hospital administration, BMS,HR and TQI from dR JOY ,TISS

MHA,IIIrd Semester : internship :at Dr L.H.Hiranandani Hospital, Powai, Mumbai.

project report 1: Dr Joy K Banerjee, [2008HO017], MHA, TISS

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Project 1 :

Aim : to do a case study of the BMS (Building Management System) in the Dr LH Hiranandani

Hospital powai.

Objective :

1. What is BMS?

2. The services it provides to the hospital and its interlinking

3. The human resource associated with it ?

4. The administrative and management inter linking for optimum utilization and cost saving and

minimizing critical times.

Methodology:

1. To observe their day to day activities.

2. To accompany them to their complaint areas.

3. To understand the work organization

4. To follow the reaction time to a complaint received.

5. By personal interviews with the shift engineers and the technicians.

Data collection :

The data collection was done in the following manner.

Real time reaction to the complaints received.

Accompanying the staff/technician during his shift hours.

Registered maintained in the department and the quality and quantity of the content filled.

Observing the routine interaction between the technicians and the shift engineer and the

facility manager.

Information shared during shift of the duties amongst the technicians

Studying and making the flow chart of the various systems which fall under the BMS.

Analysis :

The data collected through out the study was a mix of quantitative and qualitative in nature. It

was a difficult task to segregate technical data from the process I was trying to study. The

entire engineering department had been of great help during my study and co operated with

my own limitation of technical knowledge of the engineering system.

The data have been analysed and are put forward in the study.

Introduction :

BMS (Building Management System)

A Building Management System (BMS) is a computer-based control system installed in buildings

that controls and monitors the building’s mechanical and electrical equipment such as ventilation,

lighting, power systems, fire systems, and security systems. A BMS consists of software and

hardware; the software program, usually configured in a hierarchical manner. A BMS is most

common in a large building. Its core function is to manage the environment within the building and

http://en.wikipedia.org/wiki/Computer

http://en.wikipedia.org/wiki/Ventilation

http://en.wikipedia.org/wiki/Lighting

http://en.wikipedia.org/wiki/Power_systems

http://en.wikipedia.org/wiki/Security_system



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may control temperature, carbon dioxide levels and humidity within a building. As a core function in

most BMS systems, it controls heating and cooling, manages the systems that distribute this air

throughout the building (for example by operating fans or opening/closing dampers), and then locally

controls the mixture of heating and cooling to achieve the desired room temperature. A secondary

function sometimes is to monitor the level of human-generated CO2, mixing in outside air with waste

air to increase the amount of oxygen while also minimising heat/cooling losses.

BMSs are usually delivered as fully integrated systems and services through companies such as

Siemens, Honeywell, Johnson Controls, Trend Controls, TAC and others. It is a network of software

and hardware controlling the electrical and electronic points which in turn controls the main machines

for specific operation. Thus it acts as a one point node of control and monitoring various factors

essential for the smooth functioning and safety of a building.

BMS in Dr L H Hiranandani Hospital.

The BMS in the Dr L H Hiranandani Hospital is outsourced and is maintained by iFLCM(integrated

facility life cycle management). The BMS in the Dr L H Hiranandani Hospital maintains and controls

the following functions. That is to say the BMS has the following departments under it for

maintenance and control.

Fire fighting – fire hydrant points + sprinklers + smoke alarms

Electricity -

HVAC – chillers + AHUs + FCUs + Exhausts + Fresh Air Blowers

Plumbing

The compliant register is also a part of the responsibilities of the outsourced BMS and it serves two

important purposes. First it takes all the compliant as a record to assess the performance of the BMS,

secondly these complaints registration helps in analysis and identify the problem areas and correct

them. The registration of the complains happens under the following sub headings.

1. Date

2. Time in of compliant

3. Time out of compliant 4. Compliant number.

5. Floor from where compliant came.

6. Department 7. Compliant notifier

8. Compliant receiver.

9. remark

10. Close date engineer sign

11. Extension no. of the department

12. Nature of the compliant.

13. Action taken 14. Compliant attendee

Analysis of the data :

1. The BMS monitoring system of the hospital in BMS :

An operator well versed with the BMS has to monitor the readings that are received ,

recorded and displayed on the BMS system computer.

The computer is attached to the server which in turn is attached to the 3 parallel lines

of connection servers which monitors each and every machine related to A/C.

http://en.wikipedia.org/wiki/Carbon_dioxide

http://en.wikipedia.org/wiki/Oxygen

http://en.wikipedia.org/wiki/Siemens

http://en.wikipedia.org/wiki/Honeywell

http://en.wikipedia.org/wiki/Johnson_Controls

http://en.wikipedia.org/wiki/Trend_Controls

http://en.wikipedia.org/wiki/TAC



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The hospital BMS system is connected to all the main equipments of the following

systems but only the functional controls are given to the AIR CONDITIONING

system and the water tank valve system. The remaining systems are for the purpose

of display only. The other system connected to the BMS but are manually controlled

from their respective sites are

o Fire fighting system

o Plumbing motor system

o Biomedical gas system

o Electrical reception and distribution system

o Public Announcement System.

