Final Ambulance

7/30/2019 Final Ambulance

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BUSINESS PLAN

ZINDAGI AMBULANCE SERVICES PVT. LTD.

Submitted By:

(GROUP 5)

Badal Nirwan (07)Himanshu Kumawat (12)

Kritika Pal (17)Saurabh Arora (33)

ShreyaChatterjee (35)Tanuj Kandpal (39)


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INDEXS.No. TOPIC Page No.

1 Business Plan 3

2 Market Study 5

3 Technical Study 11

4 Financial Study 16

5 Economic Study

6 Management Team & its Vision

7 Conclusion

8 References


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BUSINESS PLAN


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MARKET STUDY


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OVERVIEW OF THE SERVICEZindagi Ambulance Service is a special service which is planned to be operating

in a certain geographical area of Pune, Maharashtra. This is a private service

which will be starting from March, 2013 for the purpose of providing emergency

medical services to the citizens within the certain area of Pune city. Our

ambulance service has been linked to various hospitals like Inamdar, Sancheti,

Oyester & Pearl and Shree Hospital of that region. This service industry is small

scale joint-venture of two people, one of them is MBA who is having an industry

experience 17 years and the other one is having an experience of 10 to 15 years

in Hospital services.

INDUSTRY ANALYSISIndia, by virtue of statistics, is a country that needs high-quality ambulanceservices nationwide. One of the most disaster-prone areas in the world, almost

57% of Indias landmass is vulnerable to earthquakes, 68% to drought, 8% to

cyclones and 12% to floods.

Man-made disasters are also plentiful in India, where the ratio of traffic

accidents per 1000 vehicles is around 25 times higher than the world average. A

study carried out, revealed that nearly 3 people die in road accidents in Pune

every day. Whether the accidents are natural or man-made, 30% accident victims

in India die due to delays in transportation to medical facilities after an accident

occurs, greater highlighting the need for speedy responses to tragedies.

The majority of Pune citizens use auto-rickshaws and taxis for emergency

transport due to their low cost, high availability and familiarity. Public

ambulances run by hospitals and NGOs are available but not widely used due to

the predominantly accurate perception of their unreliability and lack of

timeliness. Most private ambulances in Pune act as hearse ambulances,

transporting dead bodies rather than saving lives.

Basically there are two types of ambulance services:

1) Basic Life Support (BLS) ambulances that are used to transport relativelystable patients

and

2) Advanced Life Support (ALS) ambulances that contains all emergencyequipment and drugs necessary to manage any kind of patient emergency.

Basic Life Support will be provided in our case. BLS is a ground ambulance

service with the provision of medically necessary supplies and services, includingBLS ambulance services as defined by the state. The ambulance must be staffed


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by an individual who is qualified in accordance with state and local laws as anemergency medical technician basic(EMT Basic). These laws may vary fromstate to state or within a state. For example, only in some jurisdictions is anEMT-Basic permitted to operate limited equipment onboard the vehicle, assistmore qualified personnel in performing assessments and interventions and

establish a peripheral intravenous line.

MARKET ANALYSISKey Drivers:The ambulance market holds huge potential as its niche market with not somuch of competition as well.

The awareness being created by various ambulance and emergency equipmentsuppliers, who are making various solutions available for the emergency anddisaster management, is one of the major driving forces.

Various types of natural and man-made disasters happening frequently inIndia are also raising concerns amongst emergency care providers leading tomore investments in this field.

Organizations like NDMA(National Disaster Management Authority) andDGHS(Central Government Health Scheme) are also making consistent efforts

to identify suitable methods for emergency management and providing training,education, and setting up suitable guidelines for the management of emergenciesand disasters for all the states in India.

Necessity for the Service - Medical necessity is established when the patient'scondition is such that use of any other method of transportation iscontraindicated.

Major Manufactures and Product Line


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In the initial years we are taking 2 Force Motors Traveler, 2 Force Crusier andsix Maruti Suzuki Omni Ambulances and in later years we will be increasing the

numbers as per the requirements as well as the returns that we are expecting to

receive. Out of six omnis, two are for our personal use.

PRICING STRATEGIES

We have initially taken 2 Force Traveler, 2 Force Cruiser and 6 MarutiSuzuki Omnis which takes an initial investment of Rs. 63 lakhs.

Insurance of the vehicles for the first year is Rs. 1.8 lakhs.

Fuel cost for the first year is Rs. 8 lakhs.

Drivers salary is Rs.19.20 lakhs for the first year.

Administration costs are Rs. 8.5 lakhs.

So, our pricing strategies are:

1. For contracted vehicles:ambulances Units sales/unit/mth revenue/mth

totalrevenue/year

omni 1 4 45000 180000 2160000traveller 2 80000 160000 1920000cruiser 2 60000 120000 1440000

total 5520000

2. For self-run vehicles:omni 2 2 48000 96000 1152000


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With rising cost, pricing will be change in tune with the market rates.

MARKETING STRATEGIESAlthough the healthcare industry is booming, running a profitable ambulance

service business is no small feat. To market an ambulance service, its important

to look at the niche market with attractive revenue streams. We will be

aggressively marketing and will also track our records.

We will be finding out the attractive revenue sources.

We will be trying to have government contract later in the future, this will

be great source of revenues. Our marketing plan will be to reach out more and more nursing homes as

well as hospitals of Pune so as to spread our services in the city.

Through our contacts, we will be looking for revenue opportunities from

events like sports, parades, festivals and other gatherings by hiring them

our ambulance in case of medical emergency.

A robust measurement and evaluation process will be there, that will

include metrics that can be monitored on a monthly, weekly or even daily

basis.

These are designed to monitor marketing efforts on a campaign-by-campaign basis; these metrics can be used as a baseline for strategic

planning. For e.g. Simple quantitative tools can be a good start.

We will be consulting professional marketers for assessment tools and

strategic insights.

Signage also plays as important part as signage can be used to

communicate the companys value to its customers.

Print advertising can be used to market ambulance services.

Use of Internet will be done. We will be making website for our ambulance

services so as to give more and more information to the customers aboutour services, etc.


