` Service Oprations Management

Comparison of service operations in 2 hospitals

Brahmeswara Reddy KV ePGP-01-003 Kannan Kesavapillai Kartikeya Misra Pankaj Gandhi Sandeep Ravindranath Sanjay Kumar ePGP-01-010 ePGP-01-011 ePGP-01-018 ePGP-01-027 ePGP-01-030

Introduction operations is most important part of the services organizations. With the present competition in the services industry there is less scope for profits unless the betterment in the services. Organizations have to adopt the competitive service strategies like overall cost leadership, Focus, Differentiation etc. This study is on the patient appointment, hospital location facility layout and the patient discharge process in 2 hospitals, Columbia Asia hospital, Bangalore (private hospital) and Travancore Medical College (A private Hospital worth 500 cr. investment in the state of Kerala) Mode Of Operation This project is study the service Operations strategy of two hospital operating in India based on various Service Operational Analysis tools like Blue Print Layout analysis Following activities are part of the project a) b) c) d) Questionnaire shall be prepared for interviewing Patients./Staffs/ Doctors Compare the effectiveness of one workflow based on the time and effort Compare the Service Strategy vision of both hospital Recommendations for improving two hospital shall be prepared .

Hostpital under study Columbia Asia hospital Columbia Asia has developed a unique model for hospitals. This deliver advanced medical care through facilities located in neighborhoods, rather than the central city. With sophisticated hospitals based in their communities, patients have dramatically improved access to quality affordable care.

Its facilities in India, Indonesia, Malaysia and Vietnam use progressive medical protocols and modern equipment, managed by well-trained and experienced doctors and other health professionals. They have 14 facilities in operation and are planning to open 17 new hospitals by the end of 2011. Our current facilities are among the leading hospitals in Bangalore, Kolkata, Delhi area (Gurgaon) and Mysore in India; Kuala Lumpur area (Puchong and Shah Alam), Seremban, Taiping and Miri in Malaysia; Saigon and Gia Dinh in Vietnam and Medan in Indonesia. With such geographic diversity and aggressive expansion, Columbia Asia is rapidly becoming the healthcare provider of choice for the emerging middle-income group of Asia.

Travancore Medical College

One of the premier medical facilities for emergency, trauma, critical care and ambulatory care, providing high-quality services to all patients within the community, as well as striving to provide leadership in the education and training of health care professionals. Travancore Medical College stands out as one of the most prominent and reputable emergency medical centers in the South Kerala region. It receives the majority of complicated case referrals from many other hospitals. The administration and medical team are highly qualified professionals base on education, trainings, experiences, mastery and good manners. We are equipped with the most advanced and high technology machines providing the best treatment. Our nursing team, carefully chosen with their education and experiences, design to provide safe treatment and avoid mal-practice .Providing personalized patientcentered treatment and care, 24/7 support and services, we uphold high ethical standards while breaking new grounds in the field of healthcare and medicine. We have to our credit numerous path breaking achievements in the field, which is indeed the result of our undeterred pursuit of excellence in healthcare.

Operations@Columbia Asia hospital Queues: no queues at all. Patients have proper seating arrangements, and good number of hospital staff available to help the patients. Service Package analysis: a. Supporting facility: Hospital is in good environment with gated compound b. Facilitating goods: has world class medical equipment and also consumable medicines to patients c. Information: Patients records are well maintained. During the OPD the next patients name, Doctor name and the MRN (Medical Record Number) will be displayed in the OPD area. This helps the patients to go to Doctor room while also there is staff monitoring this and help the patients if required. d. Explicit and implicit services will be discussed in the Discharge process module. Facility Location: This hospital extremely strategic in its locationconsidering the amount of open space that is existent in the centre of the city. It is at the junction of three large areas of BangaloreYeshwantpur, Malleswaram and Rajajinagar. Also understand that their locations will be generally in the surroundings of high raise buildings or multi residential locations.! other apartments nearby. Operations@Travancore Medical college Service Package analysis: a. Supporting facility: Hospital is in good environment with gated compound. It is situated in 400 acres of land. b. Facilitating goods: Introduces concept of different medicine approaches in same campus which is unique in India. Allopathy,Ayurveda and Homeopathy c. Information: Patients records are well maintained. But patients need to cross check with staffs about their turns. Our observations of their other hospitals support this strategy. Other hospital (Airport road, Hebbel) also has Godrej and few

d. Explicit and implicit services will be discussed in the Discharge process module. Facility Location: This hospital situated in one of the tier 2 city, Kollam in Kerala. Hospital located in Bypass road of the city centre and easily accessible through national highways NH220 and NH47.Hospital is situated in 400 acres of land which gives enough opportunity to hospital management to expand its services Hospital is situated in an area where dense population exits .

Analysis: Blue Print of Patient appointment-Columbia Asia hospital Blue print of patient appointment Physical Evidence

hospital

OP department

Patient Action Call the Number

Arrives at the reception

Arrives at the OPD

Line of Interaction-----------------------------------------------------------------------------------

Onstage Contact Person registration

OPD recep checks the apntment .

