRI), Manipur for sharing generously their knowledge and precious time which inspired me to do best during summer training. I owe a great debt to Dr.KH.Palin, Managing Director and Chairman, Shija Hospitals and Research Institute, Manipur for allowing me to do my summer training at the hospital. I would also like to thank Dr. Jugindra S, Medical Superintendant and Ms. Gayatri S, Head - Human Resource, for their valuable guidance and at whose behest I received tremendous assistance from other departments and their respective heads without which the project would not have been completed. I would like to extend my special thanks to, Ms. Leema and Ms. Arti, Operations Executives, for sparing their valuable time and sharing with me the nuances of Hospital operations and to all Executives of HR and Operations department, for their support and guidance throughout the summer training. Most importantly, I would like to thank my mentor Dr.Neetu Purohit, for her unconditional support, and motivation throughout the study period and Dr.Tanjul Saxena, for her guidance on the report preparation and compilation of the same.

INTRODUCTION

Shija Hospitals is a pioneer ISO 9001:2008 certified private health institute in Manipur providing advanced healthcare technology with humane touch. With the recognition by its customer for their holistic approach, personal touch and technological advancement, Shija Hospitals has been successful, to a great extent, in bringing highly needed medical technology in the region. Shija Hospitals located at environment friendly Langol, Manipur is 200 bedded, fully computerized institute having five modern operation theatres and 18 bedded fully functional ICU with all the latest life supporting equipments. The hospital currently has 500 trained and dedicated staff. Shija Hospitals has becomes the only centre in Eastern India having, under one-roof, the total state of the art solution for treatment of stones at different locations of the body viz., Lap-Chole, Lap-CBD Exploration, ERCP, ESWL, PCNL, URS, CLT and LapUrosurgery. In Manipur, it is the only private hospital having a consolidated Neuroscience centre under one roof has all the requisite resource in its Neurosurgery and Neurology unit. Also SHRI is today a premier institute in India for minimally invasive surgery (MIS) viz., Laparoscopic Surgery, Arthroscopy, Thoracoscopy, Functional Endoscopic Sinus Surgery (FESS) and Upper and Lower GI Endoscopic procedures. To mention the recognition, the hospital has been awarded Guinness World record for removing the largest neck tumor in the world from a 12 days old baby; the tumor weighed 40% of the body weight. Facilities: Shija Hospitals, Langol, has the following departments Emergency and Trauma Care Pathology Radiology and imaging General Surgery Paediatric Dental E.N.T Obstetrics & Gynaecology Ophthalmology Orthopaedics Cardiology Anaesthesiology Medicine and Psychiatry Physiotherapy Surgical Gastroenterology Plastic Surgery Neurosurgery Neurology Urology

Vision 2015 To be a premium & leading brand in healthcare services in the South East Asia, recognized by our customers for our holistic approach, personal touch and technological advancement. Mission Customer needs Quality system People development Core Values: Integrity Agility Passion for Excellence Research and development Networking

FRONT OFFICE
In Patient MAIN RECEPTION
Patient entry

Out Patient

I)

Main reception area

Registered

If Not Registered Registration done (At Main Reception) OPD Billing

OPD Nursing Station

Consultation with Doctor

Advised Medication Admission

Advised Investigation

Advised

OPD Pharmacy Counter Admission &

Sample collection

Diagnostics

Billing Counter

EXIT

Report Collection

Registration Procedure OPD requisition form to be filled Submitted at the front office A unique hospital ID is assigned Cash Memo is issued

Mode of payment Cash payment was accepted. Debit/ Credit card payment were under process. Waiting area There were three different OPD complexes General OPD Eye OPD Obstetrics & Gynecology The General OPD waiting area would accommodate 150-200 people whereas the other OPDs had a capacity of 100 with no sub waiting area.

In case of empanelled organizations: o o o o The client has to produce an authorisation letter Compendium of orders by Central Government Health Scheme is strictly followed Same charges and rates according to states are followed In Manipur, Delhi rates followed for all examinations and procedures

Payment method for clients from empanelled organizations: o o o IP payments are always due and payments have to be drawn from the empanelled organization. OP payments have to be collected in cash from the patients, which they can refund it on their own. IP patients can give cheques.

SHIJA MASTER HEALTH CHECK


Patient enters hospital

Registration done at Main reception

Billing done at IPD Counter

Sample collection done in Master Health Check Sample Collection Room

Sample sent to Lab

IN PATIENT DEPARTMENT
Categories of wards : o Male General Ward o Female General Ward o Intensive Care Unit o Neuro ICU o Special rooms o Cabins/ Twin sharing o Deluxe Suites

In Patient Flow: Patient can come from

OPD OPERATIVE

ICU

EMERGENCY

POST -

WARD

Admission counter by Assistant gives a call

- Nursing staff of ward changes the patient status in HIS

doing CHECK-IN of the patient received. 8

to nursing station to where confirm for bed their availability.

- ICU/ EMERGENCY/ POST-OPERATIVE WARDS (from

the patient is coming) changes the patient status in

HIS by doing CHECK-OUT of the patient.