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SERVICE AREA

Initially, our ambulance services will be provide in the NIBM region covering

INAMDAR HOSPITAL, Shivajinagar region covering SANCHETI HOSPITAL

and OYESTER AND PEARL HOSPITAL and Nagar Road covering SHREE

HOSPITAL.

Later we will expand our services in more regions of Pune and in various states

of Maharashtra, too.


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TECHNICAL STUDY


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Technical Study:

1.Details of Capacity/Capacity Utilisation

Vehicle Year Capacity CapacityUtilisation

Maruti Omni 1 7 6

2 9 8

3 10 10

Force Cruiser 1 2 2

2 3 3

3 4 4

Force Traveller 1 2 2

2 3 3

3 4 4


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2. Flowchart of Activities:

FOLLOWING ARE THE ESTIMATION FOR THE FIRST YEAR:

SALESsales

ambulances units sales/unit/mth revenue/mth total

revenue/year

omni 1 4 45000 180000 2160000

omni 2 2 48000 96000 1152000

traveller 2 80000 160000 1920000

cruiser 2 60000 120000 1440000

total 6672000

Delivery of the Ambulances to the Hospital Premises

Monitoring Of Ambulances andDrivers;Maintenance of Vehicles

Looking for new business opportunities

Delivery of Ambulance Vehicles

Training of Drivers Retrofitting of ambulances

Setting Up of Company ;Administration Set-Up

Sign contracts with the hospitals Ordering Of Ambulance Vehicles


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FUEL EXPENDITURE

fuel expenditure

ambulance units expected run fuel

expense/unit/month

total fuel

expence/

mth

total feul

expense/year

omni 1 4 1000 5550 22200 266400

omni 2 2 800 4440 8880 106560

travelar 2 1000 10000 20000 240000

cruzer 2 1000 7500 15000 180000

total 792960

DRIVERS SALARY

drivers` salary shifts salary/driver/mth total salary

expense/year

20 2 8000 1920000

SELLING AND ADMINISTRATIVE EXPENDITURE

selling &

administrative

expenses

per

month

per year 2nd Year

rent 15000 180000 198000

telephone

bills

1500 18000 19800

electricity bills 1500 18000 19800

admin salary 35000 420000 420000

stationery 500 6000 6000

misc 8000 96000 50000

total 738000 713600

OFFICE EQUIPMENT

Office Equipment

PC X 2 50000

Printer 3500

Furniture 10000

misc 8000

71500


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INVENTORY

INVENTORY cost/unit units total

gas cylinders 7000 5 35000

stretchers 2000 5 10000

medicalsupply

2000 5 10000

55000

INSURANCE

Cost per Vehicle Fitting Total/Veh units total Insurance(1st

year)

250000 100000 350000 6 2100000 60000600000 150000 750000 2 1500000 40000

1150000 200000 1350000 2 2700000 80000

6300000 180000


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FINANCIAL STUDY


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FINANCIAL ANALYSISSOURCES OF FUNDS AMT(RS

LAKH)UTILISATION AMT(RS

LAKH)YEAR 1

EQUITY 10.5 ASSETS PURCHASED 63TERM LOAN 42.5SUBORDINATE DEBT 10

YEAR 2TERM LOAN 25.71 ASSETS PURCHASED 30.25REINVESTMENT 4.54

YEAR 3TERM LOAN 28.28 ASSETS PURCHASED 33.27

REINVESTMENT 4.99

In future the accumulated reserves of the project would be utilized to finance

further expansion plans.

REASONS FOR THE FINANCIAL PLAN Huge investment involved No access to capital market

Debt provide discipline Cost of debt is low Tax shield

COST OF CAPITALCost of debt15.5% charged on the bank loan. Which reduces to 10.85% after taking the effect

of tax shield.

Cost Of EquityFor the purpose of calculating the cost of equity the risk free rate is taken from

10 yrs government bond which stands at 8.24%. the risk premium for the

medical service sector stands at 7.39%. The beta for the sector is 0.91.

Thus the cost of equity is calculated as 14.965% .

The cost of capital is computed using WACC which comes to 11.78%.


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TERM LOANThe loan from the bank consists of auto finance scheme of the bank and personal

loan whose cost is taken from OBC bank. The term loan provide discipline to the

project. It also provide tax shield and cost of debt is less than cast of equity. The

margin is 15%. This is provided by the partners from their personal savings.

LEGAL AND MARKETING EXPENSESYEAR LEGAL MARKETING1 30000 1000002 75000 1200003 150000 180000

The legal expenses are taken in exceptional items in income statement. It takecare of the expenses incurred in getting the licenses and clearance.

The marketing expenditure includes advertisement and other additional cost.

IMPORTANT RATIOSYEAR1 YEAR2 YEAR3

NPV 10941665

BREAKEVEN 7 YRSIRR 26%ICR 2.140542191 2.527441937 2.882233293DSCR 1.005607714 1.037266324 1.043635083LLCR 1.736772238

TAXESThe taxes are calculated on PBT at 30%.

DEPRICIATIONThe depreciation is calculated using WDV method at 20%.


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Income Statement:

1 2 3 4 5

Revenues(Ambulance

Service Fees) 55,20,000.00 77,40,000.00 1,11,86,400.00 1,28,64,360.00 1,40,22,152.40Other Income 1152000 1728000 2304000 26,49,600.00 28,88,064.00

66,72,000.00 94,68,000.00 1,34,90,400.00 1,55,13,960.00 1,69,10,216.40

less:

raw material

consumed(refilling of

oxygen cylinder) 19200 29568 41817 50180.4 60216.48

Insurance 180000 224000 259200 298080 342792

Fuel 792960 1235124 1597992 20,18,439.37 25,49,510.56

manpower expenses 1920000 3024000 4752000 5702400 6557760Office Equipment 71500 10000 50000 50000 50000

