OPERATIONS MANAGEMENT

STUDY OF HOSPITAL OPERATIONS

The main purpose of this project is to map comprehensively the operations of the hospital and the relationship between each of the hospital departments which aid in the effective operation of the hospital itself

Objective
To map the operations of the hospital and the relationship between each of the hospital departments which aid in the providing effective products and services to the customers.

About Nazareth Hospital

The hospital which had been considered for study is Nazareth Hospital. The hospital is a 350 bed hospital located in Laitumkhrah-Shillong. It belongs to the Archdiocese of Shillong. It was started in the year 1959 as a patient treatment center by missionaries from Spain. It started with 60 beds and was converted to a hospital in 1965. Ever since, the hospital is on its path of developments and modernization adding new departments and services. The administration of the hospital has been handed over to the sisters of Holy Cross, Kottiyam, Kerala in 1988. Now the hospital is well established with 350 beds having many specialties and super specialty and it's outreach program covering 10 villages both in urban and rural areas.

Mission Statement
PROTECT, PRESERVE AND NURTURE LIFE. To provide quality health care with human kindness and the love and compassion of God, to patients who seek care in our institution, to treat everyone with dignity and respect, irrespective of caste, creed and religion, to protect, nurture and preserve life.

Background
Administration:
The Archdiocese of Shillong, the legal owner of Nazareth Hospital has entrusted its administration and management to the Sisters of the Holy Cross (North Indian Province) from the year 1988. The decision making Body is the Governing Board. The administration is guided and assisted by the General Body. At the Annual General Body Meeting the report of the functioning, achievements, future plans and problems are presented for discussion, consideration and changes for the better. The hospital always upholds its objectives and philosophy, that is, to provide quality health care with human kindness and the love and compassion of God, to patients who seek care in our institution, to treat everyone with dignity and respect, irrespective of caste, creed and religion, to protect, nurture and preserve life. The institution endeavors to achieve and maintain high standard of professionalism by being open to the changes and developments in the health care delivery system. This is by the coherent effort of the medical fraternity with its dynamic leadership of Dr. G. Rangad,

CMO, and paramedical and supportive staff. The Administration critically evaluates its activities and learns from the past and make amendments for a better performance of tomorrow.

Organization Structure:

Medical Facilities
The hospital is a multispecialty hospital and has a list of good medical facilities:

Accident and Emergency

Emergency Service is one of the most important health care system of Nazareth Hospital. It provides initial medical care to the patients reporting to the department. Services are provided 24hrs a day. Patient reporting the emergency service are screened by the duty emergency doctor to assess the seriousness of the ailment and then investigated accordingly. The patient is then provided the immediate medical treatment before being transferred to the ward admitted or sent back home with medicines with advice for follow up. The emergency doctor, if circumstances demand, can request the concerned consultant to examine the patient and deliver the necessary health care in the emergency itself and then transfer the patient once stabilized.

General Medicine
In the department all acute and chronic illnesses are treated. There is regular counseling of the patients in respect of diet, physiotherapy etc. according to the patient's requirement. The hospital has diabetic clinics on Tuesdays and Friday for outdoor patients, where a team of Doctors, dieticians, physiotherapists, ophthalmologist and trained nurses/counsellers guide the patients regarding their Body Mass Index (BMI), Ideal weight, foot care, dietary requirements, neuropathy assessment, renal status, HbAIC, eye checkup and exercises.

General and Paediatric Surgery

This department attends to all sorts of Emergency as well as elective cases. The following is a short overview of the types of surgery which are carried out in this hospital: Neonatal Surgery : Tracheo-oesophageal Fistula repair, congenital diaphragmatic hernia, neonatal management of ano-rectal malformations, meningomyelocoele and emergency management of other congenital defects, excluding cardiac surgery. Other Paediatric Surgery : Cleft lip and Palate, elective surgery for ano-rectal malformations and Hirschprung's disease, and other common paediatric conditions, excluding orthopaedic surgery and neurosurgery which are handled by the speciality department, and cardiac surgery which is not available. Adult General Surgery : Includes oesophageal and pancreatic surgery, among other general surgical conditions. Gallstones are very common in this area and account for a large percentage of the surgery, laparoscopic as well as open surgery.