Nursing staff prepares the room/bed. Entry done in HIS, Register, White Board Nurse informs the concerned Doctor Doctor comes & prescribes medication and investigation (if any) Nurse writes the prescribed drugs on Indoor Drug Requisition Form Ward boy goes and collects the drugs from Pharmacy Nurse starts medication + prepares the patient for investigation (if any).

OPERATION THEATRE
Doctor sends request for OT Availability OT Incharge confirms OT availability Entry into OT Booking Register regarding Scheduled surgerys Date, Time, Doctor, Patient

A day before surgery verification of: Surgery Set Drugs


Depleted stock for surgery use Sufficient stock/ Inventory

Instrument Verification In Non Usable condition Discarded Entry into Instrument Replacement Register Respective HOD informed Request send to stores Request sent to Purchase department OT Instrument inventory replenished Not expired Expired Suitable for use in surgery In usable condition

Verification of CSSD & other consumables

Expiry check

Unused & not expired

Used Requisition sent to Pharmacy through Drug Requisition Form

Suitable for use in surgery

Linen & Instrument check Dirty Linen list formed & sent to Laundry & received later Entry made into: Autoclave, ETO, Plasma registers Send to CSSD

Separated Suitable for surgery Entry made into REAUTOCLAVE register Send to CSSD

Pharmacy replenishes request

Surgical set & consumables prepared

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Before start of surgery, Inspection of: Before start of surgery, Inspection of:

Patients Records

Medical Gas

Sterilization

Instrument checklist form

Electrical points in OT

Equipments

Pressure, Leakage

Daily OT cleaning records duly filled Mopping of OT floor with Bacillocid Disinfection of OT items listed on form with 2% Trigene

Completion of opened by & cross checked columns

Transfer of equipment, specific for surgery, into OT

OT Preparation done Reception of Patient in Pre Operation area 20 minutes before surgery Patient shifted to OT Patients Identification done & verified Surgery performed Recording of all consumable used is recorded Surgery completed

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Surgery completed

Collection of OT Waste

Count of instruments Post Column of Instrument check list form completed

Transfer of patient to Recovery room

Updation of records

OT Drug inventory checked

Disposal by housekeeping staff as per rules

Patient shifted to Ward/ SICU

Operation notes & patients record completed

Requisition send to Pharmacy

Operation Daily charge bill formed OT Prepared for next surgery

OT Inventory replenished

Operation Theatre:
Layout : 1st flooor No. of OTs : 6 General OTs 3 Eye OT- 1 Minor OT - 2 No. of beds in Pre operative ward : 7 No. of beds in post operative wards : 8 Utility room : 1 Doctors Lounge : 1 Nurse and Technician Lounge : 1 Pantry : 1 Sterile room : 1 Changing rooms : 4 Doctor (male) changing room : 1 Doctor (female) changing room : 1 Nurse (female) changing room : 1 Technician + Nurse (male) changing room : 1

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Patient admission procedure in ICU Physician (Desiring admission of a patient in ICU) contacts Admission Office Contacts for Bed Availability with ICU (Nurse Ward Supervisor)

Beds Available Admission done

No ICU Bed available Admission office contacts Nursing Administrator Nursing Administrator starts ICU patients status evaluation

Any patient can be shifted to Wards Patient shifted to ICU after one patient is shifted to Wards

None can be shifted

Patient is stabilized Nursing Supervisor contacts Administrator on-call

He authorize transfer of patient to other hospital

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HUMAN RESOURCE DEPARTMENT

Layout: -Administrative Block Ground Floor Total Staff: 4 Organogram: Head Manager HR Executives (3) Trainee Jobs & Responsibilities: Manpower Planning Internal Job Posting Process CV Selection Confirmation and Appraisal Staff Queries Follow up with selected candidates Issuing of appointment letters Disciplinary Policy Leaves sanctioning Payroll Budgeting for departments Doctors payout Duty roster Issuing of Experience letters Finger print report checking Manpower planning Dispatch of salaries Pre recruitment calls Organizing interviews Preliminary interviews Joining formalities Leave record maintenance Issuing of I-Cards Salary statement Full and final settlement Induction and orientation
Investigation of staff grievances

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STORES
Layout: -New Stores Block Staff: 4 Hierarchy: Stores Manager

Store Supervisor

Bio medical Engineer

GDA

Records Maintained: Goods Receipt Note Quotations Purchase Requests Capital Sanctioned Record

Issue Note Return File Purchase Receipt Purchase Orders

WORK FLOW
Department in need of material Through HIS Indentation or Requisition slip Store Store checks for the required material and the quantity YES NO

Material issued and recorded in Issue Register Register Record of the material entered HIS HIS

Entry into Shortage Purchase Request is filled in

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Duties of Store In charge: Forecasting requirement Budgetary requirement Inventory control Stock verification Communicate the purchase department about requirement Bin card maintained At a time 2800 items maintained in the stores Random sample check to ensure the genuinity and authenticity of product Disposal of surplus/ obsolete Material Distribution

Minimize pilferage.