Maintenance 1,20,000.00 1,68,000.00 259200 5,87,770.00 10,00,000.00

- -

less:

selling and

administration

expenses 738000 763600 1270410 15,22,555.33 18,24,745.35

Marketing

Expenditure 100000 120000 180000 2,25,000.00 2,81,250.00

EBDIT/PBDIT 27,30,340.00 38,93,708.00 50,79,781.00 50,59,534.90 42,43,942.02

less:

depreciation &

amortisation 1260000 1613000 1955900 1805064 1731848.64

EBIT/PBIT 14,70,340.00 22,80,708.00 31,23,881.00 32,54,470.90 25,12,093.38

less:

Interest 686900.733 902378 1083840.44 780994.6 500745.9

EBT/PBT 7,83,439.27 13,78,330.00 20,40,040.56 24,73,476.30 20,11,347.48

Add:exceptional items -30000 -75000 -150000 -200000 -200000

EBT/PBT 7,53,439.27 13,03,330.00 18,90,040.56 22,73,476.30 18,11,347.48

Tax @ 30% 226031.78 390999.00 567012.17 682042.89 543404.24

EAT/PAT 5,27,407.49 9,12,331.00 13,23,028.39 15,91,433.41 12,67,943.23
mailto:[email protected]%20%25mailto:[email protected]%20%25


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Balance Sheet

LIABILITIES 1 2 3 4 5

SOURCES

OF FUNDS

EQUITY 1050000 1050000 1050000 1050000 1050000

TERM

LOAN 4250000 6193675 7866492 6157064.349 4304768.224

SUB DEBT 1000000 852335 678503 478503 278503

less

principalpayments 775240 1296390 1909429 2189676.1 2496193

RESERVES 527400 989481 1813384 34,04,817.41 46,72,760.65

total 6052160 7789101 9498950 8900708.661 7809838.87

ASSETS

FIXED

ASSETS 6300000 8065000 9477000 9021100 9216036

less depri 1260000 1613000 1955900 1805064 1731848.64

net block 5040000 6452000 7521100 7216036 7484187.36

CA 1207160 1628261 2424369 3306675.385 3100044.398

inventory 55000 63250 72737.5 83648.125 96195.34375

receivables 460000 645000 932200 1072030 1232834.5

bank/cash 692160 920011 1419432 2150997.26 1771014.554

less CL 195000 291160 446519 535822.8 616196.22

accruals 195000 291160 446519 535822.8 616196.22

net assets 1012160 1337101 1977850 2770852.585 2483848.178

total 6052160 7789101 9498950 9986888.585 9968035.538


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CASH FLOW STATEMENT

CASH FLOW

STATEMENT

CASH FLOWOPERATING

ACTIVITIES 1 2 3 4 5

Cash received

from

customersand

users 62,12,000 94,68,000 1,34,90,400 1,55,13,960 1,69,10,216

Total

Outflows 3972692 5674131 8531112 10600645 12593482

Net Cash

inFlow from

Operating

Activities 22,39,308 37,93,869 49,59,288 49,13,315 43,16,734

CASH FLOWS

FROM

INVESTING

ACTIVITIES

Purchase of

Assets 6300000 3025000 3025000 1500000 2000000

Net CashoutflowFrom

Investing

Activities -6300000 -3025000 -3025000 -1500000 -2000000

CASH FLOWS

FROM

CAPITAL AND

RELATED

FINANCING

ACTIVITIES

Equity and

Reserves 1050000 0 0 0 0

Loan 5250000 2571250 2828375 0 0

Loan

Repayment 1462141 2198768 2993269 2970671 2996939

Net Cash

From Capital

and Related

Financing

Activities 4837859 372482 -164894 -2970671 -2996939


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NET INCREASE

IN CASH AND

CASH

EQUIVALENTS 777167 1141351 1769393 442644 -680205

CASH AND

CASHEQUIVALENTS,

BEGINNING

OF YEAR 0 692160 920011 1419432 2150997

CASH AND

CASH

EQUIVALENTS,

END OF YEAR 692160 920011 1419432 2150997 1771015

RATIOS:

1 2 3 4 5

INTEREST

COVERAGE

RATIO 2.141 2.527 2.882 4.167 5.017

DSCR 1.006 1.037 1.044 1.096 0.838

LLCR 1.737

NPV IRR

1 2 3 4 5

EBiT 14,70,340.00 22,80,708.00 31,23,881.00 32,54,470.90 25,12,093.38

ebit(1-t) 10,29,238.00 15,96,495.60 21,86,716.70 22,78,129.63 17,58,465.36

add

depriciation 1260000 1613000 1955900 1805064 1731848.64

less capex 0 3025000 3025000 1500000 2000000

less nwc 320000 417090 558418.5 619855.325 712833.6238

cf 6300000 2410340 451618 1496362.5 2939679.579 1531108.394

kd 0.1085

ke 0.149649

Rf premium debt beta

growth

normal

0.0824 0.0739 0.155 0.91 0.055


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wacc 0.117763133

0 1 2 3 4 5

discount

factor 1 0.894643928 0.800387758 0.716062047 0.640620563 0.573127296

d cf 6300000 2156396.045 361469.5183 1071488.395 1883219.185 877520.0142

tv 19003757

10891572

npv 10941665

irr 26%

SENSITIVITY ANALYSIS:

Sales pat

PAT TO

SALES 527407.5 3941660

0.8 5337600 -806993

0.9 6004800 -139793

0.95 6338400 193807.5

1 6672000 527407.5

1.05 7005600 861007.5

1.1 7339200 1194607

1.2 8006400 1861807

Ebit Dscr

1.005608 1462141

0.8 1176272 0.804486

0.9 1323306 0.905047

0.95 1396823 0.955327

1 1470340 1.0056081.05 1543857 1.055888

1.1 1617374 1.106168

1.2 1764408 1.206729

cost pat

pat to

cost 527407.5 6672000

0.8 4915674 1756326

0.9 5530133 1141867

0.95 5837363 834637.1


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1 6144593 527407.5

1.05 6451822 220177.9

1.1 6759052 -87051.8

1.2 7373511 -701511

Ebit Iscr

2.140542 686900.7

0.8 1176272 1.712434

0.9 1323306 1.926488

0.95 1396823 2.033515

1 1470340 2.140542

1.05 1543857 2.247569

1.1 1617374 2.354596

1.2 1764408 2.568651


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ECONOMIC

STUDY


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percentage of women increased from 26% to around 35% of the workforce. Manyof these women are highly educated: the ratio of women to men who have acollege degree or higher level of education is 40:60. Thanks to rising income,today at least 100 million Indians can afford to buy Western medicinesamarket only 20% smaller than that of the UK. If the economy continues to grow

faster than the economies of the developed world, and the literacy rate keepsrising, much of western and southern India will be middle class by 2020.

