CHAPTER- 1

INTRODUCTION

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1.1 OBJECTIVE

A. Primary Objective

 To analyze the root cause for the delay in discharge process in the month of of
May 2015 – July 2015 (18/05/2015 – 18/07/2015).

B. Secondary Objectives

 To identify the reason for delay in discharge process, if any and thus
improving the process and to attain patient satisfaction.
 To check whether there was any delay discharge in the month of May 2015 –
July 2015 (18/05/2015 – 18/07/2015).
 To provide suggestions for reducing the delay in discharge process.

1.2 PERIOD OF THE STUDY:

In the month of May 2015 – July 2015 (18/05/2015 – 18/07/2015).

1.3 SAMPLE SIZE

Total 80 Patient discharges were in this period of study. Out of 80 patient discharges,
67 discharges were taken as the sample.

1.4 TOOL OF THE STUDY

Discharge process – checklists were used to collect data from Nursing, IP billing
section and IP Pharmacy. The doctor's medicine indenting time was tracked from the
hospital software (Yassassi).

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1.5 LIMITATION OF THE STUDY

1. Responses may be biased

2. Non-cooperation of some departments.

3. Sample size may not be representative of the interest of entire population.

4. Time limit of the study

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 CHAPTER - 2

INDUSTRY PROFILE

4
2.1 INTRODUCTION
The health care industry, or medical industry, is a sector within the economic
system that provides goods and services to treat patients
with curative, preventive, rehabilitative, and palliative care. The modern health care
sector is divided into many sub-sectors, and depends on interdisciplinary teams of
trained professionals and paraprofessionals to meet health needs of individuals and
populations.

The health care industry is one of the world's largest and fastest-growing
industries. Consuming over 10 percent of gross domestic product (GDP) of most
developed nations, health care can form an enormous part of a country's economy.

2.2 BACKGROUND

For purposes of finance and management, the health care industry is typically divided
into several areas. As a basic framework for defining the sector, the United
Nations International Standard Industrial Classification (ISIC) categorizes the health
care industry as generally consisting of:

1. hospital activities;
2. medical and dental practice activities;
3. "Other human health activities".

This third class involves activities of, or under the supervision of, nurses, midwives,
physiotherapists, scientific or diagnostic laboratories, pathology clinics, residential
health facilities, or other allied health professions, e.g. in the field of optometry,
hydrotherapy, medical massage, yoga therapy, music therapy, occupational therapy,
speech therapy, chiropody, homeopathy, chiropractics, acupuncture, etc

The Global Industry Classification Standard and the Industry Classification

Benchmark further distinguish the industry as two main groups:

1. health care equipment and services; and

2. Pharmaceuticals, biotechnology and related life sciences.

Health care equipment and services comprise companies and entities that provide
medical equipment, medical supplies, and health care services, such as hospitals,
5
home health care providers, and nursing homes. The second industry group comprises
sectors companies that produce biotechnology, pharmaceuticals, and miscellaneous
scientific services.

Other approaches to defining the scope of the health care industry tend to adopt a
broader definition, also including other key actions related to health, such as
education and training of health professionals, regulation and management of health
services delivery, provision of traditional and complementary medicines, and
administration of health insurance.

2.3 PROVIDERS AND PROFESSIONALS

A health care provider is an institution (such as a hospital or clinic) or person (such as

a physician, nurse, allied health professional or community health worker) that
provides preventive, curative, promotional, rehabilitative or palliative care services in
a systematic way to individuals, families or communities.

The World Health Organization estimates there are 9.2 million physicians, 19.4
million nurses and midwives, 1.9 million dentists and other dentistry personnel, 2.6
million pharmacists and other pharmaceutical personnel, and over 1.3 million
community health workers worldwide, making the health care industry one of the
largest segments of the workforce.

The medical industry is also supported by many professions that do not directly
provide health care itself, but are part of the management and support of the health
care system. The incomes of managers and administrators, underwriters and medical
malpractice attorneys, marketers, investors and shareholders of for-profit services, all
are attributable to health care costs.

In 2003, health care costs paid to hospitals, physicians, nursing

homes, diagnostic laboratories, pharmacies, medical device manufacturers and other
components of the health care system, consumed 15.3 percent of the GDP of the
United States, the largest of any country in the world. For United States, the health
share of gross domestic product (GDP) is expected to hold steady in 2006 before
resuming its historical upward trend, reaching 19.6 percent of GDP by 2016. In 2001,
for the OECD countries the average was 8.4 percent with the United States
(13.9%), Switzerland (10.9%), and Germany (10.7%) being the top three. US health
care expenditures totaled US$2.2 trillion in 2006. According to Health Affairs,
6
US$7,498 is spent on every woman, man and child in the United States in 2007, 20
percent of all spending. Costs are projected to increase to $12,782 by 2016.

2.4 THE DELIVERY OF HEALTHCARE SERVICES

From primary care to secondary and tertiary levels of care is the most visible part of
any health care system, both to users and the general public.] There are many ways of
providing health care in the modern world. The place of delivery may be in the home,
the community, the workplace, or in health facilities. The most common way is face-
to-face delivery, where care provider and patient see each other 'in the flesh'. This is
what occurs in general medicine in most countries. However, with modern
telecommunications technology, in absentia health care is becoming more common.
This could be when practitioner and patient communicate over the phone, video
conferencing, the internet, email, text messages, or any other form of non-face-to-face
communication.

Improving access, coverage and quality of health services depends on the ways
services are organized and managed, and on the incentives influencing providers and
users. In market-based health care systems, for example such as that in the United
States, such services are usually paid for by the patient or through the patient's health
insurance company. Other mechanisms include government-financed systems (such
as the National Health Service in the United Kingdom). In many poorer
countries, development aid, as well as funding through charities or volunteers, helps
support the delivery and financing of health care services among large segments of
the population.