INFORMATION TECHNOLOGY (IT) DEPARTMENT


Layout: -Ground Floor, Main Building Staff: 3 Functions and responsibilities: To keep the servers alive To keep the network alive To keep internet connection alive To take care of all the desktops & laptops in the organization To track the records of all the desktops To keep an eye on the employees desktops. To resolve the complaints of the employees Training of the other staff for the HIS Major Work Areas: I) General Administration & HIS

General Administration: Servers: Anti virus server Database server Application server Archive server HIS (Hospital Information System)

II)

Application by: Avanttec


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Access to Information:

Billing Ward management Laboratory services Discharges + Medical Records Housekeeping Pharmacy Payroll Medical equipment

o User specific access according to their roles HIS Backup: Done once a day Centralized database Internal backups

MEDICAL RECORD DEPARTMENT


Layout: -MRD Block Staff: 3 Infrastructure: Organogram: Desktop: 1 Printer: 1 Medical Records Officer, Statistician Medical Records Technician

Functions of MRD To ensure that the Shija Hospital has complete & accurate medical record for every patient. Public dealings with respect to Bill verification, MLC cases and dealing with

Summons to the doctors, hospital. To maintain high level of confidentiality as far as patients records are concerned. To ensure that the records are Identified and stored safely to prevent unauthorized changes and easily retrieved whenever required.
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Issuing Emergency, Medical, Birth & Death certificates. To generate Bed Occupancy reports, ALOS and other hospital statistics (daily & monthly)

Record Retention Periods: IP Record Emergency Register MLC Records Birth/Death Register OPD documents : : : : : 05 years 02 years Not to be destroyed Not to be destroyed Handed over to the patient

CLINICAL NUTRITION & DIETICS DEPARTMENT


Layout: -Ground floor, OPD Block Head Dietician: Ms. Bimota Functions: Catering to Inpatients. Diet counseling Education Smooth provision of laid out diets to the patients. To check the patient food for quality, preparation, presentation and packing. Coordinating closely with the Nursing shift in charges for changes in the patients diet or new admissions etc.

Records Maintained: Diet order sheet Meal count register Store register. Diet Sheets Counseling Register Type of Diet Normal Diabetes Mellitus Chronic Renal Failure Liquid Diet
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Diet Card Color White Yellow Blue Pink

Flowchart of Dietician and Inpatient Interaction: The Dietician takes details of new patients such as name, UHID, doctors name, diagnosis and diet prescribed. Then Dietician takes a detailed round wherein she meets every patient and determines patients actual intake. Dietician then provides nutritional counseling and education, ensures patients compliance to recommended diet. She also recognizes personal eating and food preferences. Afterwards, the dietician does nutritional screening in order to know about patients clinical condition, appetite and tolerance to food and acceptance to hospital diet, personal preferences, disliking and food allergies if any. After the rounds, detailed food summary sheets are planned and prepared for every patient keeping in mind medical history and preferences of patient as well.

SECURITY
Own security force, not outsourced since 2009

Area of Operation (Present): To deal with 3 M- Man, Material & Machinery

Visitors check Entry restriction at ICU gate Security for doctors and nurse quarter Surveillance of hospital through CCTVs Theft , Burglary Violence Material movements in & out of the hospital Handling visitors pass In case of patients death, handling emotional chaos of attendants Parking management and traffic control.

HOUSEKEEPING
Status: Own Department Manager: Mr. Arju

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FUNCTIONS: \ Clean Floor ,Wall Ceiling Discharge Cleaning Remove Garbage Replace Supplies In Utility Rooms Clean Housekeeping Equipments Clean Room, Wards, Reception, OT, ICU Etc. Infection Control Pest & Rodent Control Odour Control

Environment Hygiene Sanitation Hygiene Checking Cleanliness Of All Areas Control & Reporting Of All Maintenance Works Hospital Waste Disposal In-Service Training Cooperation with Other Depts

LAUNDRY- Own
Department in charge- Ms.Umajini Functions: Segregation of soiled and clean linen Traffic flow of linen before 8am Carrying the linen around the hospital Registered linen and purpose System of collection o Colored bins Infected linen handled separately- soaked in sodium hyperchloride Register maintained separate for infected and un-infected linen Floor wise collection Different registers for each type of linen Separate people for ironing and drying from those who collect and wash Shared responsibility with nurses in charge Report- washing record submitted to HR dept Due list of linen- expected on Monday

GAPS IDENTIFIED IN STORES MANAGEMENT No forecasting of requirement done i.e. Reorder Levels not defined.
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No analysis like ABC, VED done for inventory control. Codification of items still in progress. HIS for Stores still not completely streamlined. AMC & CMC not maintained for all Some departments go beyond the indent allowance

Repair and Maintenance of equipments There are instruments which are not used at all o Non-functional o Repair required o Condemned For Quality assurance o Quality calibration, o Annual Maintenance Contract o Complete Maintenance Contract Instruments go for regular servicing or they are serviced and examined regularly Some machines are serviced in the hospital- eg computers, printers, patient monitor, BP instrument Alternative arrangements are available during that period of time- Patient monitors from other wards are managed o No back up stock available Shortage during repair period Patient monitor completely mobile, thus record maintenance difficultcommunication gap between the material managers.
3 total staff

GAPS IDENTIFIED IN HMIS: Avanttec is a Chennai Based HIS system, hence immediate access to providers not available Strong foundation but HIS is still not fully streamlined. Personnel shortage in the department. No staff at night.