RISE OF DISEASE

Another factor driving the growth of Indias healthcare sector is a rise inboth infectious and chronic degenerative diseases. While ailments suchas poliomyelitis, leprosy, and neonatal tetanus will soon be eliminated,some communicable diseases once thought to be under control, such

as dengue fever, viral hepatitis, tuberculosis, malaria, and pneumonia,have returned in force or have developed a stubborn resistance to drugs. Thistroubling trend can be attributed in part to substandard housing, inadequatewater, sewage and waste management systems, a crumbling public healthinfrastructure, and increased air travel.

In addition to battling infectious diseases, India is grappling with theemergence of diseases such as AIDS as well as food- and water-borneillnesses. And as Indians live more affluent lives and adopt unhealthywestern diets that are high in fat and sugar, the country is experiencing a rise inlifestyle diseases such as hypertension, cancer, and diabetes, which is reachingepidemic proportions.

Over the next 5-10 years, lifestyle diseases are expected to grow at afaster rate than infectious diseases in India, and to result in an increase in costper treatment. Wellness programs targeted at the workplace, where manysedentary jobs are contributing to an erosion of employees health, could help toreduce the rising incidence of lifestyle diseases.

DETERIORATING INFRASTRUCTURE

Indias healthcare infrastructure has not kept pace with the economysgrowth. The physical infrastructure is woefully inadequate to meet todayshealthcare demands, much less tomorrows. While India has several centers ofexcellence in healthcare delivery, these facilities are limited in their ability todrive healthcare standards because of the poor condition of the infrastructure inthe vast majority of the country.Of the around 25,000 hospitals in India in 2010, roughly two-thirds were public.

After years of under-funding, most public health facilities provide only


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basic care. With a few exceptions, such as the All India Institute of MedicalStudies (AIIMS), public health facilities are inefficient, inadequately managedand staffed, and have poorly maintained medical equipment.The number of public health facilities also is inadequate. For instance,India needs 74,150 community health centers per million population but has less

than half that number. In addition, at least 11 Indian states do not havelaboratories for testing drugs, and more than half of existing laboratories are notproperly equipped or staffed.The principal responsibility for public health funding lies with the stategovernments, which provide about 80% of public funding. The federalgovernment contributes another 15%, mostly through national health programs.However, the total healthcare financing by the public sector is dwarfedby private sector spending. In 2003, fee-charging private companiesaccounted for 82% of Indias $30.5 billion expenditure on healthcare. This is anextremely high proportion by international standards.Private firms are now

thought to provide about 60% of all outpatient care in India and as much as 40%of all in-patient care.

HEALTHCARE INFRASTRUCTURE EXPANSION

An enormous amount of private capital will be required in the comingyears to enhance and expand Indias healthcare infrastructure to meet the needsof a growing population and an influx of medical tourists. Currently India hasapproximately 860 beds per million population. This is only one-fifth of the worldaverage, which is 3,960, according to the World Health Organization. It is

estimated that 450,000 additional hospital beds will be required by 2015aninvestment estimated at $25.7 billion. The government is expected to contributeonly 15-20% of the total, providing an enormous opportunity for private playersto fill the gap.

CONCLUSION

The Indian healthcare sector can be viewed as a glass half empty or aglass half full. The challenges the sector faces are substantial, from theneed to improve physical infrastructure to the necessity of providinghealth insurance and ensuring the availability of trained medical

personnel. But the opportunities are equally compelling, from developing newinfrastructure and providing medical equipment to delivering telemedicinesolutions and conducting cost-effective clinical trials. For companies that viewthe Indian healthcare sector as a glass half full, the potential is enormous.


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Porters five forces analysis:Porter's five forces analysis is a framework for industry analysis and businessstrategy development formed by Michael E. Porter ofHarvard Business School in

1979. It draws upon industrial organization (IO) economics to derive five forces

that determine the competitive intensity and therefore attractiveness of a

market. Attractiveness in this context refers to the overall industry profitability.

An "unattractive" industry is one in which the combination of these five forces

acts to drive down overall profitability. A very unattractive industry would be

one approaching "pure competition", in which available profits for all firms are

driven to normal profit.

Three of Porter's five forces refer to competition from external sources. Theremainder are internal threats.Porter referred to these forces as the micro environment, to contrast it with the

more general term macro environment. They consist of those forces close to a

company that affect its ability to serve its customers and make a profit. A change

in any of the forces normally requires a business unit to re-assess the

marketplace given the overall change in industry information. The overall

industry attractiveness does not imply that every firm in the industry will return

the same profitability. Firms are able to apply their core competencies, business

model or network to achieve a profit above the industry average. A clear example

of this is the airline industry. As an industry, profitability is low and yet

individual companies, by applying unique business models, have been able to

make a return in excess of the industry average.

Porter's five forces include - three forces from 'horizontal' competition: threat of

substitute products, the threat of established rivals, and the threat of new

entrants; and two forces from 'vertical' competition: the bargaining power of

suppliers and the bargaining power of customers.