The structure of health care charges can also vary dramatically among countries. For
instance, Chinese hospital charges tend toward 50% for drugs, another major
percentage for equipment, and a small percentage for health care professional
fees.] China has implemented a long-term transformation of its health care industry,
beginning in the 1980s. Over the first twenty-five years of this transformation,
government contributions to health care expenditures have dropped from 36% to 15%,
with the burden of managing this decrease falling largely on patients. Also over this
period, a small proportion of state-owned hospitals have been privatized. As an
incentive to privatization, foreign investment in hospitals up to 70% ownership has
been encouraged.

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2.5 GLOBAL HEALTHCARE & HOSPITAL INDUSTRY

Globally, healthcare industry is on a high-growth trajectory, with strong emphasis on

the Asian and Middle Eastern markets. Economic growth, corresponding increase in
standard of living, and aging population will continue to create a greater demand for
better healthcare facilities globally. Majority of healthcare facilities, of late, are
reducing bed capacity to minimize cost, and to promote advanced, short-stay surgical
methods.

It's a world where technology comes to the aid of everyone, not just patients and
Practitioners, but also labs, clinics, hospitals, insurers, administrators, and data
centers. The healthcare environment of the future can be visualized as an integrated
community where information flows seamlessly across departments, facilities,
regions, and even nations, and where medical records are available and accessible
when needed. Healthcare delivery is becoming corporatized with the emergence of
conglomerates changing the rules of the game. Rising costs, expanding market
demand, and increasing customer satisfaction characterize healthcare in this decade
and help redefine the roles of patients, providers and payers. Basically, healthcare
organizations face a growing imbalance of supply and demand. On the demand side is
a large population of aging patients in deteriorating health who demand more
services, pharmaceuticals and medical breakthroughs. The supply side, however, is
hampered by a shrinking pool of investment capital, a shortage of willing caregivers,
and aging physical plants straining under the current volume of patients.

Clearly, demand is driving the system and flipping the traditional paradigm in which
many health systems attempted to control costs by controlling supply. Under these
conditions, healthcare providers must meet the challenge of effectively managing the
demands of the patients, while healthcare insurers must be able to guide the patients
to the most cost-effective providers. The healthcare organizations that prosper in this
environment will be those that recognize the supply/demand imbalance and respond
with flexible and effective processes for delivering superior customer service. The
striking feature of the sector is that it has the potential to grow at a much faster rate in
the foreseeable future and will present new sectors of opportunity within healthcare,
which will emerge as growth drivers. The healthcare industry has exponential growth

8
potential as software and pharmaceutical industries in the world. There are abundant
opportunities for entrepreneurs, equipment makers and service providers to invest in
curative and preventive services and possibilities of investing in medical
infrastructure and medical tourism. Preventive care is increasingly gaining acceptance
as the world is growing to ‘wellness concept’. Cost-effective services have made
laboratory services and radiology tools affordable. However, there is a prominent
vacuum in terms of networking of diagnostic centre.

Private hospitals are not restricting themselves to their territorial borders alone.
Hospitals are also aggressively launching overseas marketing initiatives, thereby
creating a favorable business policy environment. In the private sector, there is an
increase in privatization of public sector units and networks in healthcare inclusive of
strategic link ups of reputable healthcare management companies with foreign
companies, foreign hospitals, medical centers and medical alliances between business
groups and medical institutions.
Hospital services, healthcare equipment, managed care and pharmaceuticals in Asia
are all poised to grow by 13% annually for the next six years. India, China, Middle
East and Vietnam are making a chain of the fastest growing healthcare markets. The
technology in the last two decades has revolutionized the way healthcare is delivered
worldwide. It has greatly aided patients and providers alike by enhancing the quality
of delivery, reduction in turnaround time of workflow and thus the overall cost,
besides bringing in higher accountability into the system.

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2.6 MARKET OVERVIEW

Currently, Global Healthcare market is on high growth. Global health market is

valued at US$7.72trillion in 2007; it is growing at 7.5%, and estimated to reach
US$10.31 trillion by the end of 2012.

Geographical Share Global Healthcare Market

The major share of global healthcare pie is occupied by USA, which is valued at
US$4.98 trillion of the global healthcare market, then followed by Europe, valued at
US$2.87 trillion, Asia valued at US$1.53 trillion(16%) and Middle east/ Africa at
US$0.19 (.2%)

Geographical Share of
Global Health care Market,,2015

30%
us
52%
Asia
East Africa

2% Europe

16%

FIGURE – 2.1 – Geographical share of global healthcare market,2015

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2.7 INDIAN HEALTHCARE INDUSTRY

Healthcare is one of India’s largest sectors, in terms of revenue and employment, and
the sector is expanding rapidly. During the 1990s, Indian healthcare grew at a
compound annual rate of 16%. Today the total value of the sector is more than $34
billion. This translates to $34 per capita, or roughly 6% of GDP. By 2012, India’s
healthcare sector is projected to grow to nearly $40 billion. The private sector
accounts for more than 80% of total healthcare spending in India. Unless there is a
decline in the combined federal and state government deficit, which currently stands
at roughly 9%, the opportunity for significantly higher public health spending will be
limited. The Indian healthcare industry has witnessed a massive spurt in healthcare
spend and is expected to reach US$100billion1 by 2015 from the current ~US$65
billion in2012, growing at a CAGR of 20% a year
India currently faces a chronic shortage of healthcare infrastructure, especially in rural
areas and Tier II and Tier III cities, and it is expected that India will have potential
requirement of 1.75 million new beds by the end of 2025The industry is adopting
innovative business models to work in the sector but still needs high upfront
investments, has long gestation periods and faces ever-rising real estate costs
In the present scenario, high entry barriers such as huge capital requirements and a
cash crunch amongst most big business houses will favor existing players to pursue
accelerated growth in the segment
The healthcare industry in India is attracting a significant amount of capital from
investors and de-centralized healthcare delivery models are the flavor of the season
among private equity investors