GAPS IDENTIFIED IN LAUNDRY DEPARTMENT: 6 Set rule per patient not followed. Presently only 2 sets per patient. No weighing scale. No sewing machine for repair No supervision over measured use of detergent and other chemicals.

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PROJECT 1

A Study on Discharge Procedure with Special Emphasis on In-Patient Feedback

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INTRODUCTION
The study was carried out in Shija Hospitals and Research Institute which is a 180 bedded hospital located in Manipur. The Hospital is well known for its high end technology and services in the region. The Hospital looks forward to continually develop its services and improve the facilities available in order to become a well known health service provider in the South East Asian region in the future. The operations management had identified the discharge procedure as an area where there was a scope for improvement. Hence, the hospital had assigned the project to study the discharge procedure. Discharging a patient is an activity common to every hospital - small, large, community, inner-city, teaching or non-teaching. The discharge process can have an impact on numerous factors, such as patient satisfaction, bed availability, timely tests and procedures needed for discharge, transportation, and nursing home arrangements. No matter what type of patient is being discharged (maternity, medicine, orthopedic, neurologic) numerous activities must be completed for each before the patient can be released. This work toward discharge day should begin upon admission. As part of a progress towards NABH accreditation at Shija Hospital, the discharge process is one of the many process improvement projects. The discharge process at this hospital also incorporates obtaining feedback from the in-patient regarding the services at the time of discharge. Due to inappropriate management, the hospital was facing an acute shortage in the feedback response from the patients. The management at the hospital realizes the need and importance of patient satisfaction and a need of a measurable index through feedback analysis. In all service industries, customer retention is a vital issue. Hence the management wanted to do all that they could to obtain feedback from the patients at the time of discharge and make the discharge procedure as smooth as it can get. The objective of this study was to study the process of discharge and find out the probable reasons for the failure to attain feedback from the patients at the time of discharge

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STUDY METHODOLOGY
AIM To study the discharge procedure practiced at Shija Hospitals with special emphasis on analyzing the reasons for the short-fall of In-Patient Feedback OBJECTIVE 1. To find the steps followed during discharge of an in-patient. 2. To find the total time taken for a discharge of a single patient. 3. To find the contributing reasons for the short fall of in-patient feedback received in the wards.

RATIONALE The discharge of a patient is a very important component of in-patient service and needs to be smooth and efficient. On the other hand in-patient feedback is equally important as it provides the performance standards of the hospital which needs to be continually enhanced. METHODOLOGY Study design Area- Shija Hospitals and Research Institute, Manipur Duration- From 11-04-2011 to 30-04-2011 Type of study- Observational and Survey study Sample size-120 in-patients and the following hospital staff: Nurse Superintendant RMOs on duty Staff nurse Front office executives Service entry staff.

Sampling Method-Convenience sampling Study tool: Questionnaire and personal interviews

Type of Data collected Interviewer guided questionnaires collected from patients by visiting the different wards. Personal interview of various hospital staff and officials involved in discharge procedure.
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DISCHARGE PROCESS
Doctor prescribes the discharge Nurse informs the patient about the time of discharge

Staff nurse starts discharge formalities by

Giving the feedback form to the patient attendants

Asking the Resident Medical Officer / Concerned Physician to make discharge summary.

Asking the service entry assistants to enter all the details regarding the patients starting from the no. of consultant visits to medicines consumed.

Informing Dietician to make discharge diet report for patient.

Sending to Pharmacy : Daily Billing Activity Sheet Daily Pharmacy Bills Discharge medication details Medicines left unconsumed

Counseling of the patient by the dietician and physiotherapist (if physiotherapy is going on for patient)

In Pharmacy, Summary of Pharmacy Bill is prepared.

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Daily Billing Activity Sheet

Summarized Pharmacy Bill

Billing department finalizes the bill

Payment taken by billing department from attendants

IPD Billing informs at the nursing station about the clearance of bill

Discharge Summary completion by Medical Transcriptionist

Nurse informs the patient & patient changes clothes

Nurse checks the checklist given for discharge of patient Collects the filled up feedback form from the patient attendants

All medications + Investigations reports + Patients file given to the patient

Patient given & explained about how to take the medications + any special instruction + follow up schedule

Patient Discharged

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Fig1. Communication channels during the discharge procedure

There is a lot of inter-department as well as intra-department communication that takes place during discharge of a patient. This communication needs to be fully synchronized and coordinated to avoid errors and unnecessary delays. Fig 2. A chart showing the compliance of the staff to some of the steps of the discharge procedure of the hospital

Compliance to discharge procedure


120 102 100 No. of patients 82 80 60 40 20 0 No. of feedback collected Discharge confirmed Patients counseled Information given to before 24 hrs regarding discharge patients for care and medication 39 28

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Table1. Duration of various parameters related to discharge Parameters Average Length of Stay Duration 4-5 days

Average time taken for discharge

3 hours 42 min

Average time of the day when patients are discharged Average time of the day when the doctor confirms discharge