Obstetrics and Gynaecology

There is a 70 Bedded exclusive department with Private Cabins on Demand. There is also a 6 Bedded Labour room, catering to 300 deliveries in a month. Daily Antenatal Clinics are available too. Fully Equipped Operation Theatre deals with :

All Caesereans Sections (Emergency and Elective) Various Gynaecological Surgeries Laparoscopic Gynaecological Surgeries Hysteroscopy assisted Surgeries Harmonic Scalpel Available for special surgeries Various Oncological Surgeries. Ultrasonography- 24 hours for Labour Room, with additional TVS probe. Digital Colposcopy- for Cancer Cervix Detection

Intensive Care Unit

The ICU beds are fully motorized with air mattress in each bed with central oxygen and vacuum ports for each bed. Presently the ICU is equipped with

Bedside monitor for each bed capable of doing invasive monitoring. Ventilators Two hemodialysis machines operating round the clock. Blood gas analyzer, Electrolyte analyzer Defibrillator Syringe Pumps Portable X ray machine and ECG machine

Paediatrics
This department has a sixty bedded pediatrics ward with six semi ICU beds with central oxygen supply. This sixty bedded ward admits patients from 1 month to 12 years old. Older children from 13 years to 18 years are admitted in medicine wards under the department of Pediatrics. The department caters to non-critical and critical cases belonging to all sub specialties of pediatrics including cardiology, respiratory medicine, nephrology and pediatric endocrinology.

E.N.T
The ENT Department is equipped with all modern facilities available for diagnostic and Therapeutic purpose. All types of surgical procedures are frequently carried out in this hospital, viz Septal corrective surgery, Tonsillectomy, Myringoplasty, Mastoid Surgery, Thyroid Surgery, Rhinoplasty procedures. The hospital has a good set - up for Functional endoscopy Sinus Surgery (FESS) and other microsurgical procedures like Micro Laryngcal Surgery (MLS) and micro ear surgery. Endoscopy procedures like Bronchoscopy and Oesophagoscopy, both rigid and flexible are regularly carried out here. Head and neck cancer surgeries like Laryngectomy, Radical Neck Dissection etc. are also being done here. The department is well equipped to cope with any ENT emergency. The OPD registers quite a good number of patients coming with various types of ENT ailments. Facility for audiometry evaluation of patients is also available in the department.

Orthopedics
This department renders emergency services to the trauma cases involving the limbs and spines. It also attends to the elective cases in the OPD. The surgeries that are carried out in this department are the total hip arthroplasty, hemi artroplasty of the hip (Bipolar and Austin Moore prosthesis), the dynamic hip screw and dynamic condylar screws fixaion, the inter locking nailing, the locking plate fixation, external fixators application, surgical correction of the club fet, artrodesis and excision arthroplasty and the routine compression plating.

Other departments
Some of the other deparments in the hospital are: Neo Natal Care Neuro Surgery Anaesthesiology Haemo-Dialysis Opthalmology Community Health

Investigation Facilities:
Laboratory Services

24x7 Services Licensed Blood Bank B.Sc. Lateral entry Job training for B.Sc. Biotechnology students Integrated Counselling and Testing Centre) Study center for B.Sc. MLT Tests o Microbiology o Haemotology o Clinical Pathology o Biochemistry o Histopathology

Radiology and Imaging

This department is catering the whole medical imaging needs of the hospital round the clock. Services and facilities offered are:

Conventional Radiology : all x-rays Ultrasonography o General ultrasonography o Doppler studies and Echocardiogram CT Scan : Whole body CT Interventional Radiology

Other prominent services

Ultrasonography with Color Doppler CT Scan Treadmill Test (TMT) Video Endoscopy

Paramedical Services
Nursing
Nursing Service in Nazareth Hospital aims at imparting holistic approach to patient care coupled with compassion, concern, and love with a human touch and professionalism. Scientific and advanced Technological application in Nursing care and Nursing procedures enhances efficiency, accuracy and modernism. Quality nursing care is provided with special attention to patient's physical and spiritual needs. Good rapport with patient's family members is maintained through communication and timely information. In-service and continuing education keeps the Nurses abreast with modern advancement in the field of Nursing.

Pharmacy
A well organized and fully computerized 24 hrs pharmacy is the pride of Nazareth Hospital. The department's priority interest is care and well-being of patients. All the life saving and essential drugs are available in the pharmacy. Pharmacy is ever alert and cautious that banned and spurious drugs do not occupy its shelves. A number of counters are open with separate counter for OPD, IP, Emergency and staff to enhance better and efficient service.

Nutritional Services
Nutrition & Dietetic services deal with planning and implementing the daily nutritional requirements of patients, special therapeutic and restricted diets. They plan balanced diet, therapeutic diet, special tabulated meals, and food items as diagnostic criteria for Diabetes and special feeds for critically ill patients. The department offers nutrition counseling to patients and their care takers.