Five forces in our Company:-

1. Threat of new competitionProfitable markets that yield high returns will attract new firms. This results in

many new entrants, which eventually will decrease profitability for all firms in

the industry. Unless the entry of new firms can be blocked by incumbents, theabnormal profit rate will tend towards zero (perfect competition).
http://en.wikipedia.org/wiki/Michael_Porterhttp://en.wikipedia.org/wiki/Harvard_Business_Schoolhttp://en.wikipedia.org/wiki/Industrial_organizationhttp://en.wikipedia.org/wiki/Markethttp://en.wikipedia.org/wiki/Profit_(economics)#Normal_profithttp://en.wikipedia.org/wiki/Marketing#Marketing_environmenthttp://en.wikipedia.org/wiki/Environmental_scanninghttp://en.wikipedia.org/wiki/Companyhttp://en.wikipedia.org/wiki/Profit_(economics)http://en.wikipedia.org/wiki/Marketplacehttp://en.wikipedia.org/wiki/Industry_informationhttp://en.wikipedia.org/wiki/Firmhttp://en.wikipedia.org/wiki/Core_competencieshttp://en.wikipedia.org/wiki/Business_modelhttp://en.wikipedia.org/wiki/Business_modelhttp://en.wikipedia.org/wiki/Industryhttp://en.wikipedia.org/wiki/Bargaining_powerhttp://en.wikipedia.org/wiki/Incumbentshttp://en.wikipedia.org/wiki/Perfect_competitionhttp://en.wikipedia.org/wiki/Perfect_competitionhttp://en.wikipedia.org/wiki/Incumbentshttp://en.wikipedia.org/wiki/Bargaining_powerhttp://en.wikipedia.org/wiki/Industryhttp://en.wikipedia.org/wiki/Business_modelhttp://en.wikipedia.org/wiki/Business_modelhttp://en.wikipedia.org/wiki/Core_competencieshttp://en.wikipedia.org/wiki/Firmhttp://en.wikipedia.org/wiki/Industry_informationhttp://en.wikipedia.org/wiki/Marketplacehttp://en.wikipedia.org/wiki/Profit_(economics)http://en.wikipedia.org/wiki/Companyhttp://en.wikipedia.org/wiki/Environmental_scanninghttp://en.wikipedia.org/wiki/Marketing#Marketing_environmenthttp://en.wikipedia.org/wiki/Profit_(economics)#Normal_profithttp://en.wikipedia.org/wiki/Markethttp://en.wikipedia.org/wiki/Industrial_organizationhttp://en.wikipedia.org/wiki/Harvard_Business_Schoolhttp://en.wikipedia.org/wiki/Michael_Porter


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The existence ofbarriers to entry (patents, rights, etc.): The ambulance industry

is highly regulated and require several state permits. Health is a state subject

and is subject to many regulations.The industry requires knowledge of internal

processes and knowledge of the practices in the industry,therefore,the entry

barriers are quite high.The exit barriers are low because ambulances can be soldoff as vehicles to recover a part of the cost anytime and investors can make an

exit.

Brand equity: The brand equity of the hospital being served by us automatically

gets attached to our company resulting in high brand equity for our ambulance

company.

Capital requirements: Capital requirements are only for the vehicles being

purchased and the retrofitting being done to convert them into ambulances.

There are no other capital requirements in the start-up.

Absolute cost: The absolute cost is low; comprises of operating cost in terms of

fuel, maintenance and salaries whereas capital cost is mainly through the bank

debt.

Industry profitability; the more profitable the industry the more attractive it will

be to new competitors: Industry profitability is high, but even as the profitability

is high, due to high entry barriers, it requires deep knowledge of the industry to

make an entry.

2. Threat of substitute products or servicesThe existence of substitute products increases the propensity of customers to

switch to alternatives. The buyer propensity to substitute is low. The relative

price performance would be of low consideration to the patient in an emergency

situation. The switching costs would be high because customer would be

changing his preferred hospital which can escalate his costs.The perceived level

of product differentiation is low and the number of substitutes available are

high.

3. Bargaining power of customers (buyers)The bargaining power of customers is also described as the market of outputs:

the ability of customers to put the firm under pressure, which also affects the

customer's sensitivity to price changes. The customers sensitivity to the price

changes is very low because the health market is seldom affected by price

changes. The ambulances can be run for the hospitals in the initial years at a low

return but eventually can be turned into a full fledged ambulance care provider

of its own due to the experience gained in the field. The customers have high
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bargaining power in the initial years, but that risk has been mitigated by signing

long term offtake contracts.

4.Bargaining power of suppliersThe bargaining power of suppliers is also described as the market of inputs.Suppliers of raw materials, components, labor, and services (such as expertise) to

the firm can be a source of power over the firm, when there are few substitutes.

Suppliers may refuse to work with the firm, or, e.g., charge excessively high

prices for unique resources.

Suppliers have low bargaining power because a number of companies are

producing ambulance vehicles and also retrofitting them. The fuel prices are

controlled by the government,but also their hike has been taken into account for

the next years in the agreement signed.The degree of differentiation of inputs islow.The impact of crucial inputs such as fuel prices has already been taken into

account.The drivers are being paid the current market price and thus no problem

is seen in their services.The employee solidarity is high which can be lowered

through giving ample chances to the employees to grow in the organization.The

suppliers have been competitors for the past many years and they are unlikely to

form a cartel so as to cut out a buyer.

5.Intensity of competitive rivalryFor most industries, the intensity of competitive rivalry is the major determinantof the competitiveness of the industry.The industry has ample growth

opportunities today due to low presence of healthcare providers in India.The

competitive advantage can be made through making use of high technology and

usage of innovative supply chain practices incorporated in the company.The

company has a flexible strategy to scale up in the future years through newer

contracts or even going for acquistions of established companies.
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MANAGEMENT

TEAM


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Management Team:

1. Himanshu Kumawat: Promoter Director, has experience of handling ambulance services

in a large private hospital in Pune for the past 14 years. As the manager of emergency

services, Inamdaar Hospital,Pune has handled several pressure situations and responded

effectively to them. He knows the procedures, processes and the various rules and regulationsof the industry. He holds B.Com degree from Gujarat University and a diploma in health care

management from Pune University. He also holds LLB from Pune University.

2. Badal Nirwan: Promoter Director, holds MBA in Hospital Adminstration from MIMS,

Chennai. He has extensive interests in the healthcare industry. He is currently working with

Sasoon Hospital,Pune as in capacity of Head, Administration Deptt for the past 3 yrs.Holds

total experience of 17 yrs in healthcare industry.