14:38 hrs

10:30 hrs

Table2. Level of discharge related activities completed


Parameters No. of feedback collected Actual 82/120 Percentage 68.33%

Discharge confirmed before 24 hrs

28/120

23.33%

Patients counseled regarding discharge Information given to patients for care and medication

39/120

32.50%

102/120

85%

Areas of Major delays Preparation of the discharge summary by RMO. 1 Service entry in charge on each floor; hence shortage during peak hours. Negotiation of the final bill at the Billing office by the attendants. Since all the outstanding bill payments are done in cash there is a delay as the money needs to be brought from homes, banks or ATMs(which are not available at the hospital). Unexpected System failures 3%.
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In Patient Feedback

Fig3. Process of collection of IP feedback

Distribution of the forms to the patients to be discharged Feedback form inserted in the case file from the front office Collected by the nurses or submitted at the front office

Reasons for low feedback 27% case files arrived at wards without feedback forms inserted in them by the front office personnel. Pressure on nurses during peak hours as the entire responsibility is upon them of both the admitted patients as well as the ones to be discharged. Negligence on the part of attendants on submitting the forms duly filled amounted to about 36%. Feedback forms not a part of discharge checklist. 9% of the patients and their attendants are worried about the way feedback is going to be received by the hospital staff. They think that the treatment of their next visit will be influenced by the feedback they give 27% of them do not really believe that anything is going to be done about the feedback forms. General practices that can be implemented to make discharges effective. The discharge planning process should begin as soon as is practical after the patient is admitted to hospital. No discharge should be considered routine. All discharges have the potential to become complicated. Time spent talking to patients and assessing their needs at the start of the process can uncover potential problems and help to facilitate a smooth planned discharge. A discharge date should be set as early as possible, although it is recognised that ultimately any discharge is dependent on the clinical progress of the patient and may be subject to change. Discharge plans should be clearly documented in the patients medical and nursing records.
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Discharge documentation should be concise, easy to use and, most importantly, relevant. Staffs should familiarize themselves with documentation used in the discharge process and ensure they are competent in its completion. Adequate on the job training can be provide for the same. Clearance of bill must be done in installments instead of paying a large sum at the end of the stay at the hospital. Most of the large hospitals such as Fortis follow the same Use of software such as patient tracker, which captures and sorts patient information easily and efficiently, using palm top or computer during rounds or online is recommended for use. Features include the ability to track patient data, view patient lists, and generate reports. This software is being used by Johns Hopkins. Compliance to the discharge procedure by all medical staff and regular and timely rounds by the Doctors Complete System back up Complete and comprehensive counseling to the attendants Implementation of lean six sigma to reduce the time taken for discharge and to reduce chances of error in the process

If a system is not strictly adopted for the purpose of making discharge procedure efficient then there could be some serious implications. Table3. Analysis of threats and opportunities of streamlining discharge procedure. Threat (If we do not follow a standard process) S Continue to encounter difficulties H admitting and discharging O patients R Non compliance with medical care T Inaccurate census, staffing, billing, room occupancy T Dissatisfied customers E R M L Less revenue per bed O Potential for serious violations of N norms G Billing issues T E R M Opportunity (If we follow a standard process) Turn around time of bed availability will improve Decreased admission time Increase revenue Improved communication among departments Increased patient satisfaction

More revenue per bed More efficient operation Increased patient satisfaction

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Ways to obtain more feedback: Short and brief feedback forms which are in a form of a checklist Feedback part of discharge checklist Relevance of feedback explained to the nurses who will in turn explain to the patients and their attendants Introducing a new system, such as Patient Welfare Department which will be a dedicated team to collect feedback as well as address grievances of the patients and ensure quality service thus facilitating an efficient discharge. All patients should receive a comprehensive assessment of their actual and potential discharge needs by relevant members. Feedback based action. The recommendations and suggestions must be seriously looked upon and evaluate the feasibility to implement them. Appreciations of nurses, doctors or other service staff given by the patients and attendants must be conveyed to them to encourage them in providing better service every time.

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Fortis Malar Hospital, Chennai (May 4- June 4, 2011)

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ACKNOWLEDGEMENT

I am extremely indebted to all the professionals at Fortis Malar Hospital, Chennai for sharing generously their knowledge and precious time which inspired me to do best during summer training. I owe a great debt to Mr. Venkat SR (Head Human Resource), Dr. Sajan Nair (Medical Superintendant) of Fortis Malar Hospital for showing their interest and sharing their valuable views in spite of their busy schedule. It has been my privilege to work under their dynamic supervision in the hospitals. The data collection and my learning would have not been possible without in depth discussions with Ms. Sheetal (Assistant Manager HR) Ms. Ammu, Ms Sravya (Executives HR), Ms. Hazel (Assistant Medical Administrator), Mr. Egambaram (Medical Records Officer) of Fortis Malar Hospital. I thank them for providing timely guidance, assistance & kind support during my study.

Most importantly I would like to thank my mentor Dr. Neetu Purohit for her unconditional support, guidance and motivation throughout the study period.