2. The compliant monitoring system :

The compliant system in place is efficient and the entire procedure is documented for

every time of compliant.

On an average the 60 - 70 complaints are received.

The average response time is 05-15 minutes, depending on the nature of the

compliant.

The complaints are of mixed in nature.

Maximum complaints are to be attended by the electrical department followed by the

A/C department and then plumbing and carpentry team respectively.

The maximum compliant comes during the start of the week i.e. Monday and

Tuesday.

The maximum number of complaints is observed to come from the 3rd

-4th

and 5th

floors.

3. The BMS Compliant And Recording System :

The BMS completely controls and monitors the A/C system of the hospital..

The timely regular charts are maintained for all the six OTs 2 hourly for temperature

and humidity.

The department also controls the chilling and the humidity of all the areas supplied

with A/c from the control monitor.

The readings of the Cath lab are noted manually also by going to the department each

morning. This policy is in place after the SPECIFIC CATH LAB instruments

sensitive to temperature and humidity failed early this year.

4. Electrical preventive maintenance schedule :

1. The electrical department has AMC Contract details of all the equipments and the same is

printed in a large sheet and put on display in the department for a year round maintenance

check.

2. Preventive maintenance schedule for medical gas pipe line system is scheduled for monthly

check floor wise.

3. Reverse osmosis plant is installed to provide specialized treated filtered water to the artificial

dialysis department. The Preventive maintenance schedule for this is monthly once.

4. Mock drill schedule – once in 6 months



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sl. No. activity subject planned date completed

date

next due

date

1. fire mock drill 13.03.09 25.03.09 13.03.09

2. non fire emergency

Otis elevator

10.01.09

17.01.09

10.10.09

3. non fire

emergency

flooding

14.12.08

05.01.09

14.06.09

5. Engineering training schedule of the 2009 year.

training subject trainer times a month/ year

a) Communication skill shift engineer on duty once a month

b) HVAC System shift engineer on duty 5 times a month

c) Electrical system shift engineer on duty 5 times a month

d) Fire fighting system Senior engineer 5 times a month

e) MGPS system OUT SOURCED once a month

f) Elevator outsourced once a month

g) Water treatment plant shift engineer on duty 5 times a month

h) Diesel generator vendor once a month

i) UPS shift engineer on duty 5 times a month

j) HAZARDOUS system

and NABH awareness

senior engineer

once a month

6. Energy conservation methods in place for the hospital.

Bypass the chillers water to other systems AHU when a required level of cooling is

obtained.

Complete usage of the CFL lamps through out the hospital

VFD(variable frequency drive) : it’s a unique system in place which lowers the power

supply to the motor pumps once the motor pumps deliver the required pressure of

liquid or gas through out the hospital. This saves a lot of energy and also increases the

working life span of the motors.

Power factor : the hospital has in place POWER FACTOR machine manufactured by

the datar electricals . This electrical machine maintains the power supply to a

constant prevents fluctuation which is generated due to usage. This is beneficial in the

long run because TATA POWER the main power supplier to the hospital does not

have to spend money to provide un fluctuating power. Thus TATA POWER gives

huge incentive to the hospital over the main bill. The incentive given over the

electricity bill for the month of September is Rs 108381.!!!

7. Issues In regards to technicians :

Most technicians have been with hospital since its inception.

Though the maintenance / engineering department work is outsourced to IFCLM , the

company has hired the same employees which were with the hospital since its beginning but

were not the permanent employees to the hospital. These technicians were brought in by the

first maintenance vendor and after the term of contract got over with the hospital , these

technicians preferred to stay with the hospital than to go away with

In spite of a long service most of these technicians are at the mercy of the annual contract



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With IFCLM.

Its brought to the knowledge that these technicians can be of profuse use to the hospital if the

hospital hires them, especially those who have been with the hospital since its beginning as

they are extremely efficient and know the hospital in and out, and not leave them at the mercy

of a third party contractor.

It is always better to have few permanent technicians in hand especially during the shift of

maintenance contract form one to another.

Recommendations in general:

Siemens , the company which is the vendor for the BMS in the hospital should update the

engineering department about the timely updates and changes in place.

The AMC for the BMS is in place but the vendors are irregular to visit and superficial in

their maintenance work.

This has lead to the slight variations in the values displayed on the BMS monitor and the

actual values in place (minus the standard deviation of the values which is normally

accepted).

The other systems are merely connected to the BMS but cannot be operated from the central

monitor. This leads to the increase down time of the equipments and thus increases cost of

maintenance.

The only system well operated from the BMS control monitor is the A/C and 50% of the

plumbing system (the water tank valves). A step wise update of control should be brought

into get one point control over the remaining systems which are only displayed in the BMS

monitor but can’t be controlled.

The technicians are found working with bare minimum safety measures which can be

dangerous any time. The IFCLM should also be requested to bring safety gadgets for its

technicians so as to save lot of time and money in case of any eventualities.

The most alert system of all is the fire fighting system after the A/C Control system.

Limitation to study :

in order to submit a brief report , many of the data collected and analysed are not put in this

copy as compared to its importance. Yet they are incorporated in the project study submitted

to TISS.

The BMS was an entirely a new yet fascinating thing to study and therefore its possible to

have some limitation in my case study. CRITICISM to the report is warmly welcomed.