3. Saurabh Arora: Business Operations Manager, 7 yrs experience in a large ambulance

company based out of Kolkata. Holds MBA in marketing from IISBWM,Kolkata. Holds

equity in the company to the tune of 20 %.

4. Tanuj Kandpal: Product Lead Manager, IT & Supply Chain Management, Holds 5 yrs

extensive experience in various verticals across different industries in the domain of supply

chain management. He holds MCA from Delhi University and PGP-SCM from SCDL,Pune.

5. Dr.Kritika Pal: Equity Promoter Director, holds 10 % equity,practicing Cardiologist in

Inaamdar Hospital, Pune. She holds extensive experience of 8 yrs in healthcare industry.

6. Dr.Shreya Chatterjee : Equity Promoter Director,holds 10 % equity,practicing general

physician, Sasoon Hospital, Pune. She holds extensive experience of 6 yrs practicing

medicine in Pune.

Resourcefulness of the management team: The management team comprises of seasoned

professionals of the healthcare industry having immense knowledge of the inside out of the

industry.The management team has good financial resources for the capital investment in the

initial years and to also take the exposure. The management team can easily reinvest the

profits generated back into the company and also reinvest in case of losses in the initial years.

Vision of the management:

The City of Pune needs a secure and safe Ambulance service at a reasonable cost to the

patients delivering quality healthcare and fast service.

Mission of the management:

To save lives, reduce suffering and enhance quality of life, through accessible and responsive

quality patient care and transport.

Our Target: Reach patient site within 15-20 minutes and shift patients to the contracted ornearest hospital.


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Analysis of the organization through Mckinseys 7S model:-

1. Strategy: Quickly scaling up in the next 3 years on getting hospitals contracts as fast aspossible. Strength of the organization lies in its management team having extensive

experience in the healthcare industry across all domains ranging from first point of contact to

the medical expertise providers. As there are negligible unified ambulance services in India,the industry is expected to grow at a very fast rate initially in the coming years. The

opportunities lie in the very fact that the country is under equipped in the area of the health

care industry and it is the immense demand that will drive the growth in this segment. The

threat is of the similar services being started in the competition but as the management team

is comprised of healthcare specialists, this risk is mitigated. The contracts are expected to

come easily due to the promoters network in the domain and the sheer demand of the

ambulance services in the city. The long term strategy is to move out from the city of Pune to

the other parts of the Maharashtra namely Satara, Kolhapur, Jalgaon etc(namely tier-II cities

comprising population greater than 10,00,000 and inadequate health infrastructure).The long

term strategy also encompasses running mobile hospitals in tier-III cities and rural areas.

2. Structure of the organization:-

Himanshu Kumawat,CEO

Badal Nirwan,

AVP,Marketing and

Customer Satisfaction

Tanuj Kandpal,ProductLead Manager,IT & supply

chian management

Ms.Bhanupriya,Secretary

Saurabh Arora,

Business OperationsManager

Ms.Kanupriya,Secretary to the CEO

Mr.Prem Kumar,Office Executive

Ms.Sonali,Customer Care Executive


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3. Systems:Systems are routine processes and procedures followed within an organisationto implement the strategy and to run day-to-day affairs. These processes are mainly designed

to achieve maximum effectiveness. Traditionally, the higher management makes the most

decisions. Increasingly, the organisation are using innovation and new technology to make

decision-making processes quicker. Ours is a leaner organization following flat structures.

The decision making is quick and prompt. The faster the decisions taken at the spot, thehigher is the probability that they can be wrong. So, accordingly the BDM can take decisions

concerning business growth at his own judgment and later take CEO in confidence in the

vertical assigned to him. The marketing vice president can take routine marketing decisions

without any delay if the budget is in within the limits assigned to him by the CEO, and supply

chain manager has to ensure that the business doesnt suffer due to lower inventory levels or

delay in ambulance delivery dates to the clients.

4.Staff: As the organization is a start-up the key employees are the promoter directors of

the company and are highly competent professionals of the healthcare industry and are highlymotivated and keen to see that this project works well.

As for the driving staff, the drivers of the ambulance will be trained through an agreement

signed by us with the Motor Learners Institute through a module specially designed by them

for ambulance drivers. The focus is on hiring good quality local drivers with knowledge of

local roads and ways. The selection criteria is a pass in Xth class and 6/6 both eyes and good

physical and mental condition. The drivers have a good opportunity to grow with the

organization. The drivers are entitled for their own vehicle loan after 5 years of continuous

service and also to hold common equity in the company so as to have a high retention ratio

with our company.

As the company will grow in the coming years we will require huge supply of trained good

quality drivers

5.Skills: Management team has adequate skills to start this project due to previous industryexposure.The team comprises of 2 MBAs, and an healthcare experience of more than fifty

years combined in the healthcare industry comprising of ambulance services specialists to the

medical practitioners.

6. Style: - Open management style, focus more on team work. Lateral organization.

7. Shared Values: Common Equity participation and the experience of the healthcareindustry helps the team have shared beliefs and expectations from this service. The team is

highly motivated and keen to see the success of this project.


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Mckinsey 7S framework for Ambulance Company

The whole of the 7S creates synergy for our organization to help it achieve excellence and

grow in the field. We can also add 8S that is surroundings, whose contribution we have taken

into account on the fact that ambulance lease providers are niche service providers and we

can establish ourselves easily due to prior industry knowledge and the contacts in the

industry.This 7S model for the our company differs from the regular 7S models,instead of

keeping Shared Values in the middle,we have kept synergy in the middle because Shared

Values are boundary conditions,if we have shared values of the management intact then the

company can keep bay with the outside elements.The company creates synergy through the

interaction of all the elements with each other in an effective manner.


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LEGAL AND

TECHNICAL ASPECTS

FOR OPERATING

AMBULANCE SERVICE


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LEGAL ASPECTS TO BE CONSIDERED WHILE

OPERATING AN AMBULANCE SERVICE:

Introduction:Over the past 20 years, the field of prehospital medicine has undergone

impressive growth. As the body of knowledge continues to grow, as more

technology is introduced, and as research defines and refines the uniqueness of

prehospital medical care, the challenges of the prehospital setting are becoming

more than operational and medical. Efficient response, appropriate care, and

safe, expeditious transport are the expectant fundamental components of

prehospital care. However, more and more prehospital providers are facingchallenging ethical dilemmas.