Physiotherapy
The Hospital has a well-established Physiotherapy Unit equipped with Hand finger exerciser, Parallel bar, Quadriceps table, Static cycle, Foot exerciser, shoulder wheel, electrical gadgets and Paraffin wax. The department provides the services to both the outdoor and indoor patients.

Support Services
Medical Records Department
Nazareth Hospital maintains a fully computerized medical record department. The hospital has introduced International Code of diagnosis. Medical records are maintained in chronological order of Registration.

Central Sterilization Supply Department

CSSD is solely responsible for reception, preparation, sterilization, storage and distribution of sterilized instruments and linen twice daily to all the departments, ensuring sufficient supply of sterile materials in the department.

Laundry
A mechanized laundry under the same roof receives, washes and supplies neatly pressed clean linen twice daily to the entire hospital departments.

Bio-Medical Waste Management

Nazareth Hospital follows the directives of State Pollution Control Board regarding the BMWM. BMW are segregated at the source of generation, transported to a safe place and disposed by the Municipal pollution Control Board. Syringes are mutilated and needles are burned at the site of injection.

Material Stores
Hospital has its own central store providing all types of disposables, printed materials, detergents, disinfectants and equipments. Materials are issued on weekly basis to all the departments.

House Keeping
House keeping department does a dedicated service in keeping the hospital wards and premises clean and fresh, creating a homely atmosphere with fresh air free from the usual stink of hospital detergents.

Maintenance
The maintenance department includes carpentry, Electrical works, plumbing, painting/calligraphy, Plumbing and tailoring. These departments play a key role in creating an aesthetic and new look to the physical structures in the campus.

Basic Operations
Nazareth hospital is organized into many units and departments. These departments are interrelated and there is a central administration that controls and supervises the operations of all other departments. There are two main sources of patients: 1. The accident and emergency department 2. The Specialist and Outpatient clinic, or referral from private doctors Most patients who come to the hospital are directed to the OPD Out Patient Department.

Admission Process:
In most hospitals, the doctors on duty usually allow the admission of patients into the hospitals. However, in Nazareth Hospitals, the medical officers on duty only observe the patients and either treat and discharge them or refer them to specialty medical officers on call. These specialized doctors then examine the patients and decide whether or not they need to be admitted. The system will result in a more efficient use of hospital resources, since such a process would reduce the

admission of unnecessary patients who do not really need hospital admittance. It also lowers the congestion of hospital wards. The admission process followed in the Out Patient Department (OPD) is as follows:

An exercise was carried out to find out the bottlenecks in the OPD. A single patient tracking was done for 20 patients and the time spent at each stage of the process was studied. The results for one patient are as follows:

It was found that waiting time in the pharmacy queue was very high. Since the pharmacy is located at the entrance of the hospital, the long waiting queue presents an unpleasant appearance to the patients visiting the hospital.

Nurse Shifts
Nursing services are integral elements in the seamless running of a hospital. There are basically three types of nurses in a ward at Nazareth. They are the sisters, the registered nurses, and the student nurses. The nurse patient ratio differs from ward to ward, depending on the department to which the wards belong. For example, for the Intensive Care Unit, the ratio may be as in the order as one to one while the average ratio for other departments is about one nurse to six patients. Each nurse is allotted to, a particular ward upon joining the hospital. Rescheduling of nurses from one ward to another is infrequent since all nurses are not very comfortable working with all departments. Over the period of evolution of the hospital a pattern of nurse scheduling has been used. For instance, generally speaking a nurse is scheduled a morning shift after an afternoon shift, or a night shift may be followed by a leave. Moreover, a nurse can ask for a day off to be granted to her on a certain day. However, the final decision still rests with the nursing officer, who may or may not grant the nurse's request. The present system has the merit of flexibility and takes into account the personal needs of the nurses as they are allowed to request the dates of their days off. Also, an afternoon shift followed by a morning shift allows the nurses to be more familiar with the patients' conditions because they are only off-duty for 91/2 hour over a 24-hour period. It is a natural desire for people to prefer their day off on Sundays and holidays so as to have some personal time for themselves. In the present system, some nurses have the feeling that they are granted a lesser no of days off on Sundays and holidays than the other nurses. This feeling may be just an illusion. However, it may also be that the present distribution of days off among nurses during Sundays and holidays is not equitable enough.