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2.8 HEALTHCARE MARKET SEGMENTS

FIGURE – 2.2 – Healthcare Market Segment

The global medical industry is one of the world's fastest growing industries, absorbing
over 10% of gross domestic product of most developed nations. It constitutes of broad
services offered by various hospitals, physicians, nursing homes, diagnostic
laboratories, pharmacies
armacies and ably supported by drugs, pharmaceuticals
pharmaceuticals, chemicals,
medical equipment, manufacturers and suppliers.
The medical and health care industry provides enormous employment opportunities to
choose from. Apart from using the services of medical professionals, this industry
also utilizes the expert services of public policy workers, medical writers, clinical
research lab workers, IT professionals, sales/marketing professionals and health
insurance providers.

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2.9 PORTER’S FIVE FORCES ANALYSIS

Threat of New Entrants Threat of Substitutes

 High capital
requirements order  Home care and natural
to build hospitals treatments
only allows serious
players in the
sector

 Hospitals are
heavily regulated
by the government

Bargaining Power of Consumers

Consumers have little power and

basically cannot negotiate on pricing

Bargaining power of
Rivalry among Suppliers
Competitors
 Hospitals face
 Now a day’s some threat
hospitals are from medical
facing cut equipment
throat companies as
completion they could
choose not to
sell their
equipment, but
there are a
fairly large
number of
suppliers

FIGURE – 2.3 – Porters five force model

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RIVALRY
The rivalry within the healthcare industry is very intense within pharmaceutical
companies and insurance companies, while being less intense amongst hospitals
(certain exceptions exist). Amongst hospitals, the competition is not as intense due to
the fact that within a certain area there is only one hospital available to individuals. If
an individual becomes sick, there is usually one hospital that individual can go to.
However with the recent trend of numerous urgent care centers in major metropolitan
areas, we can see an increase in competition. In cities we have seen independent
urgent care centers being open due to the fact that most of them do not accept
insurance, and they are essentially cash businesses. Some of these urgent care centers,
provide faster service (avoiding wait in ER). In this essence, the urgent care which has
the cheapest prices and best care seem to win. This win decreases the profits of major
hospitals who usually have urgent care centers on-site. In regards to the
pharmaceutical companies, the competition within rivalries is intense. Each company
is spending a tremendous amount of money within their research and development
department, so that they can be the first to develop a new drug. Within the
pharmaceutical industry, the first company that develops a new drug will get the
patent to make the drug for a certain amount years, therefore eliminating their
competition. Within the healthcare insurance industry, the competition is very intense.
Every insurance company is continuously bidding with companies to sell their
services. However, most companies only select one insurance company, therefore
making the competition intense. Since, most Americans only choose one insurance
policy provided by the company, there is a strict competition that each company
wants one of their insurance policies is chosen by the company.

Pressure from Substitutes:

In the healthcare industry, the pharmaceutical industry profits are greatly affected by
substitutes after the patents of drugs has expired. When the patents expire, all
pharmaceutical companies have the opportunity to make the drug. By allowing all
companies to make the drug, this reduces the profits experienced by the sole
company. In regards to insurance companies, substitutes do not really affect them. In
America, most individuals obtain healthcare insurance through jobs. Most companies
only have a certain type of HMO or PPO insurance plan to choose. Therefore, the

14
plan is usually chosen according to the persons finance. However, there is usually
only one type of PPO or HMO within a company. Substitutes usually affect
individuals who are self-employed and purchase their own insurance. In this situation,
individuals have the opportunity to choose from a number of providers. In the U.S.,
the number of individuals who purchase their own insurance is insignificant. In
regards to the healthcare sector, substitutes do not usually affect the field. For
example, if a patient has to obtain an ankle surgery, he or she has to go to a surgeon.
Now, one can go to any physician they would like, but that would be more of
competition amongst physicians. In recent times, there are certain substitutes such as
alternative medicine which treat primary care problems. However the amount of
individuals who believe and practice this type of medicine is very negligible when
talking about substitutes.

Threat of New Entrants:

Within the healthcare industry, the threat of new entrants is very tight. For example,
pharmaceutical companies must have the initial capital to invest into their research
and development department to develop new drugs. After developing these new
drugs, these companies must also deal with the policies that must be meet by the
government agencies before the drug is released. When it comes down to insurance
companies, the threat of new entrants is also limited. This is due to the fact that there
are many federal and state guidelines that these insurance companies must follow to
remain open. These policies make it very hard for anyone to open an insurance
company. Besides federal and state regulations, new insurance companies would need
to have a significant amount of capital to be able to attract physicians to their network.
Having to compete with the large insurance companies like Aetna, Kaiser
Permenante, and Blue Cross, would take a require a strong supporting cast and the
necessary capital to draw other physicians from their existing network. In regards to
actual healthcare, this field also seems to be very tight for new entrants to enter. This
is very difficult due to the fact that the US has very strict guidelines and regulations
set by the government to open a hospital. These guidelines also prevent the huge
monopoly of hospitals being open in a certain area by only allowing certain amount of
hospitals to be open within a given area.