There are three fundamental ethical premises that guide prehospital medical

care. The principle of justice implies that the system be fair and equitable. The

principle of beneficence requires that actions and intentions are in the best

interest of the patient. Respect for patient autonomy dictates that the requests of

the patient are honored and nothing is done which is contrary to the wishes of

the patient.

The Relationship Between Ethics And Law:Ambulance services must look to the law for guidance when developing methodsto honor advance directives to limit resuscitation or to implement policyregarding involuntary transport of serious patients. However, legal guidancedoes not provide the answer to every difficulty that may arise. There are manysituations in the prehospital setting that have not been addressed by statute orcase law. In addition, statutes may vary substantially between states. Ethicaltheory should set a universally applicable standard. Also, the law may beambiguous, so no clear guidance is offered, or it might be very specific, applyingonly to cases with substantially similar circumstances. The law also does notaddress the breadth of ethical imperatives which obligate ambulance services.Finally, the law may not reflect ethical behavior. For example, case law hasstated that a person who knows how to swim has no legal obligation to rescue adrowning child. While the law is limited in its ability to provide universalguidance and direction, ethical analysis should provide a frame work fordetermining moral duty, obligation and conduct.Similarly, ethical analysis does not substitute for appropriate legal guidance.

When dealing with dilemmas, when initiating policy and protocols, or whenupdating existing procedures, informed legal advice is mandatory.


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The Ambulance services` Ethical Obligation:When an ambulance service system holds itself out to the community as an

emergency response network, it is assuming an important ethical obligation. Ithas the duty to respond regardless of the patient's income or social position. Caremust not be limited unfairly to any specific group or class of people. Financialconcerns do dictate the resources available, and often set the community level ofprehospital care. Financial limitations do not necessarily present an ethicaldilemma. The duty of the system is to uphold those standards that it sets foritself; whether the services are basic or advanced, they must be medicallyacceptable.

Ambulance services often set priorities of care or classify certain calls as "non-emergencies." Patients with minimal illnesses may not be transported, or may

have transport delayed. This rationale or triage of care must be based only uponmedical indication and well-defined protocols. These efforts are appropriatebecause they allow the system to be fluid and accessible to critically ill or injuredpatients. These allocation decisions must not be arbitrary, and must not penalizeany group unfairly. When planned appropriately, Ambulance services might beregarded as one of the most fair of health care institutions. Ambulance servicepolicies must remain equitable and just.

Informed Consent:Patients will express preferences and voice demands regarding interventions and

hospital destination. They will refuse care, refuse elements of care, prefertransport without interventions, or prefer interventions without transport.Theprovider must be trained to deal with these difficult circumstances, whilerespecting both the patient's autonomy and the obligation of beneficence.

The prehospital care provider operates, as does the paramedic, only at therequest and with the consent of the patient. This is complicated particularly inthe prehospital setting when the patient may not have been the one to call forassistance, but is confronted with providers who are eager to intervene.

Prehospital care practitioners must respect patient autonomy. Nothing can bedone to a patient without the patient's consent, whether this consent is explicitor implied. Prehospital care providers comfortably operate under implied consentwhen patients request and cooperate in the care. The emergency rule, or consentapplied by law, presumes that consent is offered if the patient is unable toexpress it because of illness or injury. In these cases, treatment must proceedwhen prompt intervention is necessary to prevent loss of life or disability. Trueinformed consent requires that


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the patient participate in the decision-making with a full understanding of therisks and benefits of treatment as well as the risks of lack of treatment. Theideal of informed consent is difficult to achieve in the typical prehospital setting.Nevertheless, in the routine of prehospital emergency medicine, whenappropriate care is provided in the best interests of the patient without patient

objection, no ethical dilemma is present.A dilemma may arise when a patient refuses to consent to care. The competentpatient's wishes must be honored: it only is with the patient's permission thatcare is rendered. However, patients in acute medical crisis might lack the abilityto make reasoned judgments regarding their care. Withholding care based on apatient's impulsive refusal would not serve the patient's interests. Patients withintracranial injury, drug or alcohol intoxication, metabolic derangements, ormental illness might offer unreasoned refusals of care. Conversely, patients withdementia, mental retardation, or drug or alcohol intoxication may offer valid,autonomous decisions (i.e., a decision made with an appropriate understanding

of the facts, risks, and benefits that are consistent with their personal values).Sometimes, it is difficult to know when a prehospital patient's refusal representsan informed decision. A patient may refuse care despite a serious illness. In thiscircumstance, if the patient was declared by law to be temporarily incompetentto make such decisions, care could be instituted. However, such decisions requirea judicial determination. Only the rare ambulance service system can obtainrapid judicial determinations of competence.

Most ambulance services are challenged to determine which patient refusals areacceptable, At a minimum, a patient must demonstrate an understanding of hisor her illness, recognition of the risks of refusing care, be able to manipulate theinformation rationally, and freely and voluntarily refuse intervention. Furtherintervention should be carried out on any patient who cannot meet these criteria.In daily operations, the provider is confronted with the reluctant patient, theagitated patient, the impulsive, the incoherent patient, or the intoxicated patientwho refuses transport to an emergency department.

CIVIL LIABILITY ACTIONS:Because patients may be entitled to monetary compensation for injuries causedby careless acts of ambulance service providers, aparamedic may become a defendant in a civil suit. Two terms must bedefined with regards to this type of action

STANDARD OF CARE

The standard of care is the basis for evaluating a claim of negligence.The standard of care is determined by what a reasonable, prudent ambulanceservice provider of similar training, skills, and experience would do in likecircumstances.


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MALPRACTICE

Malpractice usually refers to negligent conduct by a professional in theperformance of duty. To win a case alleging malpractice, the patient must proveeach of the following four elements by a preponderance (more than 50%) of the

evidence:

1. The defendant had a duty to act according to the standard ofCare.2. A breach of that duty occurred;3. The breach of duty caused the injury; and4. The patients injury can be assessed monetarily.