Operation Theatre Procedures

The hospital has 3 operation theatres. The operations happen in units of time called sessions. Each operation theatre holds about 5 sessions each day. The operations are based on Emergency cases of outpatient cases. The exact demand for day to day operations in not known because the number of emergency cases on any given day in unknown. Patients who were first checked up in the outpatient department form a part of the queue. However the emergency cases are given higher priority. The basic structure of a surgery schedule process is as follows:

It was also noticed that there were priorities assigned to patients in the waiting list also. This was because some patients needed to be operated much in advance that the other patients. However the general waiting time in the waiting list was not more than 3 days.

Data Storage
In the present, Nazareth Hospital uses a computer system to handle information flow of patients and their respective medical tests. Earlier Nazareth hospital used to work out of patient data stored in documents which had much higher retrieval problems when compared to the present day computerized system. Upon acceptance of a patient, all necessary data such as name, gender, age, etc. will be entered as data input. Much more data about the patient is also garnered from the physicians, nurses, surgeons, medical tests, etc will also be used as data input. The combination of all such data makes data retrieval very easy. However, these data storage mechanisms still face the problem of not having all data in soft copy. Old patients visiting the hospital after a long time will not be able to find their old records in the computerized systems and hence will have to wait for their records to be searched over the stack of records kept in the records store.

Medicines Inventory Control

Inventory control of medicines is done using a computer system. As soon as medicines arrive at the pharmacy the stock quantity is entered as Received in the computer system to keep a track of the quantity of medicines available. Also, a periodic check is done on the stock of medicines to order medicines.

Problems identified and Suggestions

Partiality in Nurse Shifts
As already discussed above, some nurses still feel that they do not get a weekly OFF day on Sundays like their colleagues. Programming approaches can be used to solve this issue. However, trying to schedule the nurse shifts manually will lead to problems. Hence it is suggested to carry out the scheduling using computers. Also the below described priority scheduling method was proposed to carry out the scheduling of weekly OFF days. Priority Scheduling Each Nurse is assigned points Points increase by 1 if a nurse/sister takes an OFF on a Weekday Points decrease by 1 if a nurse/sister takes an OFF on a Sunday Every week, Sunday OFF preference will be given to the sister/nurse who has the highest number of points In case of a tie between nurses/sisters, seniority must be considered. In case the seniority is also the same, preference should be given to the nurse/sister who took an OFF on a weekday in the previous week.

The table shows scheduling of OFFs over a period of two weeks using Priority Scheduling

S Denotes an OFF on a Sunday, WD denotes an OFF on a Weekday

Operation theatre scheduling

At present, it is observed that the operation theatres seem to be running smoothly. However, it is advisable to do a study of the present queue and develop a more robust queuing system. However there are a few parameters that have to considered while developing that system. Such a system can be developed considering: No of rooms for recovery (or) ICU capacity No of Surgeons Availability of Operation Theatre Weekly schedule of waitlist surgeries Arrival rate forecast Length of stay in Hospital

Long queues in the Pharmacy

It was observed that there were long queues in the pharmacy throughout the day. Every day there are 700-800 patients. Approximately 300-400 patients in both the morning and evening sessions respectively. To make the situation worse, the arrival of patients in the pharmacy is not in random order. The pharmacy has 5 counters. The process was studied and it was found that the storing mechanism did not have flaws.

Some of the suggested alternatives are: Employ more persons and increase the no of counters in the pharmacy Increase resources Make separate pharmacies near the doctors cabins for specific medicines and provide medicines to the patients Distribution of Demand Carry out motion study and reduce motion waste to reduce the cycle time

Learnings
The study project at Nazareth hospital acted as a vital avenue to learn the different aspects/constraints of hospital management. A summary of the same is presented below: The entire working mechanism of a multi-specialty hospital was understood and acknowledged It was inferred that bottlenecks do not disappear. Bottlenecks reappear somewhere else in the process when the previous bottleneck is eliminated. Time is as good as money the more time you save the more efficient you are, the more profits you make Employee satisfaction plays a big role in operations. Interdependency in processes creates complexity unless managed efficiently. Co-ordination between parallel processes must be coherent to achieve efficient end results. The importance to manage and balance the 4Vs of OM was physically visible. In case of an imbalance in any of the 4Vs, complexity prevails.

Conclusion
The above study was carried in a single week. If further studies are carried out many such areas of inefficiency can be identified and the problems can be rectified. The basic aim of Nazareth hospital is to PROTECT, PRESERVE AND NURTURE LIFE. Being a missionary hospital it would like to reduce prices even further and hence needs to cut down on operations costs to reduce its cost. It should also concentrate on providing satisfaction to all its patients. It can only do so by making its major systems more efficient. Scope for improvement is huge, considering the fact that it one of the largest medical services provider in the State.