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Bargaining Power of Buyers:
In the field of healthcare, it seems as though the bargaining power of buyers is very
limited. People will get sick and suffer from diseases whether the economy is doing
well or bad. Individuals do not have the opportunity to determine when they get the
flu, or need a knee replacement. Individuals are at the mercy of insurance companies,
pharmaceutical companies, and hospitals to provide the best quality of care. Now
individuals have the opportunity to choose a certain hospital or insurance company
over another, but since there are limited amounts of insurance companies within a
network or limited amount of hospitals within an area it becomes very hard to have
buyer power.
Bargaining Power of Suppliers:
As a physician, I have seen that doctors have a huge bargaining power over insurance
companies. If I do not join a specific network that means I will not be able to accept a
certain type of insurance plan. Now if a certain amount of physicians do not join a
specific network, it will limit the amount of individuals who would want to join that
insurance network. For example, it a physician chooses not to accept a specific
insurance plan he will be restricting a certain amount of sick people, thereby
decreasing the amount of companies buying that insurance plan. In regards to
pharmaceutical companies, the bargaining power varies. When a company delivers a
new drug in the market, it needs the hospital to carry the drug to make its profits. In
this essence, the hospital can decided whether or not they want to carry the drug. But
if a hospital wants to attract new patients and keep their old patients, they must have
the latest medications. So the hospital needs the pharmaceutical companies, and the
pharmaceutical companies need the hospitals. If the hospital decides to carry it, the
pharmaceutical company wins, because it is a patent drug distributed by the hospital
and the pharmaceutical company can charge the higher price. However, when the
patent expires and the drug becomes a generic, the bargaining power of the supplier
becomes less effective because everyone can carry the drug, dropping the price of the
drug. Since there is a shortage of physicians, the bargaining power of physicians to
hospitals is huge. Hospitals must maintain competitive salaries for physicians,
because they need to have quality physicians to treat their patients. If a hospital
chooses not be competitive, physicians will search for other hospitals to work. Once a
hospital loses a certain amount of quality of physicians to another group, their patient
population has the choice to switch to the new group. If your patient population
moves to another group, you will be decreasing your profits. This will cause hospital
profits to decrease. In areas such as these, hospitals know that if one physician leaves

16
they can find another physician because there is an abundance of well-trained doctors.
Therefore, their salaries do not necessarily have to be the extremely high. Lower
salaries sometimes mean lower expenses, thereby increasing profits

2.10 GROWTH DRIVERS

Increasing
Growing Policy Investments
Demand Support

Increasing Lifestyle
Related Issues and
increasing
population Rising
Initiatives to Foreign
Increase Sector Direct
Affordable Treatment Investments Investment
Cost and Increasing
Disposable Income

Reduction of Lucrative
Custom Duty M&A
Faster Diagnosis on Opportunities
leading to early Equipment
treatment Policy

Medial Tourism and

Improving health
Insurance penetration

FIGURE – 2.4 – Growth Drivers

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2.11 KEY TRENDS IN THE INDUSTRY

Shift from communicable to lifestyle disease

 50% of the spending on in-patient beds will be from lifestyle – related
diseases, which will result in increased demand for specialized care

Management contracts

 Many healthcare players such as Fortis and the Manipal Group are signing
management contracts to provide additional revenue stream to hospitals

Evolution of telemedicine

 Telemedicine is evolving fast in India, supported by the ICT sector. Currently,

about 650 telemedicine centres exist throughout India

Expat doctors / foreign doctors

 This trend is being supported by Improved healthcare infrastructure in India,

increase in medical tourism, improved compensation structures and growing
restrictions on licensing and practicing in UK and Europe (e.g. Back 2 Health
started by Dr. Shiv Bajaj who returned to India from Canada, Vardan by the
Times of India Group, Active Ortho in Delhi set up by a German physical
therapist etc.)

Holistic well-being
 Various hospitals have tied-up with holistic health centres to combine
traditional healthcare knowledge and practices with conventional systems.

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2.12 IMPORTANCE OF HEALTHCARE INDUSTRY:
Aging populations and increasingly prevalent chronic diseases are the fundamental
drivers creating demand for expansion of lifestyle medical procedures and healthcare
industry. There will be huge demand for medical technology products for years to
come.

The major inputs of health care industries are:

 Hospitals
 Medical insurance
 Medical software
 Health equipments

Health care service is the combination of tangible and intangible aspect with the
intangible aspect dominating the intangible aspect. In fact it can be said to be
completely intangible, in that, the services offered by the doctor are completely
intangible. The tangible things could include the bed, the decor, etc.

Different types of health care services available in India

 Hospitals
 Pathology Clinics
 Blood Banks
 Meditation Centers
 Emergency services like Ambulances, etc.
 Online Medical Services

The health care industry is one of the largest industries in the world, and it has a direct
effect on the quality of life of people in each country. Health care (or healthcare) is
the diagnosis, treatment, and prevention of disease, illness, injury, and other physical
and mental impairments in humans. Health care is delivered by practitioners in
medicine, chiropractic, dentistry, nursing, pharmacy, allied health, and other care
providers. The health care industry, or medical industry, is a sector that provides
goods and services to treat patients with curative, preventive, rehabilitative or
palliative care.
19
The modern health care sector is divided into many sub-sectors, and depends on
interdisciplinary teams of trained professionals and paraprofessionals to meet health
needs of individuals and populations. The health care industry is one of the world's
largest and fastest-growing industries and forms an enormous part of a country's
economy.

The delivery of modem health care depends on groups of trained professionals and
paraprofessionals coming together as interdisciplinary teams. This includes
professionals in medicine, nursing, dentistry and allied health, plus many others such
as public health practitioners, community health workers and assistive personnel, who
systematically provide personal and population-based preventive, curative and
rehabilitative care services.