Summary :

BMS is a very crucial and critical for sustenance, maintenance and optimum utilization of

resources and power.

Its none less than the central nervous system to all the support system which a building

functioning as a critical health care unit will require.

Almost everything available as system is automatic these days which have their own built in

monitoring system… never the less the importance of a skilful human monitoring and control

can never be ruled out and the BMS thus also needs to well monitored and maintained.



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PROJECT 2:

Major Project : To study the welfare measures in place for the hospital employees and to evaluate

the motivation level of the team leaders in the hospital and the employee satisfaction of a small

sample.

Aim : to study the welfare scheme in place and the motivation level of the team leaders in the

hospital. also assessing the employee satisfaction level.

Objectives:

To study the approximate utilization of the welfare schemes in place by the hospital

management

To find out the motivation level of the team leaders.

To assess the employee satisfaction level.

Methodology :

Sample selection.

Direct interview of the HR department

Survey of the selected sample.

Data collection :

First hand report of the Details of the existing welfare schemes obtained from Mr Pinto, HR

dept.

Survey of the team leaders (20) for motivation level working at different capacities in the

hospital.

Random employee satisfaction survey (5).

Introduction.:

The welfare measures in the place for the hospital employees are as follows :

1. The hospital provides transport facility to the employees from the nearest vikroli railway

station to Dr L H Hiranandani hospital at a monthly charge of rupees 200/ month/employee.

2. Mediclaim policy : the hospital provides free admission to all the employees to an amount of

Rs------. This is even extended to their first family members i.e. spouse and two kids. The

OPD consultation is also provided which is free of cost to the employees.

3. 80% discount is given on medicines amounting to Rs 4000. This scheme varies with different

tier of employee. Rs 4000 being the minimum.

4. All employees are entitled to concession on medicines purchased from the hospital pharmacy,

but this benefit is restricted only to prescriptions issued by consultants empanelled with our

hospital.

5. All employees are entitled to free investigations, if done in our hospital. For this, the

employees are required to fill up the requisite concession forms available with the concerned

departments.

6. All employees are covered by group insurance scheme of MEDICLAIM.

7. Outside food is not allowed in the visitor’s cafeteria on the ground floor. The hospital has

provided the basement canteen for that purpose. The basement canteen serves tea/coffee,



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breakfast, lunch and dinner for the employees against coupons. Coupons may be purchased

from the back office situated on the ground floor. These coupons give 40% discount on the

actual bill amount. However, the tea/coffee coupons are given free of cost.

8. Outside visitors (family members/friends) are not allowed in the basement canteen.

9. Eating / drinking (anything other than water) are not allowed at the place of work.

10. Grievance Handling Mechanism

o This involves the process of natural justice.

o Both the parties are given equal opportunities to explain their course of action/deed,

based on which impartial judgment is passed by the management.

o The redress procedure addresses the grievance. (Example, in case of a salary cut based

on the number of days present in a month, as reflected in the attendance of an

employee, the employee has the right to file a grievance stating malfunctioning of the

punching machine. Following which he/she will be asked to submit the OD slip, duly

signed by the department co-coordinator).

o Actions are taken to redress the grievance. (Example in continuation of the above,

amount deducted from the salary is credited in the next month’s salary, on receipt of

the OD slip).

11. ANNUAL DAY IS ORGANISED on 22nd

February each year. The entire cultural program is

put up by the hospital staff.

12. Ports day is organised few days prior to the annual day.

13. Awards given are as follows.

a. Best employee award (monthly)

b. Best idea award – any idea given by the employee who helps in the improvement of

the quality and efficiency of the organization. This award is given once a year.

c. Chairman award :

i. For the most valued employee (once a year)

ii. Improvement employee – that employee who have shown remarkable

improvement in their performance, communication skill, personality,

knowledge of the hospital and organizational attitude.

14. Annual employee satisfaction survey.

Survey forms:

a. Motivation survey for the team leaders :

b. Employee satisfaction survey

I. Analysis of the motivation of the team leaders. :

The form was as follows:

This questionnaire on employee motivation focuses on the role of leaders in empowering employees and

improving motivation. Answer the questions honestly to score your motivational capability.

I arrive at the office on time and do not leave early.

I expect the same levels of accuracy in my own work as my employees’.

I do not blame others. I take responsibility for my part in mistakes.

I encourage a 'no blame' culture where staff is able to admit mistakes and learn from them.



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I do not keep secrets from my employees.

I do not encourage gossip or rumour.

I set high ethical standards for my behaviour towards employees and hold myself to those standards.

I ensure that staff has the training they require.

I participate in training to improve my own skills and competencies.

Employees have an active role in developing objectives for themselves, their team and the company as a whole.

I regularly check that objectives between different parts of the team or company are congruent. Everyone pulls together for the same end rather than competing for different results.

I have a clear system for handling employee discontent.

Employees are aware of the system for handling discontent and feel encouraged to use it to address problems.

Members of my team do not ask me simple questions. Significant matters are brought to my attention. But smaller challenges are considered and resolved by those responsible. I am not bothered by minor matters.