Fail point C

Check the Queue status Waiting for doctor

Avoi dable wf

Line of Visibility------------------------------------------------------------------------------------

Verifies the pat. record number.

Backstage Contact Person Line of Interaction--------------------------------------------------------------------------------Fail point A

Support Process gives appointment with specific Doctor and record in a book Fail point B

1 hr. before the appointment, SMS will be sent to patient

software

Fail point A: With the patient symptoms the appointment may be given with the different specialization Doctor. So the back stage person should be knowledgeable enough on the different symptoms and the corresponding department to give the correct appointment. Fail point B: If the doctor is not available (due to any reasons) and the SMS is not sent 1 hr. before, it creates lot of uncomforts to the patient. As the process set the expectations it has to be fail proof. Fail point C: While doing the registration there should be enough references (ex: First name, telephone contacts, e-mail id., house number etc.) so that it will be easy to verify the records just in case the patient forgets the Medical Record number. Avoidable workflow While taking the appointment itself, hospital can give the possible queue status to the patient. So that he need not wait extra time. It would be great if the counter can display the next token number for meeting the doctors.

Blue Print of Patient appointment-Travancore Medicla college Blue print of patient appointment Physical Evidence

hospital

OP department

Patient Action Call the Number

Arrives at the reception

Arrive at OP reception

Line of Interaction--------------------------------------------------------------------------------Onstage Contact Person registration OPD recep checks the apntment . Fail point C

Nurse in charge verifies records Verifies the pat. record number.

Verifies queue list

Line of Visibility-----------------------------------------------------------------------------------Backstage Contact Person Avoi dable A

Avoi dable B

Attender takes old op file or new file from repositiory

Attender puts the file in doctors room

Line of Interaction---------------------------------------------------------------------------------

Support Process

Fail point A gives appointment with specific Doctor and record in a book Sending the inforation to OP dept. Fail point B

Fail point A Reservation is not allowed if the patient is not registed with the hospital already. This is because, there is no way to track the id for nurse in charge. Fail point B If the doctor is getting delayed, there is no means to communicate back to the patient. Fail point D: Only the nurse in charge will know howmany appointments are planned for a particular doctor Avoidable workflow A: Since all medical records are available with the hospital that

too in a separate file storing room, there will be delay of 10 minutes to get each file and send to OP department. But this is occurring in a backstage operation. Avoidable workflow B: While taking the appointment itself, hospital can give the possible queue status to the patient. So that he need not wait extra time . It would be great if the counter can display the next token number for meeting the doctors. Facility Layout Analysis Facility location at a hospital should be designed such a way that Facility Layout Analysis@ Travancore Medical Hospital Locations which analyzed

A B C D E F

Reception OP department Radiology department Pharmacy Billing IP department

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A B C D E F

A 100 300 200 50 400

B 100 400 100 50 350

C 300 400 500 400 300

D 200 100 500 250 250

E 50 50 400 250 350

F 400 350 300 250 350 -

Impact of the design 1. Basic facilities are available in different buildings 2. A person who required to be scanned from OP needs to travel around 400 meters 3. Since there is no space constraint ,buildings which are related are located in a distance which causes discomfort for the staft Recommendation 1. Make connection between each building so that patients or staffs can commute easily 2. Move the complete billing section near to Reception

Facility Layout Analysis@ Columbia Asia Hospital Locations which analyzed

A B C D E F

Reception OP department Radiology department Pharmacy Billing IP department

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A B C D E F

A 50 65 20 1 100

B 50 15 30 50 50

C 65 15 50 64 40

D 20 30 50 19 80

E 1 50 64 19 100

F 100 50 40 80 100 -

Impact of the design 1. One of best thought allocation 2. Considered all possible aspects of service strategy 3. Used space properly

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Patient discharge process @ Columbia Asia hospital

Activity 1. 2. 3.

Description Doctor advices patient discharge Discharge summary prepared by Doctor Nurse sends message to all departments (thru SMS) Indent/drug return by same Nurse Issue or acceptance of drug by pharmacy And Clearance from pharmacy to finance

Cycle time mts. 2 10 2 7

4. 5.

5 5 5 8

6. 7. 8.

Clearance from radiology Clearance from lab Parallelly finance checks the Dr. bill etc. (Then it sends to billing section)

9.

Discharge summary printout (by Nurse) (with Doctor signature)

11. 12.

Cash counter personnel makes a call to patient attendant Patients attendant makes bill payment 10

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13. 14. 15. 16.

Clearance slip issued by Finance Staff nurse receives clearance from billing section Hand over of all documents by nurse to patient/attendant Patient leaves the room !

2 2 2

Activities 4, 6, 7 and 8 happeneds parallelly while co-ordinator for all these activities is the same Nurse. Nurse sends SMS to all the departments while they all clear the patients related records through the system and final clearance will be from Finance to billing.