The Indian healthcare sector is predicted to reach US$ 280 billion by 2020,
contributing an expected Gross Domestic Product (GDP) spend of 8 per cent by 2012
from 5.5 per cent in 2009, according to a report by an industry body. Growing
population, increasing lifestyle related health issues, cheaper treatment costs, thrust in
medical tourism, improving health insurance penetration, increasing disposable
income, government initiatives and focus on Public Private Partnership (PPP) models
are some of the driving factors for the growth of healthcare sector in India.
Some of the key players in the Indian healthcare industry who are helping in making
the sector buyout include Apollo Hospitals Enterprise Ltd., Fortis Healthcare Ltd,
Max Hospitals.

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2.13 KEY PLAYERS IN HEALTHCARE INDUSTRY

No. Of
Company Presence
beds

Chennai, Madurai, Hyderabad, Karur, Karim

Nagar, Mysore, Visakhapatnam, Bilaspur,
Apollo Hospitals Aragonda, Kakindada, Bengaluru, Delhi,
8,500
Enterprise Ltd Noida, Kolkata, Ahmedabad, Mauritius, Pune,
Raichur, Ranipet, Ranchi, Ludhiana, Indore,
Bhubaneswar, Dhaka

Aarvind Eye Theni, Tirunelveli, Coimbatore, Puducherry,

3,649
Hospitals Madurai, Amethi, Kolkata

Hyderabad, Vijaywada, Nagpur, Rajpur,

CARE Hospitals 1,400
Bhubaneshwar, Surat, Pune, Visakhapatnam

Fortis Mumbai, Bengaluru, Kolkata, Mohali, Noida,

5,044
Healthcare Ltd Delhi, Amristar, Rajpur, Jaipur, Chennai, Kota

Max Hospitals 800 Delhi and NCR

Udupi, Bengaluru, Manipal, Attavar,

Manipal Group
+7,000 Mangalore, Goa, Tumkur, Vijaywada,
of Hospitals
Kasaragod, Visakhapatnam

TABLE - 2.1 – Key Players in the industry

21
Healthcare Industry in India

FIGURE – 2.5 – Healthcare Industry in India

Healthcare sector growth trend in India
The Indian healthcare industry size is expected to touch US$ 160 billion
by 2017 and US$ 280 billion by 2020.

FIGURE – 2.6 – Healthcare sector growth trend in India

22
Market break-up by revenues of total healthcare revenues in the country hospitals
account for 71 per cent.
Per-capita healthcare expenditure in India
Per capita healthcare expenditure in India is estimated to grow at a CAGR of 15.4 per
cent during 2008-15 to reach US$ 88.7.

FIGURE – 2.7 – Per-capita healthcare expenditure

Private sector's share in healthcare delivery is expected to increase from 66 per cent in
2005 to 81 per cent by 2015.Healthcare has become one of India's largest sectors -
both in terms of revenue and employment. The industry comprises hospitals, medical
devices, clinical trials, outsourcing, telemedicine, medical tourism, health insurance
and medical equipment. The Indian healthcare industry is growing at a tremendous
pace due to its strengthening coverage, services and increasing expenditure by public
as well private players.
The Indian healthcare delivery system is categorized into two major components -
public and private. The Government, i.e. public healthcare system comprises limited
secondary and tertiary care institutions in key cities and focuses on providing basic
healthcare facilities in the form of primary healthcare centers (PHCs) in rural areas.
The private sector provides majority of secondary, tertiary and quaternary care
institutions with a major concentration in metros, tier I and tier II cities.
India's primary competitive advantage lies in its large pool of well-trained medical
professionals. Also, India's cost advantage compared to peers in Asia and Western
countries is significant - cost of surgery in India is one-tenth of that in the US or
Western Europe.

For over 70 per cent of the population, is set to emerge as a potential demand source.
Only three per cent of specialist physicians cater to rural demand.

23
The hospital and diagnostic centers attracted foreign direct investment (FDI) worth
US$ 2,793.72 million between April 2000 and January 2015, according to data
released by the Department of Industrial Policy and Promotion (DIPP)

Scope for growth

Considering the demand given above, the domestic healthcare sector is expected to
rise to $100 billion by 2015, according to the India Brand Equity Foundation. And
71% of this growth is expected to take place in hospitals.

Investment in private healthcare is going up too. The sector was the second favorite
destination for foreign investment in 2013, receiving 27 investments worth $181
million from the US. Overall, hospitals and diagnostics centers received an FDI of
$2191.91 million, while medical and surgical appliances (medical equipment)
received $741.80 million in the last 13 years. (April 2000-December 2013) according
to the Department of Industrial Policy and Promotion.

What are these funds being utilized for Setting up new facilities, research and
development into innovative practices, super-specialization for chronic diseases like
diabetes, Hepatitis B and medical treatments for both the domestic patients and those
from abroad. These mean rise in recruitment and acquisition of a skilled workforce
too.

Ambit for medical tourism

According to a sect oral outlook prepared by Accenture on India, the country hosts
150,000 medical tourists and this number will see a hike of 15% every year. To
capture this segment many corporate ventures have stepped into the sector, offering
multi-specialty healthcare, diagnosis and treatment packages.

Low cost medical innovation is an Indian specialty too, attracting investment from
both domestic sources and foreign companies. Currently GE is in the process of
setting up a manufacturing plant in Pune, which will see production of medical and
surgical products too. This is expected to become operational by mid-2014.

24
Meanwhile, National Instruments, a US-based company, is in talks with Indian
Institute of Technology, Madras, to work on a research facility for healthcare
technology innovation. Apart from working towards newer processes to make
diagnostics more efficient, this facility would look at production of automated testing
equipment and virtual instrumentation software.