Another common basis for civil cases against ambulance service providers isabandonment which is the unilateral termination of a provider/patient

relationship when the patient still needs care, but provision is not made for thatcare and an injury results. Refusal to transport a patient or talking a patient outof being transported to a hospital is an invitation for an abandonment claim.

LIABILITY PROTECTION:LIABILITY INSURANCELiability insurance is not a means to avoid liability itself. Rather, itprovides payment for legal representation and damage awards enteredagainst the policy holder. Because the provision of ambulance service is unique

and considered a specialized aspect of medical care, paramedics may considerseeking malpractice coverage with an insurance companyfamiliar with ambulance service procedures.

RISK MANAGEMENTThere are various ways that ambulance service providers can reduce theirexposure to lawsuits. First, ambulance service providers must pay strictattention to patient run report documentation. A properly documented runreport can diffuse potential lawsuits. In addition, preparation and preventionmay provide some liability protection.

Training records must be up to date and skills must meet, at a minimum,current guidelines and practices in the industry.

GUIDELINES FOR NON EMERGENCY AMBULANCE SERVICE:Definition:A Non-Emergency Ambulance Service is one that provides ambulances forferrying non-emergency patients e.g.-a. Patients requesting for ambulance for regular outpatient clinic attendance.

b. Patients requesting for ambulance for transport to hospital with medicalproblems.


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c. Inter-hospital transfers of non-critically ill patients.

d. Patients discharged from hospital to home.

In spite of the above, it must be remembered that such non-emergency patientsmay occasionally develop acute emergency problems while en-route in theambulance.

Non-Emergency Ambulance Agency:The Agency that intends to provide the service must be a company or abusiness entity registered with the Registry of Companies & Businesses or abona fide registered voluntary or charitable organisation.

The Agency must have the following:

a. A qualified person (either a doctor or a paramedic) employed by the Agencywho sets protocols of care for patients transported and organises training andsupervision for medical care provided by ambulance crew. Voluntaryorganisations must also provide for a qualified person to supervise the service.

b. A programme for training and monitoring performance levels of ambulancecrew and records of such performance monitoring.

c. Acceptable scales of ambulance equipment and ambulance medicalsupplies.d. A system for activation of the ambulances of the Agency.

Non-Emergency Ambulance Crew:A) Each Non-Emergency Ambulance should be staffed by at least a two membercrew, one of whom is a driver, and the other the Ambulance Officer who may beeither a Registered Nurse or trained Paramedic.

B) The Driver should have the following minimum qualifications/ experience:-

a). Possess a valid licence to drive the ambulance.

b). Understand the usage of ambulance stretchers.

c). Undergone training in Standard First Aid.

d). Trained in defensive driving and be well aware of the use ofsirens and flashing lights for conveying emergency patients to hospital.

C) The Ambulance Officer should be able to :-

a). Measure vital signs eg pulse rate, respiratory rate, blood pressure.


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b). Perform Basic Cardiac Life Support (BCLS) and be currently certified inBCLS.

c). Use airway adjuncts such as oropharyngeal airway, nasopharyngeal airway,suction devices and basic oxygen delivery devices such as bag valve mask.

d). Use various types of stretchers and body immobilisation devices.

e). Perform basic emergency procedures such as:-i). Control of external bleeding

ii). Application of dressings, bandages, slings and splints.

f). Monitor peripheral lines of stable patients.

g). Transfer and maintain patients with nasogastric tubes and urinary catheters.

h). Establish contact with a receiving hospital if the need arises.

.

Various State Clearances:-The various state clearances will be taken by the hospital. We will supply all theother clearances required with the vehicle such as pollution certificate, insurance

certificate, maintenance certificate, and driver credentials. The majority of theclearances required would be borne by hospital and we would reimburse themthe cost associated with it.

TECHNICAL ASPECTS TO BE CONSIDERED WHILE

OPERATING AN AMBULANCE SERVICE:

NON-EMERGENCY AMBULANCE SERVICE: AMBULANCE EQUIPMENTAND MEDICAL SUPPLIESA) VEHICLE EQUIPMENT1. Siren and Wail Sound Horn or Two-Tone Horn.2. Red Beacon Light.3. Fire Extinguisher.4. Street Directory.5. Bench Seat and Safety Belts.6. Water Tank and Sink.7. Frosted or Tinted Side and Rear Window Glass (excluding the front sidewindows).

8. Radio Network Communication or Mobile Phone or other Ambulance-HospitalCommunication Equipment


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9. Adequate rear (including roof mounted) warning lights

B) MEDICAL EQUIPMENT1. Main Stretcher with Mattress, Firm Base and Patient Restraints.2. First Aid Box (standard)/Ambulance Bag.

3. Blanket.4. Trolley Sheet.5. Pillow.6. Hand Carried Stretcher.7. Wheel Chair with Restrainers.8. Receiver for Vomits (kidney dish).9. Bed Pan.10. Urinal.11. Pocket Mask with One-Way Valve (for CPR).12. Bag-valve Mask.

13. Vital Signs Equipment eg Blood Pressure Set and Thermometer.14. Stethoscope.15. Hand Torch.16. Portable oxygen including Spare Cylinder.17. Tubing and Mask for Oxygen.18. Portable Suction Unit.19. Detachable Drip Stand for use with Stretcher.

CONCLUSION:Above studies have been done with the best of our efforts and we hope that the

project would reap benefits.


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REFERENCES

1)EMRI ambulance services websitewww.emri.com

2)

Apollo Hospitals Annual Report 20123)Andhra Pradesh Govt Website

4)Google Maps www.maps.google.com

5)ZVH Ambulance suppliers, New Delhi Quotations

6)SAI ambulances Pune

7)

Inamdaar Hospital Pune8)Ministry of Healthcare,India,website
http://www.emri.com/http://www.emri.com/http://www.emri.com/http://www.emri.com/

Documents

Final Ambulance