I do not build rapport with my team by sharing my weaknesses and fears. I am honest but professional.

Employees are encouraged to make mistakes.

Employees tell me when mistakes have been made, how they have been rectified and what the key learning’s are from such mistakes.

I have a coach or mentor who keeps me focused and motivated about my work.

I do not teach. Instead I lead, share, encourage and stimulate team members to grow, develop and learn.

I trust my staff.

Total score ……….

Data collection: out of the total 20 team leaders selected as per their availability only 13 could be

successfully approached to get the forms filled by them. They are as following:

a. Front office Sr executive : Mr Abhijit

b. Chief Sr engineer : Mr anil Dhamdere

c. Executive staff nurse ward manager ICU : Ms Ashmita

d. Executive staff nurse ward manager suite : Ms Elizabeth

e. Executive staff nurse ward manager OT : Ms Jolly

f. Executive staff nurse ward manager OPD : Ms vaishali

g. Blood bank officer : Dr lincy Jacob

h. Lab investigation Chief pathologist : Dr suvin

i. Executive staff male nurse : Mr Saiju Jacob.

j. CSSD manager : Mr ganesh devdiga

k. Pathology department asst manager : Mr Ravi Kabir

l. AGM materials : Ms Brenda.

m. Executive staff nurse ward manager Casuality : Sr kamalakshi.

n. Biomedical department : Ms pooja.

Each of the 20 points in the survey was put in place to identify a particular trait in motivation. These

points put were as following:

1. Punctuality

2. Accuracy with job at hand.



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3. Taking responsibility for one’s own mistakes.

4. Sharing of knowledge while working with a team.

5. Focus and concentration over the job in hand.

6. Moral ethics in work organization.

7. Regular training for improvement to keep juniors motivated

8. Self training to professional enhancement

9. Decentralization of authority to encourage the junior staff.

10. Foresight of the result and goal oriented approach

11. Impartial to all the team mrmbers

12. Encouraging fare play in the team

13. Approachable by the junior staff

14. Elasticity in team to cultivate positive attitude

15. Trust , confidence and motivation to the staff.

Out of the 20 statements the scoring was done as following

15-20 points – highly motivated and a great team leader. The team accomplishes the job on

time and with efficiency

10-14 points- the basics are there but the leader needs to upgrade on the existing skills.

5 – 9 points – there is a need to rise your standards. This is a boundary line between a leader

and a dictator.

0 – 4 points – complete lack of integrity. Not fir to be a leader.

The actual results of the survey :

All the 13 completely filled survey had an individual score between 11 to 18.

The majority i.e. 12 out of 13 scored above 12.

7 out of 13 scored between 16-18.

5 out of 13 scored between 13-15

1 out of 13 scored 12 points

Interpretation :

The hospital has highly motivated team leaders who lead their team and juniors with a goal

oriented approach.

More than 53.8% of the team leaders are skilful and efficient task masters. They are

functioning at their optimum and are acting force behind the hospital’s aggregate success.

The remaining 42.2% are team leaders who have proved their merit in one and more

occasions. There are some obstacles which can be external or internal preventing them from

on time achievement.

These leaders need to have sessions with the management to harness their skills.

Overall motivation level of the employees and the team leaders is good and this has been one

of the major factors in the continuous quality improvement and stupendous success of the

hospital.



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Recommendations :

Interactive sessions amongst the team leaders of various departments.

More quantitative study amongst and between the departments to surface the flaws and timely

correction.

Processes mapping of the inter dependency of the various department and identifying the

critical activities.

Real time study and operational mapping of the activity time both within the department and

the different departments put together.

The effort should be directed to realization that ―US is always stronger than ALL‖

Also evaluation of the flowchart which depicts the critical node of activates between the

departments and the collective efforts put together by the various department to achieve a pre

defined goal.

If the message is borne in mind that every singe activity no matter how simple it is , it has an

important role to pay in the overall performance of hospital, the team leaders will have self

motivated juniors and an ever ready team at their disposal to achieve the any given target.

Limitations :

Absence of in depth interviews with the team leaders.

Absence of critical study of any given processes or activity involving multi department co

ordination.

Absence of observation of interaction between the team leader and their team.

II. Analysis of the employee satisfaction survey :

The form was as follows :

Please take a few minutes to complete this survey. Your specific answers will be completely anonymous, but your views, in

combination with those of others, are extremely important. To insure your anonymity, Dr LHHH has the full and final authority. All

data entered will be completely for study purpose only and will remain confidential through out.

1. Overall, how satisfied are you with {Dr LHHH} as an employer? (Please circle one number)

Very Very

Dissatisfied Satisfied

1 2 3 4 5 6 7

How do you feel about each of the following specific matters?