Challenges facing Indian healthcare:

Year-on-year, the challenges facing the sector have remained the same. While we are
looking at a $100 billion growth by 2015, the perennial problems facing India are still
those arising from malnutrition (infant mortality, lacking overall development),
sanitation and access to affordable hospitalization and clinical care.

On the other end of the spectrum, availability of a skilled workforce – both doctors
and nursing and support staff – is cringing. Doctor-nurse density per 10,0000 persons
of the Indian population is an abysmal 19 (6.5 doctors + 13 nurses). (WHO report
2012).

Most of the skilled medical workforce is being sought out by countries in Europe and
the Middle East and retained by attractive compensation packages there vies versa in
India.

Compliance to regulations is still a cause for concern in both government as well as

private-run organizations. What’s more the system suffers from the lack of a quick
response and redressed system, with matters related to medical negligence and failure
largely relegated as consumer affairs troubles.

Further, we need an effective mechanism to address demand for safe, affordable and
quickly available healthcare for all.

25
2.14 RISK FACTORS OF THE HOSPITAL INDUSTRY

1. Long gestation periods

Hospitals require significant upfront investments and have a long payback period.
This makes investments in the sector less attractive.

2. Lack of qualified staff

Finding qualified staff & specialized doctors is a major challenge for hospitals in
India, especially for new start ups, leading to wage inflation and inadequate quality

3. Rising real estate prices

Increasing real estate prices lead to higher initial outlay or higher lease payments,
resulting in decreased profitability
4. Lack of capital
Huge capital will be required to meet the growing demand of healthcare facilities and
only a few big business houses can afford such expenditures and have the patience to
reap the steady returns over a long period of time.

5. Increasing operating cost

Increasing cost of equipment and labour lead to margin pressure and lower
profitability and it is also difficult to keep increasing pricing for patient care.

26
 CHAPTER - 3

COMPANY PROFILE

27
3.1 ORGANIZATIONAL PROFILE

KIMS, one of Asia's most modern tertiary care hospitals is a landmark healthcare
destination in Kerala initiated by KIMS Healthcare Management Ltd. With multi-
disciplinary capacity, state-of-the-art facilities, and excellent patient care, the hospital
is poised to become the most advanced healthcare institution in this part of the world.
KIMS group hospitals has proved its commitment to qualify in healthcare with
national and international accreditation. KIMS, Trivandrum is an ISO 9001:2000
certified hospital with national [(National Accreditation Board for Hospitals &
Healthcare Providers (NABH)] & international [Australian Council on Healthcare
Standards International (ACHSI)] accreditations. KIMS Group hospitals are
empanelled with government and semi-government institutions in India, Republic of
Maldives, Sultanate of Oman, UAE, Bahrain, UK and USA.

KIMS Kochi is another venture of KIMS Group ensuring the same health standards
with a 150 bedded facility emphasizing mainly on trauma, Orthopedic and other
surgical specialties. Kims Kochi is the first hospital in kochi certified with
International Accreditation (ACHSI). Strength of the hospital is the team of highly
qualified and experienced consultants who have proved their professional caliber at
their respective fields supported by well-trained nursing professionals and
paramedical staff.

KIMS – Kochi believes quality healthcare delivery is the responsibility of each and
every staff and it is possible only through a team approach.
KIMS (Kerala Institute of Medical Sciences) Health Care Management Limited,
Asia’s leading Healthcare Group has its 450-bedded tertiary care flagship hospital in
Trivandrum and several hospitals and polyclinics in GCC countries. KIMS Hospital in
Trivandrum has to its credit the unique achievement of National (NABH) and
International (ACHSI) accreditations and is empanelled with government and semi-
government institutions in India, Republic of Maldives, Sultanate of Oman, UAE,
Bahrain, UK and USA. National and international accreditations ensure full
implementation of all criteria on patient safety, quality improvement, infection control
and other critical areas. Awarded with ISO certification (ISO 9001:2000), KIMS is

28
poised to become the most advanced and quality-oriented health care institution in
this part of world.

In Kochi (KIMS Kochi) is another KIMS venture ensuring that the same health
standards reach Kochi, the commercial capital of Kerala. This is a 125-bedded
multispecialty Hospital, emphasizing mainly on trauma, orthopedic and other surgical
specialties providing world class health care at affordable costs.

At KIMS Kochi, our strength is the team of highly qualified and experienced
consultants who have proved their professional caliber at their respective fields. These
professionals are supported by trained nursing professionals and paramedical staff and
of course, state-of-the-art modern technologies.

KIMS is a 250-bed multi-specialty tertiary care hospital where a competent team of

specialists and sophisticated technology come together to deliver high-quality medical
aid. Launched in January 2002,KIMS has emerged as one of the leading centers of
pioneering medical work, research and academics in South India with a global
outreach.
To reach out to the community and beyond, to make quality world-class healthcare
affordable and accessible. This is the commitment that defines every aspect of the
clinical care, research and education at the Kerala Institute of Medical Sciences
(KIMS), Kochi.
KIMS has invested immensely in the area of quality and safe patient care. KIMS in
2006 successfully completed both National Accreditation Board for Hospitals
(NABH) and Australian Council on Healthcare Standards International (ACHSI)
accreditation thus becoming the first hospital in India with both National &
International accreditations.KIMS has been reaccredited by NABH and ACHSI in the
year 2010.KIMS laboratory is accredited by National Accreditation Board for Testing
and Calibration of Laboratories (NABL) and the blood bank accredited by NABH.