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Hospital Profile
Fortis Malar Hospital is established as one of the largest corporate hospitals in Chennai providing quality super specialty and multi specialty healthcare services. Fortis Malar Hospital, earlier known as Malar hospital was founded in 1992 under the leadership of Dr.Ramamurthy. The Fortis Healthcare Limited had acquired the Malar hospital in the year 2007 and since then the performance and the share market of this hospital has skyrocketed. With 180 beds, the Fortis Malar Hospital focuses on providing comprehensive medical care in the areas Cardiology, Cardiac surgery, Neurology, Neuro surgery, Orthopedics, Nephrology, Gynecology, Gastroenterology, Pediatrics, Diabetics and others. Today it is one of the preferred hospitals in Chennai for patients in several parts of Tamil Nadu and other parts of the World. The hospital provides medical expertise with the finest talents amongst doctors, nurses, technicians and management professionals in an environment that enables them to deliver the highest quality of healthcare through stateof-the art facilities that aims to leave no stone unturned in perfecting ever enhancing patient centric care. Enhanced by the warmth & care of the professionally trained nurses and housekeeping staff, Fortis Malar Hospital at Chennai recreates the comfortable ambience of home within its four walls. Specialities Anaesthesia Blood Bank Cardiac Surgery Cardiology Critical care Dental

Dermatology Diabetes &Endocrinology Emergency Medicine ENT Gastroenterology General Medicine

General Surgery GI Surgery Internal medicine Intervention radiology Laboratory Services Neonatology

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Fortis Malar Organizational Structure


Zonal Director Head Liaison
MIS Manager (Vacant)

Secretary

Medical Superintendant

Deputy Superintendant

Medical Admin

MRD Blood Bank Dietics

Head HR

HR Dept
Nursing Superintendant

Head Marketing & Sales

Marketing Dept

Head PCS

Purchase
Admin

IT House Keeping Food & Beverages Engineering & Projects

Financial Controller

Credit
Finance& Accounts

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PROJECT 2

Medical Records Management and Protocol Implementation

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INTRODUCTION

The study was carried out in Fortis Malar Hospital which is a 180 bedded hospital located in Chennai. The Hospital is well known for its brand and the quality service that it provides to its patients. The business tag line of the hospital Patient First says it all about their commitment to patient care service. Maintaining and keeping records of the patients is also a very important component of patient care. The reason of its importance is well elucidated in the study.

The Medical Records Department is primarily concerned with documentation of patient care. It does not deal directly with reviews of actual treatment given or set standards of care. By ensuring that all personnel comply with regulations regarding documentation of patient care, the Medical Records department supports various medical staff committees by providing data from medical records.

Medical records play an important role in the functioning of any hospital in terms of giving vital information for conducting research, statistical data on utilization of hospital services, mortality and morbidity profiles, and to evaluate performance of clinical facilities. It is beyond doubt that a well-organized and managed Medical Records Department will go a long way in providing quality services to the patient. The objective of study was to study the medical records management and protocol implementation practiced at Fortis Malar Hospital, Chennai. The study is a thorough analysis of the structure, process and outcome of the Medical records department

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METHODOLOGY Study design Area- Fortis Malar Hospital, Chennai Duration- From 04-05-2011 to 04-06-2011 Type of study- Observational study Study tool: Personal interviews

Type of Data collected o Personal interview of various hospital staff and officials involved in medical records management. o Secondary data collected from the department

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MEDICAL RECORD DEPARTMENT


Structure

Layout: -6th floor Staff: 4 Infrastructure: Organogram: 1 MRD officer Desktop: 1 Printer: 1 Wipro HIS used to maintain and share hospital data

2 Medical Records Technicians

1 Office Assistant

3 offices in total: 1 at Fortis Malar- Main collection and work office 1 at Padmanaban- Storage 1 at Velachery- Storage

Job responsibilities Technicians -2 o Receiving files from various wards after a patient is discharged o Assembling the files o Deficiency check of the files o Coding of the files according to ICD-10 o Updating the Pending list for those patients who have been discharged but the file has not arrived at the MRD office o Birth/ Death nominal registers o Insurance related enquiries o Issuing wound certificate for MLC cases o Any information required by the MRO has to be assisted by the technicians Office Assistant o Daily update of statistics
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o o MRO o o o o o o o o o o

Overall in charge for filing sending refilling files and cupboards Department file clearance work Overall department functions Death / Birth /Insurance Mediator between the department and higher authorities Statistics Death audit Filing supervisor Department manual maintenance Dealing with police personnel related to death certificate Assignment of duties and responsibilities Representative for summons to court

Type of Discharge Files maintained: Death Files Birth files MLC cases Recovered cases

Process
Admission & Discharge Report generation of previous day by MRD Officer MRD Peon collects from each ward: Daily Floor Census + Discharge File of discharged patients Assembling & Deficiency check Completion of Incomplete documents by the MRD Officer or concerned Doctor/Nurse Daily Admission & Discharge analysis

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Coding (acc. To ICD-10) & Indexing