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DISCHARGE PROCESS at Travancore Medical College

Activity

Description

Cycle time mts. 2 25

Doctor advices patient discharge Discharge summary prepared by Doctor

(Will be prepared by junior doctors with the advice of senior docuror)

1.

Nurse sends message to all departments (thr phone)

15

Indent/drug return by same Nurse Issue or acceptance of drug by pharmacy And Clearance from pharmacy to finance Parallelly finance checks the Dr. bill etc.
(Then it sends to billing section)

30 8

Discharge summary printout (by Head Nurse) If it is casheless hospitalization, then it will be to Insurance department 2. Insurance deptartement will send to inurance firms and wait for the acceptance

2 forwarded 60

120 30 5

3.

Once the acceptance is done clearance will be send to finance

4. Cash counter personnel makes a call to patient attendant

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Patients attendant makes bill payment Clearance slip issued by Finance Staff nurse receives clearance from finacne section Hand over of all documents by nurse to patient/attendant Patient leaves the room

10 20 20 15

Activities 4-10happeneds parallelly while co-ordinator for all these activities are the same Nurse. All coordination happens through phone and documents will be send in person to each departments. Inference 1. Database are not shared across different database. If yes ,then clearance could have received earlier than present 2. Only one IP pharmacy for the whole building which delays all activities 3. Adequate facilities are required in the insurance section so that they can handle the claims faster

Service Strategy Vision Problems with the implementation of the Service Strategy 1. Confused implementation of service strategy Not decided whether to excel as the best hospital or best medical college. 2. Undermined the relevance of Support staff Even though the institution could able to hire best doctors or professors in the nearby locality , as a means of cost cutting it could not able to ensure that support staff are best in class. Nurses or the support staff who does not have very less experience were failed to get the confidence of the patients or had many problems in providing medical care

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Crowds every where Hospital is not providing any restrictions on number of by standers allowed for each patient or the visiting time. This is because hospital wants to promote the people to come in bulks and see the facilities. But this sends a wrong signals to the the Targeted market segment Analysis of Service Quality (From the perceptions of the Patients or Bystanders) Reliability Medium, Better facilities, skilled and experienced doctors Responsiveness Low .This is mainly because of inexperienced support staff Assurance Medium. Staffs are polite. Empathy Access to senior doctors, PROs Tangibles Medium. Clean environment RECOMMENDATIONS Not all basic amenities are available in the same building . Scanning available in one building where administration is in another building which delays the activities. It would have been better if there is passage connects all these building. Many a time there is a delay due to the unavailability of nursing aids in the nursing station or the aids are busy with other patient. In some cases the prescribed discharge drug needs to be arranged from outside by the pharmacy or from the OP pharmacy. Hence there will be delay in discharge process.

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RECOMMENDATIONS

Columbia Asia hospital: 1. Usually the doctor comes for morning rounds, advices discharge and enters his/her comments into the computer. After this the doctor is usually not available in the wards and hence will ask the nurse to wait or will ask the nurse to get it signed by the Med. Officer in ER. This process causes a lot of delay. Instead, as soon as the doctor announces discharge and prepares discharge summary, printout of Discharge summary can be taken and the doctor can sign it. Simultaneously, the nurse can carry out the routine activity. 2. Adequate number of wheelchairs should be kept near all the nursing stations to avoid the delay caused while waiting for a wheelchair. 3. Pharmacy clearance gets delayed usually as there are many customers at the desk and one or two pharmacy personnel. Sometimes the IP clearance sheet remains on the desk unattended for more than an hour. 4. Lab reports are not delivered daily. They are only delivered at the time of discharge. The values are just orally noted down by the nurse when required. Hence measures should be taken so that they are delivered everyday

5. CT scans and tests done before the patient is admitted (OPD) are not given directly with the other documents and are kept at the customer care counter. These can be delivered to the patients attendant as soon as he clears the bill at the next counter itself 6. Many a time there is a delay due to the unavailability of nursing aids in the nursing station or the aids are busy with other patient. 7. In some cases the prescribed discharge drug needs to be arranged from outside by the pharmacy. Hence there will be delay in discharge process.

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References

Questionnaire posed to the patients/attendants at the hospital on the below 1. Appointment process How easy to fix the appointment? Does the appointments are entertained at allotted time? 2. Supporting facility? Does the support staff respond to your need in time? Whether the staff shows cordial behaviour? 3. Information on the Doctors/specialty Does the information available easily 4. Attendants comfort How was the facilities provided for bystanders? 5. Discharge process? How long the discharge process take? Does the patient need to meet different officials to get NOC How was the insurance dept. response 6. Payment issues Does the bill shows all details? Whether the staffs are ready to recheck if there is any confusion in the bill amount 7. Follow ups information Does OP sheet and the IP discharge sheet points to follow up visit need to make 8. Parking and cafeteria How was the parking facility? How was the quality of food at canteen? 9. Miscellaneous Overall rating of the hospital? Improvement opportunities *************************

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