KIMS International Patient Relations Department offers its patients from overseas
world-class treatment, personalized attention and a comfortable stay. Air-conditioned
deluxe rooms and suites with telephone, television and internet are available to the
guests. Our plush designer rooms on the Executive Floor offer luxury to our
discerning patients.With a fine fusion of the cardinal principles of holistic care and

29
hospitality with the three-pronged approach of courtesy, compassion, and
competence, Kochi-based Kerala Institute of Medical Sciences (KIMS) offers a wide
range of services Other than a centers in Kollam, Kottayam, Trivandrum and
Perinthalmanna , KIMS has presence in Saudi Arabia, Qatar, Bahrain, Oman and
Dubai as well. The basic objective of the hospital chain is to evolve a single point
model where all possible kinds of treatments and care services can be made available.

KIMS is a 250-bed multi-specialty tertiary care hospital where a competent team of

specialists and sophisticated technology come together to deliver high-quality medical
aid. Launched in January 2002, KIMS has emerged as one of the leading centres of
pioneering medical work, research and academics in South India with a global
outreach.

MISSION
Care with Courtesy, Compassion and Competence

VISION
To be a model of excellence for the provision of healthcare and wellness
services.

VALUES
Patient Focus
Compassion
Collaboration
Innovation,
Integrity
Fiscal Responsibility

30
3.2 RECOGNITIONS
 EACOCK Award 2013 for Quality and in 2012 for Business Excellence
 Trivandrum Management Association Corporate Social Responsibility
Award 2012
 A-/ Stable rating by CRISIL Ltd. 2008
 Entrepreneur of the year 2006
 AV Gandhi memorial awards for Excellence in Cardiology (2007 & 2008)
 Regional ACLS training Centre by American Heart Association.
 Health Tourism award (2005)
 Financial Reporting 2005
 Kerala State Pollution Control Board Award 2004, 2006
 Best Customer Site Award from HCL Infosystems Ltd
 Best Power User Award by Cyber India Onlinea

3.3 KIMS CORPORATE SOCIAL RESPONSIBILITY

With over a decade of providing quality healthcare services, KIMS has always been in
the forefront as a socially committed corporate. “Inclusive Growth” has been one of
the driving forces in setting up the institution. Every member of the KIMS family is
committed to provide care and solace to the people in their location and in this
booklet, we are proud to present the various community service events that take place
in our hospitals.
Concern for the society
To give thrust and direction to our philanthropic activities KIMS Charitable Trust was
formed and registered as a charitable organization. The Trust is funded through
donations from individuals and institutions. The services of the trust include:
Providing free or subsidized care to the poor and needy
Assisting in medical and paramedical education
Grant scholarships and other charitable activities.

31
3.4 HRUDAYASPNADANAM
Reports indicate 60% of heart patients are below poverty line and cannot afford for
heart surgeries which are generally expensive. As such thousand of heart patients
succumb to the disease every year. It is for the relief of such patients, KIMS and one
of KIMS Hospital Directors and Dubai based business man Mr K Jalaluddin has come
out with Hrudaya Spandanam scheme for non affordable patients with curable heart
diseases.Patients across Kerala, from Parasala to Kasargod have benefited through the
scheme.

3.5 EMPLOYEE WELFARE MEASURES

At KIMS we realise that employees make organisations. Hard-working and content
employees make a loyal and efficient work force. Our employee welfare measures
include:
 Free Consultations
 Subsidized treatment facilities
 Free Hostel Facility
 Free Uniform
 Free Transportation
 Subsidized Food From Canteen
 KIMS Staff Welfare Fund
 Benefits on retirement on superannuation/ retirement on medical ground
 Scholarship for children of the members
 Marriage gift
 Sickness benefit
 Death relief
 Funeral expenses
 Group Mediclaim Policy
 50% of the annual premium is contributed by the management
 Training programmes

Our Human Resource wing organizes need-based In-housetraining programmes for

the different cadres of administrative staff. We believe training is an essential part of
growth and increases productivity. It adds value to the employee. Seminars and
clinical trainings are organized from time to time to enrich the skill and expertise of
our care providers.

32
 CHAPTER 4

REVIEW OF LITERATURE

33
4.1 SERVICE QUALITY

Kotler (Fandy Tjiptono, 2003: 61) explains that the quality should start from the needs
of customers and ends at the customer's perception. This means that good quality
perception is not based services provider, but based on the point of view or perception
of the customer. Customer perception of service quality is a comprehensive
assessment of a service benefits. Benefits gained from creating and maintaining
quality of service are greater than the cost to reach or as a result of poor quality.
Superior service quality as a tool to achieve competitive advantage of company.
Superior service quality and consistency can lead to customer satisfaction which in
turn will provide various benefits, such as:
(1) The relationship between the company and its customers will become more
harmonious
(2) provide a good basis for re-purchase activities
(3) Encourage customer loyalty
(4) Creating a recommendation by word of mouth (word of mouth) that benefit the
company
(5) To be a good corporate reputation in the customer’s mind
(6) Company’s profit will be increased.
The implications of these benefits is that each company must realize the strategic
importance of quality. Continuous quality improvement is not a cost but an
investment to generate greater profits (Hutt and Speh in Tjiptopno Fandy 2001; 78,
79). Zeithaml & Bitner (1996; 117) explains that the quality of service is the
excellence or superior service delivery process to those with consumer expectations.
There are two main factors that affect the quality of services, namely: expected
service and perceived service. If the service is received as expected then the service
quality is good or satisfactory, but if the services received exceed the expectations
will be very satisfied customer and perceived service quality is very good or ideal.
Conversely, if the service received is lower than expected then the perceived poor
quality of services. Quality of service will depend on how much the service provider's
ability to consistently meet the needs and desires of consumers.
There are two main aspects that describe and affect both service quality; the actual
service customers expected (expected service) and services perceived (perceived
service). Fitzsimmons & Fitzsimmons (2001: 44) explains that the creation of

34
customer satisfaction
atisfaction for a service can be identified through a comparison between
service perceptions with service expectation.