2. Dr LHHH's communication and planning (Please circle one number for each statement)

Disagree Agree

Strongly Strongly

I understand the long-term strategy of Dr LHHH .................................................... 1................ 2 ................ 3 ................ 4 ................ 5

I have confidence in the leadership of Dr LHHH .................................................... 1................ 2 ................ 3 ................ 4 ................ 5



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3. Your role at Dr LHHH (Please circle one number for each statement)

Disagree Agree

Strongly Strongly

I am given enough authority to make decisions I need to make ................................. 1................ 2 ................ 3 ................ 4 ................ 5

I like the type of work that I do ............................................................................... 1................ 2 ................ 3 ................ 4 ................ 5

I believe my job is secure ........................................................................................ 1................ 2 ................ 3 ................ 4 ................ 5

4. Corporate culture (Please circle one number for each statement)

Disagree Agree

Strongly Strongly

Dr LHHH corporate communications

are frequent enough......................................................................................... 1................ 2 ................ 3 ................ 4 ................ 5

I feel I can trust what Dr LHHH tells me ........................................................ 1................ 2 ................ 3 ................ 4 ................ 5

I believe there is a spirit of cooperation at Dr LHHH ..................................... 1................ 2 ................ 3 ................ 4 ................ 5

5. Your relations with your immediate supervisor (Please circle one number for each statement)

Disagree Agree

Strongly Strongly

My supervisor treats me fairly ................................................................................. 1................ 2 ................ 3 ................ 4 ................ 5

My supervisor asks me for my input to help make decisions ........................... 1................ 2 ................ 3 ................ 4 ................ 5

6. Dr LHHH s training program (Please circle one number for each statement)

Disagree Agree

Strongly Strongly

{ Dr LHHH provided

as much initial training as I needed .................................................................. 1................ 2 ................ 3 ................ 4 ................ 5

7. Pay and Benefits (Please circle one number for each statement)

Disagree Agree

Strongly Strongly

My salary is fair for my responsibilities ................................................................... 1................ 2 ................ 3 ................ 4 ................ 5

Disagree Agree

Specifically, I'm satisfied with the: Strongly Strongly

Amount of vacation ................................................................................................ 1................ 2 ................ 3 ................ 4 ................ 5



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Are there any benefits you would like added to Dr LHHH benefits package?

Yes .... What would you like added? ____________________________________________________________

No .....

8. How long have you worked for Dr LHHH

Less than one year .............................................................

One year to less than two years ..........................................

Two years to less than five years ........................................

Five years to less than ten years .........................................

Ten years or more ..............................................................

Data collection :

10 employee satisfaction surveys as mentioned above were circulated amongst the employee on the

random selection basis. The identity of these samples has been kept hidden as per the policy of the

hospital. Nevertheless these people work in the following capacities in the hospital. they are :

a. Male staff nurse.

b. Front office executive

c. Female staff nurse.

d. IT department

e. Customer care executive

f. Pathologist

g. Sr staff nurse

h. Medical record department

i. Engineering department

j. Administrative executive.

The response of these people was satisfactory to the purpose of the study.

Out of the 8 questions in the survey each was put to identify a particular component in the satisfaction

of the employee and the role of the management to retain tis employees in a positive attitude. The

objective behind each of the question was as follows. :

1. Impression about the employer.

2. Identifying the mission of the organization

3. Freedom at work and authority in your work place

4. Work culture of the organization.

5. Professional relationship with seniors and colleagues..

6. Personal growth in professional terms.

7. Satisfaction with remuneration.

8. Stability of the employee with the organization.



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The result :

Each of the 8 survey questions were to be ranked between 1 to 5 representing disagrees

strongly to agree strongly. Thus the higher the marks given for an individual question, the

higher is the level of the satisfaction of the individual with the hospital.

The result is as follows.

question

1

question

2

question

3

question

4

question

5

question

6

question

7

question 8

employee 1

4

3

3

3

5

3

1

2

employee

2

3

2

3

4

5

3

2

3

employee

3

2

4

5

3

5

3

2

2

employee

4

4

4

2

3

3

4

4

3

employee

5

2

2

2

3

3

2

2

2

employee 6

3

2

5

4

4

4

4

4

employee 7

3

2

3

1

5

4

3

3

employee

8

4

2

3

2

4

4

3

3

employee

9

3

3

3

2

3

3

2

2

employee

10

2

3

4

2

4

4

2

2

Interpretation Of The Result :

Impression about the employer. : The 33% of employees in general are very satisfied with

the management as an employer. Remaining 66% are partially.

Identifying the mission of the organization: 50% of the employees partially able to

understand the long term strategy of the hospital. however the remaining 50% understand and

are able have confidence on the hospital’s strategy.

Freedom at work and authority in your work place: 50% of the employees think they have

limited authority to make decision , however 20% feel they get complete authority to take

decision in their own work sphere. Remaing 30 % are moderately satisfied.

Work culture, trust and communication : 40% of the employees think they partially trust

what the management asks them to do and believe moderately there is a spirit of cooperation

at the hospital. however the remaining 40% think they can completely trust the management

and strongly believe that is a spirit of cooperation at the hospital. the remaining 20% don’t

believe at all.

Professional relationship with seniors and colleagues : 70% of the staff thinks they are

treated fairly well by their superiors and that their inputs are respected whenever they give.



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The remaining 30% moderately believe this. However there is none who feels ill treated and

unheard.!

Professional growth and importance of training : 50% of the staff believes that all the

training they receive is as per their work requirement and are positive towards the training

sessions. 40% believe they can be still improved but are in favour of the training sessions.

Only 10% are found averse to training.