Filing Sub process: Maintenance of files, numbering and colour coding appropriately Facilitation in claiming of insurance Documents required for Reimbursement Issue of Wound certificate to MLC related cases Preparation of discharge pending list Data entry for Out Patient, In Patient, total surgery, admissions, doctor-wise account of all procedures such as- CT scan, Ultra sonography, TMT etc Assembling, coding, and deficiency check of discharge files and filing Census data collected from the nurses on duty on daily basis o Manually o Consult the concerned night duty nurses Assembling o Daily files submitted by the ward secretary to the MRD office o Format of assembling order checklist is maintained Assembling Order: 1. Face sheet 2. Patients Discharge Records 3. Discharge sheet (Discharge, DOR, LAMA, Death) 4. Emergency & OPD card 5. History sheet 6. Investigation flow chart 7. Consultation form 8. Informed consent 9. Valuable handover form 10. Undertaking for payment Primary/ ADHOC PTCA 11. Angiography- Angioplasty Checklist 12. Cardiac Anaesthetic Record 13. Consultation for surgical & medical treatment 14. Pre-operative instruction checklist
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15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32.

Anaesthesia record Surgical safety checklist Operation note, Delivery note Post operative evaluation form Labor chart Progress note Temperature chart Intake output chart Blood sugar Diabetic Monitoring chart Drug prescription & Administration Record NICU Observation Chart Nurses Record ICU & CCU Observation chart Medical Certificate cause of death Release of dead body certificate Final Bills (MLC case) Any other relevant document concerning to patient

Deficiency check o Checklist maintained o All files checked against the checklist to confirm the presence of all required reports and forms o Final Summary sheet prepared by the MRD comprising of all important details- final diagnosis, procedure, etc Coding o Not done through the medical information system o Has to be done manually with reference to WHO ICD-10 code book Filing o Filing is done manually and separate colour coding is done for MLC cases, Death and General categories. Census, assembling and deficiency check done in the main office, coding and filing done in the separate office where all files are kept and maintained.

Process of issuing Birth certificate


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o A child is born in the hospital. o Birth report filled by patient or patient attendant. o Collection of birth report from Neonatal Intensive Care Unit by the MRD staff. o Details of the child entered in the birth register. o Government issued form filled by MRD signed and approved by doctor concerned. o Government issued form submitted to the municipality by the MRD staff o Patient /attendant go to the Municipal Corporation and collect the certificate( Corporation of Chennai, Zone-10 Adyar Office) Claiming of insurance Different insurance companies follow different policies and procedures. There are three categories of insurance as follows: o TPA o Group o Medical Assistance also known as Medicaid However, there are no insurance provisions for genetic related diseases or illnesses. Once admitted in the hospital, pre-authorization form is submitted to billing office by the patient. Doctor/ billing persons fills the required forms. The forms are then sent to the company for approval. Surgical procedure or treatment is carried out in the hospital. Investigator or claim analyst then comes to the MRD office to cross check all the details of the procedure and asks for all procedures and file handed over to the investigator. They can see and verify and sign saying that they have verified. They ask for some papers or reports which are allowed to be given. For the patients on a payment of Rs500 and approved by the deputy Medical Superintendant, papers can be obtained from the MRD office MLC related / Casualty These files are maintained separately for In Patients and Out Patients. Casualty wards maintain separate register for MLC cases. These files are presented in case of request for details from police stations. Wound certificates are issued on approval by Casualty Medical Officer in case of out patients and for admitted patients opinion is sought from
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doctor concerned with the final diagnosis based on the surgery related to department. The details of the wound certificate are filled by MRD staff and three copies are made of the same. MR requisition Medical records can be obtained from the Medical records department by filling a medical records requisition form. The requisition form is available only to the internal staff. Detailed requisition form is to be filled by the person who is in need of the concerned files. For requirement of more than 5 files intimation has to be given before two days. Statistical data of the following are received by the MRD from the respective departments. o CATH Lab procedures o Cardiac surgery o General surgery o Daily operation schedule With reference to these mails data is entered in the existing format for MRD Month end copy of the following statistical data submitted to higher authority o Deputy Medical Superintendant o Medical superintendant o Zonal director o Financial manager o Delhi head office

Outcome
Generation of hospital related statistics such as Bed Occupancy Rate , Average Length Of Stay, etc Record Retention Periods: IP Record Emergency Register MLC Records : : : 05 years 02 years Not to be destroyed
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Birth/Death Register OPD documents

: :

Not to be destroyed Handed over to the patients

Generation of Death/ Birth Certificates Systemized and coded files for future reference

Gap analysis Discharge files o Incomplete nurses notes o Patient details are missing o Day to day notes with date and time is missing o Sex details missing o Admission slip is missing o Discharge summary is missing in about 20 % files o Only 40 % files are completely filled and gets through the checklist. o Consent form for procedure- left blank o Patient Registration form missing o No uniformity in admission forms, various formats of admission forms Birth certificates

Birth and death report filled incorrectly or later changes requested by the family. In spite of a 6 month long period of time given to decide the name there are still a high number of cases where the parents come to change the names. Birth and death form to be actually filled by doctors but not followed Insurance o Investigator comes as a representation of the company but often fails to bring a letter authorized by the patient/relatives Coding: ICD- 10 book not available at the MRD office Insufficient space provided for MRD department, according to 180 bedded hospital.