Remuneration offered: 60% of the staff feels they can be paid better for the work they do.

Only 20% of them feel they are adequately paid and 20% feel they are very underpaid.

Stability of the employee with the organization : 50% of the employees are satisfied with

their bonding with their hospital and would like t continue further. 30 % feel this is their

dream job. And 20% feel they may leave if they get a better salary package else where.

Recommendations :

The HR department needs to be more proactive in understanding the employee organization

relation.

The out sourced staffs is given adequate respect in the hospital and are not treated outsider,

but still there is a lot of scope of improvement in this regard as these men are spread and

involved in many important processes of the hospital.

The respect and work culture amongst the staff especially the grade IV employees can be

improved.

Strict disciplinary measures should in place to avoid misconduct but the negative incentive

should not be made public as it makes the guilty more revengeful.

The HR Department has lot of areas to improve the motivation and satisfaction of the

employees to the higher and positive side like communication, punctuality, understanding the

job, smart working and missionary zeal amongst the employees.

In a health care setup the human resource are the real assets to the organization and thus the

entire mechanism should be dynamic to not only keep them motivated but also make them

realise that their growth is also cared and respected with the growth of the organization.

The hospital industry is very different from other industry as the manufacturer, the producer,

the product and the final process all are but human beings. Thus a special attention should be

given to each level in order to attain optimum benefits.

Continuous quality improvement which is one of the mission of this hospital depends a lot on

the human resource of the hospital, as the smallest work done by each of these employees

towards the attainment of the quality adds value to the hospital efficiency.

Limitations of the study :

Small sample size compared to the total working employees.

Absence of in depth analysis of the questions.

The sample was not uniformly distributed from lowest to the higher working tier of the

hospital.

Absence of the in depth interview of the selected employee in order to evaluate what they

actually meant.

The study was not open end but pre defined, thus restricting the outcome to an extent.



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Project 3 :

A case study on The continuous quality management of the Dr L H Hiranandani Hospital,

Powai.

Introduction :

Dr L H Hiranandani Hospital, Powai management has the following mechanisms in place to

continuously maintain and upgrade the quality in all strata of the hospital. They are as following.

1. Internal audits :

Internal auditors are selected by the management.

Internal auditors are trained in the audit to check for the compliance towards the set

standards.

The frequency of internal auditing is once in 6 months ( the NABH and ISO standards is

once in 6 months)

The non compliance raised are shared with all the concerned stake holders to take

appropriate corrective action.

2. Weekly surprise rounds :

This is in place to ensure the continuos maintenance of the standards.

Any department is picked up after analysis on performance parameters and are checked

over.

This is headed by a chairperson appointed by the top management and has concerned

members as the stake holders.

It is also done to evaluate if the recommended corrective measures are brought in place

and are actively followed or not.

3. Weekly quality control meeting :

Chairperson appointed by the top management and all stake holders of the hospital are

its members.

It is co coordinated by the PR department of the hospital.

4. Patient feed back form.

Patient satisfaction is studied under the following :

o Food quality served

o Medications given on time

o Cleanliness and sanitation maintained.

o Nursing staff and other staff behaviour and responses

o Doctor’s attitude towards the patient

o Housekeeping



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o Communication and precise and prompt responses.

This is collected from the patient who come for consultation to OPD or get admitted.

This can be any activity or process which thus indicates to failure of the system.

The concerned areas are noted and brought to the notice of the various stake holders

involved.

Even the stake holders are allowed to inform on the non compliance.

Negative points revealed during the weekly quality meet is also seen in he light of the

concerned problem.

Measures are taken to rectify / improve / improvise / change the needful and reported to

the concerned stake holders.

5. Various other mandatory measures in place are as follows:

a. Engineering maintenance department

b. Bio medical engineering department

c. Hospital infection control

d. Medical audit

e. Mandatory base line test for all IPD patients.

f. ALOS Analysis

g. Safety rounds

h. Radiation precaution

i. Drug committee

a) Engineering maintenance department :

All complaints are lodged down in a systematic manner.

The downtime is calculated .

Immediate plan is chalked out incase the downtime for a particular area is recurrent.

b) Bio medical engineering department :

All complaints are lodged down in a systematic manner.

The downtime is calculated .

Immediate plan is chalked out incase the downtime for a particular area is recurrent.

c) Hospital infection control

Regular check for

o Ventilator associated pneumonia

o Urinary tract infection due to catheter trip



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o OT swabs collection from regular and random areas as per the set frequency.

For eg. From surgeon’s hand before operating, table edges, floor, AC vent

ducts.

Compulsory sanitization

NSI monitored.

Special prevention and protocol measures to deal wit sudden incidences like the

swine flu.

d) Medical audit :

To assess quality of care

Any telephonic treatment iven by the consultant, should receive a counter sign asap

from the concerned physician. This is to verify and authenticate the orders given in

the line of treatment.

Proper medico legal documentation.

Signature time

Antibiotic policy

e) Mandatory baseline test for all the IPD patients.

HCV

HIV-AIDS

HbSAG

f) ALOS analysis :

Its significance as follows:

shorter the ALOS better is the quality of care provider.

Unnecessary treatment is not given to the patient.

The patient’s treatment is following the right and the shortest course.