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PROJECT 3

Employee Joining Kit

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INTRODUCTION
The assignment was carried out in Fortis Malar Hospital which is a 180 bedded hospital located in Chennai. The management team at the hospital is a strongly dedicated team. I had an opportunity to work with the Human Resource management team of the hospital. During my training I have seen that they are continuously bringing out new ways and means to delight their employees, encourage them and aid them in performing their best. The Fortis Healthcare industry is known for its high retention rates of up to 95%. It can be said without doubt that the HR team has a role to play. In the same spirit of delighting their employees the HR team assigned me to design and prepare a comprehensive employee joining kit to be given to the new employees. Joining a new organization is a moment filled with exhilaration, excitement and curiosity for the new employee. At the same time, the organization is eager to find out all about the new employee, their personal data, health condition, work experience etc. The organization also wants to acquaint the new employee with all the norms and customs of the organization. It is during the period of joining that the fresher is all eager to find out all about the organization as well. Hence it is the responsibility of the organization to bridge the gap between the new employee and the organization by providing a comprehensive and concise employee Joining kit which will contain the vision and values of the organization, guidelines for the layout, use of canteen and other activities in the organization. The objective ofthe assignment was to prepare a joining kit which will be a guide to the new employee as well as a means of conveying the entire relevant and required message to the fresher. This would also serve as a booklet attached with all the mandatory as well as non mandatory forms to be filled and submitted by the employee after they tear the sheets attached with perforations.

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METHODOLOGY

Area- Fortis Malar Hospital, Chennai Duration- From 04-05-2011 to 04-06-2011 Study tool: Personal interviews

Type of Data collected o Detailed personal interview of various hospital staff and officials. o Relevant and statutory forms collected from various departments o Secondary data collected from the department of Human Resource, Administration, Food & Beverages, Nursing etc

The Employee joining kit was successfully completed and approved by the management of the staff. The complete joining kit is attached as an annexure to give a more detailed comprehension of the requirements of preparing an employee joining kit.

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Annexure 1 FORTIS MALAR HOSPITAL ADYAR, CHENNAI -20 HOSPITAL STATISTICS FOR JAN TO DEC- 2011
S.NO 1 2 3 4 5 6 7 8 9 10 PARTICULARS TOTAL OUTPATIENTS CARDIOLOGY DAILY AVERAGE OF OPD TOTAL INPATIENTS ADMISSIONS CARDIOLOGY DAILY AVERAGE OF ADMISSIONS TOTAL INPATIENTS DISCHARGES DAILY AVERAGE OF DISCHARGES TOTAL INPATIENTS TREATED CARDIAC CASES DAILY AVERAGE OF INPATIENTS BED OCCUPANCY RATE TOTAL SURGERIES MSOT CTOT TOTAL EMERGENCY CASES OP TREATED CASUALTY ADMISSIONS MLC CASES TOTAL DELIVERIES NORMAL LSCS FORCEPS VACCUM EXTRACTOR 13 TOTAL CATH-LAB ANGIOGRAM PTCA/OTHERS 14 15 16 17 18 TOTAL ECG TOTAL ECHO TOTAL TREADMILL TOTAL DIALYSIS TOTAL PHYSIOTHERAPHY OUT-PATIENTS IN-PATIENTS 19 20 21 22 TOTAL NCV TOTAL EEG AVERAGE LENGTH OF PATIENTS STAY ( DAYS ) TOTAL DEATHS > 24 HOURS < 24 HOURS GROSS DEATH RATE ( % ) NET DEATH RATE ( % ) JAN'11 8790

FEB'11
8533 812 305 784 807 28 794 28 3399 1218 121 63.40% 264 216 50 1181 921 269 81 35 10 25 0 0 162 116 23 637 472 187 273 1821 830 991 37 33 3.80 29 23 6 3.65 2.90

MAR'11
9058 861 292 886 871 29 905 29 3555 1363 115 59.75% 374 290 84 1376 1071 310 117 39 14 25 0 0 175 135 40 952 517 175 356 2153 995 1158 46 38 3.47 23 19 4 2.54 2.10

APR'11
7749 756 258 851 760 28 824 27 3184 1094 106 54.54% 322 261 61 1145 850 285 95 36 12 24 0 0 170 124 46 608 477 129 366 1718 720 985 36 37 3.37 8 4 4 0.97 0.49

789 284
826 253

27
795

26
3712 1138

120
70.44% 289 230 59 1337 1030 307 97 38 12 26 0 0 157 110

11

Total 34130.00 3218.00 1139.24 3347.00 2691.00 111.95 3318.00 111.02 13850.00 4813.00 462.20 0.62 1249.00 997.00 254.00 5039.00 3872.00 1171.00 390.00 148.00 48.00 100.00 0.00 0.00 664.00 485.00 156.00 2846.00 1952.00 641.00 1285.00 7719.00 3402.00 4301.00 162.00 134.00 15.30 82.00 66.00 16.00 2.48 2.00

12

47
649 486 150 290 2027 857 1167 43 26

4.66
22 20 2

2.76 2.52 49