It is an indicator of overall quality in clinical care.

List of ALOS for different medical services calculated in the hospital.

ALOS maintained in the hospital is 3-4 days.

g) Safety rounds :

Checklist of the security areas.

Security policy and procedures.

Demarcation between restricted and free for all movement areas.

Proper signage system

Anti theft / anti corruption policy



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h) Radiation precautions :

TLD badges (Thermo-Luminisescent-Dosimeter) worn by the staff in the

radiotherapy department and also in the OT, Dental Lab, Cath Lab.

Radiation prevention measures. TLD badges : as Detectors the TLD badges use

tissue equivalent Li2B4O7 and highly sensitive CaSO4:Tm making it possible to

precisely measure various radiation types over a wide range of dose & energies.

Tld badge in detail.

TLD and film badges

TLD and film badges are used to detect radiation at levels that can be harmful to humans. They emit

light in amounts proportional to the radiation received. Thermoluminescent dosimeters (TLDs) are

made from one more fluoride chips that measure cumulative exposure to ionizing radiation. Like film

badges, they are worn for periods of approximately three months and are then processed to determine

the dosage of radiation detected. TLD and film badges are logged to maintain cumulative records of

an individual’s exposure to radiation over an extended period of time.

TLD and film badges include several types of thermoluminescent dosimeters, devices that can

measure doses as low as millirem. TLD badges are similar to film badges, but can measure smaller

amounts of radiation. TLDs work by measuring the amount of visible light emitted from a crystal in

the detector during exposure to ionizing radiation. The exposure of the crystal detector results in

ionization, thus producing or trapping electrons in an excited state of the crystal. The dose of radiation

exposure is proportional to the number of traps that are created. The TLD is then sent to a lab and

heated to depopulate the trap, thus releasing light. With both TLD and film badges, the amount of

light released measures the radiation dosage.

There are three basic types of personal monitors: film badges, TLD & pocket ionization chambers.

Radiation is not detectable by ordinary means; that is, we cannot see, hear or feel it. The detection of

radiation requires instruments specifically designed to detect ionizing radiation. This is done

indirectly by measuring the effect radiation has on a medium such as air (ionization) or film (density).

Occupational dose limits are set by law to protect people who work with ionizing radiation and the

limits are 50 rem/year to the occupational staff. The best way to determine how much exposure a

person receives over a long time period is through the use of personal dosimetry devices.

.

CATH LABS-RADIATION PRECAUTION

Radiation Safety : Terms for Understanding Radiation

Exposure in the Cardiac Catheterization Laboratory In the cardiac catheterization laboratory, ionizing

radiation is produced by the interaction of X-rays and matter. The use of ALARA—―as low as



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reasonably achievable‖—doses of X-ray radiation is important. Radiation exposure may be expressed

in terms of rems. Radiation injury is defined by either stochastic effects (DNA injury) or nonsto-

chastic effects (cellular injury). The average background radiation exposure is about 0.1 rem/year.

Interventional cardiologists receive another 0.004 to 0.016 rem/case. The maximum recommended

exposure by the National Council on Radiation Protection and Measurement (NCRPM) is 5rems/year

for the total body. Over an individual’s lifetime,the accumulated maximum dose should be no greater

than the accumulated rem exposure 3 age (or a maximum of 50 rems).

The additional risk from radiation exposure in the cardiac catheterization laboratory is about 0.04% 3

total cumulative rem exposure. Pregnant workers can continue to work in the cardiac catheterization

laboratory if they so choose. Fetal exposure, as measured by a waist dosimeter, should be no more

than 0.05 rem/month or ,0.5 rem for the entire pregnancy. Radiation exposure is measured by either

X-ray film badges or transluminescent dosimeter (TLD) badges. It is recommended that these badges

be worn on both the thyroid collar and under the lead apron at the waist. Ring dosimeters are rarely

worn in the cardiac catheterization laboratory, even though hand exposure may be high.

X-ray scatter is reduced by minimizing the number of

magnified views, using digital-only cine runs, keeping the image intensifier as close to the patient as

possible, and selecting the highest kilovolt level that provides acceptable image contrast (to reduce the

milliamperes generated).Most of the radiation exposure during interventional procedures comes from

the extended use of fluoroscopy rather than the brief cine runs. The closer the operator is to the X-ray

tube,the greater the radiation exposure (left anterior oblique [LAO] cranial views may result in up to 6

times more radiation than right anterior oblique [RAO] caudal views, for instance). Proper collimation

and shielding is important to help reduce exposure. To minimize patient exposure to scatter radiation,

the same rules apply, with further efforts to reduce the X-ray dose most important.

Biological Risks From Radiation Exposure

The biological risks from radiation exposure depend on the amount of energy absorbed and whether

there is injury to the DNA or the cell itself. A stochastic effect is an all-or-none effect that results in

DNA injury. This can lead to an increased risk of cancer or other genetic effects. Stochastic effects

occur with increasing frequency as the cumulative radiation exposure increases, but once the injury

has occurred, a further increase in the dose for that cell does not change the injury afflicted.

Nonstochastic effects, also referred to as deterministic effects, are dose dependent and result in cell

death. Erythema, desquamation, cataracts, marrow suppression, organ atrophy, gonadal injury,

sterility, and fibrosis are clinical expressions of this type of injury.

The greater the radiation exposure, the greater the amount of injury that occurs with nonstochastic or

deterministic injury. During an average interventional cardiac catheterization procedure, the physician

operator receives about 0.004 to 0.016 rem of exposure (117–120). In 1 review, the operating



20

physicians in the cardiac catheterization laboratory received from 0.2 to 6.0 rems/year, the nurses

received from 0.8 to 1.6 rem/year and the technologists about 0.2 rem/year, as documented by collar

and waist badges (120). Ancillary personnel in the cardiac catheterization laboratory thus receive

about 10% to 30% of the dose received by the primary operator. The maximum allowable

occupational exposure from all sources for medical workers is 5 rems/year for the whole body. Over a

total career, no one should receive a cumulative exposure .1 rem 3 age (or 50 rems). Most X-ray

scatter occurs at the entry surface of the patient. The nearer the operator is to the X-ray tube (not

image intensifier), the greater the X-ray exposure. For instance, in the cranial LAO view, where the

operator is closest to the X-ray tube and the bottom of the table, the operator exposure may be 2.6 to

6.1 times that observed in the caudal RAO view, where the X-ray tube is on the other side of the table.

PRECAUTIONS summary :

1. Guidelines on safety precautions to be observed in interventional radiology including cath lab

procedures should be made by AERB and sent to all concerned and also should be displayed on

website of AERB. This guidelines should highlight the fact that CT Scan Units and Interventional

radiology units are included under the licensing categories in Atomic Energy (Radiation Protection)

Rules, 2004, in view of their potential for exposing patients and workers to high radiation doses.

2. AERB code on Medical X-ray needs review to include various modern technologies of diagnostic

radiology such as mammography, dental, cath lab x-ray machine and interventional radiology

procedures.

3. Suppliers of cath lab units are recommended for supplying radiation protection accessories as an

integral part of the cath lab unit to diagnostic centers. A list of essential radiation protection

accessories must be prepared. Not using such accessories during work will be considered as serious

violation.

4. Every year advertisement should come in leading newspapers highlighting the importance of

radiation safety precautions and regulatory requirements in context of interventional radiology.

5. BIS should be pursued to adopt IEC standards applicable on cath lab units.

6. All consultants performing cath lab procedures should be required to use TLD badges for

personnel monitoring. The badges should be issued to the individuals so that whichever hospital they

perform the procedures, they can use it. Carrying out procedures without wearing personnel

monitoring badges will be considered as a violation. AERB shall direct licences/employees not to

allow physicians violating safe practices to continue work in their facilities.

7. In view of preoccupation of the cardiologists, AERB should consider addressing cardiologists

during their conference organized by their professional associations.

8. Licensing of all cath labs should be taken on priority basis by AERB.

9. In view of relatively high potential for exposure to staff and patient in cath lab procedures, AERB

should consider arranging for one or two days training program for 4 cath lab technicians or



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radiologists for consideration their notations for approval as RSO in Cath Lab. Each facility must

have such approves RSOs for their continued operation.

10. Personal protective devices such as lead aprons, lead gloves, lead glasses etc. should be certified

against standards for use by the concerned staff.

11. Suppliers of cath lab should ensure that the hospital requesting for installation of interventional

radiology x-ray unit meets with all the regulatory requirements prior to commissioning.

12. QA of cath units should be checked annually by the supplier.

13. Since cardiologists are not aware on the radiologist safety measures to be adopted during cath lab

procedures, it is recommended that AERB should advice Medical Council of India to include

radiation safety chapter in the syllabus of cardiologists during their educational program

i) Drug committee :

changing drug based on demand and positive reaction.

adverse drug reaction study.

Sentinel events : like bed-fall, bedsore, Needle struck injuries, thrombophlebitis, near

miss, wrong medication etc.

Immunization for patients and all staff in critical clinical areas.

6. Bench marking : the hospital goes a step further by comparing their existing quality

standards with bench marking standards across the globe. This is done in

Clinical

Non clinical

Managerial functioning and,

Financial achievements.

Incident Reporting :

Sentinel/non-sentinel events are undesirable events and unexpected occurrences requiring

immediate review, investigation and response.

Occurrence of sentinel/non-sentinel event indicates a system or process failure.

The hospital has identified various sentinel/non-sentinel events and has established processes

for analysis of such events. Based on the analysis, the events are continuously monitored for

corrective and preventive actions.

Process of reporting an incident :

An incident should be reported by filling up the Incident Form.

The form should be completely filled and submitted to Ms Uttia Majumdar,

Administration department, 1st

floor.



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All incidents should be reported immediately to the department co-ordinator.

TOTAL

External audits

ISO-9001:2000 Final Audit 1

ISO-9001:2000 Surveillance Audit 2

NABH Pre-Audit 1

NABH Final Audit 1

NABH Surveillance Audit 1

Internal Audits (ISO) 6

Internal Audits (NABH) 3

Surprise rounds 55

Safety rounds 7

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Documents

hospital administration, BMS,HR and TQI from dR JOY ,TISS