Perceived Service Quality Model

Source: Parasuraman, et al., (Fitzsimmons & Fitzsimmons, 2001: 44)

Olson & Dover (Parasuraman, et al., 1995), customer expectation is the

customer's confidence before buying a service which is used as a standard in assessing
the performance ofFIGURE
services. Customer expectations
– 4.1 – Perceived arece
serviceformed by model
quality past experiences,
talk through word of mouth and corporate promotions. After receiving a service,
customer service experience to compare with the expected. If the service suffered
under the expected, then the customer will not be interested again, otherwise if the
service experience meets or exceeds customer expectations the customer will look to
use these providers.
Parasuraman et al (Sultan & Simpson, 2000: 193) developed a measurement
scheme of service quality dimensions of tangibles, reliability, assurance,
Responsiveness, and Empathy. Measurements they have developed a term known as
Service Quality , including in his description suggests the difference between
expectation and performance (performance) from a number of criteria that currently
services are widely
ely used to measure the quality of service. This tool is intended to
measure customer expectations and perceptions, and the gap (gap) is in service quality
model (Fandy Tjiptono, 1996: 99). Measurement of service quality in this study is
35
based on service performance scores are perceived by customers (Cronin & Taylor,
1992).
Quality of services will create customer loyalty. Customers must be satisfied,
because if they were not satisfied to leave the company and will become customers of
competitors, this will decrease sales and in turn will lower corporate profits (Cronin &
Taylor, 1992; Rust, et al., 1995). The results of research conducted by Cronin &
Taylor (1992) and Taylor & Baker (1994) showed that the regression coefficient of
interaction with the service quality to customer satisfaction park services, airline and
distance telecommunications services, and significant buying interest returned. Some
researchers did test the influence of service quality, customer satisfaction and
repurchase interest. Woodside, et al., (1989) proposed an assessment model that
specializes relationship between perceptions of service quality, customer satisfaction
and interest to buy. Result directing that customer satisfaction is an intervening
variable between service quality and interest back. Affect service quality satisfaction,
and satisfaction affect the interest purchased. Research Cronin & Taylor (1992); Rust
et al. (1995); Zeithaml, et al., (1996); and Gabarino & Johnson (1999); Fullerton &
Taylor, 2000) found that the trend in terms of behavior shows the influence of service
quality on customer loyalty.

4.2 CUSTOMER SATISFACTION

Tse & Wilton (Fandy Tjiptono, 1997: 24) customer satisfaction or dissatisfaction is a
response to the evaluation of the perceived discrepancy between expectations and
service performance. Customer satisfaction is a function of expectations and service
quality performance. Engel (Fandy Tjiptono, 1997: 24) explains that customer
satisfaction as the evaluation of alternative purnabeli selected and provide results of
equal or exceed customer expectations. Dissatisfaction arises when the results do not
meet customer expectations.
Kotler (2003: 61) explains that satisfaction is the feeling of someone who described
feeling happy or disappointed that the result of comparing the perceived performance
of a product with the expected product performance. If performance fails to meet what
is expected, then the customer will feel disappointed or dissatisfied. If the
performance is able to meet what is expected, then the customer will feel satisfied. If
the performance can exceed what is expected, then the customer will feel very
satisfied.

36
Evaluating customer satisfaction can be used five approaches, namely: (1) Paradigm
of disconfirmation expectations, (2) T
The
he theory of comparative level, (3) equity
theory, (4) Norms as a benchmark standard, (5) theory of perceptual disparity value
(Natalisa Diah, 2000: 63). This study used the paradigm of disconfirmation
expectation approach, i.e. assessing customer satisfac
satisfaction
tion with a product through a
comparison of expectations with the perceived performance of customer service.

The Disconfirmation Model of Consumer Satisfaction

Source: Walker, 1995: 7

FIGURE – 4.2 – Model of customer satisfaction

Positive disconfirmation will occur if the perceived performance of customer service
is better than what was expected to create satisfaction, confirmation occurs when the
service performance as perceived by customers expected to create a feeling neutral,
negative disconfirmation
isconfirmation occurs when the performance of services that are not
perceived better than expected, leading to customer dissatisfaction (Oliver, 1997:
104). The concept of satisfaction and the quality is often equated even though these
two concepts have a different understanding. In general, satisfaction is considered to
have a broader concept than service quality assessment, which specifically focuses
only on the service dimension. Quality of service is the focus of the assessment that
reflects the customer's
r's perception of the five specific dimensions of service.
Conversely, satisfaction is more inclusive, that is, satisfaction is determined by the
perception of service quality, product quality, price, situation factors, and personal
factors (Zeithaml & Bitner,
ner, 2001: 74).

37
Customer Satisfaction Model
Source : Zeithaml & Bitner, 2001 : 75

FIGURE – 4.3 – Customer satisfaction model

Quality of service is a comparison between perceived service and expected service.

Dimensions used to measure the quality of services provided airlines on the domestic
service industry, commercial regular flights in Indonesia are as follows: reliability,
responsiveness, assurance, empathy, and tangibles (Parasuraman, Zeithaml & et.al in
Bitner, 2000; 82-83).
In the company
ompany engaged in the service, the service is the products sold by the
company. But for Service Company, not all service companies simply selling a
service only. In some other service providers, such as; hotels, then the bias in
addition to services are al
also
so offered to goods. Such as; food and beverages. Studies
conducted in various service industries addressed the importance of the goods factor
in influencing customer satisfaction (Kandampully & Suhartanto, 2000: Barsky, 1993,
Zeithaml, 1996). Quality of ggoods
oods offered in conjunction with services will affect
customer perceptions of service. The better the quality of goods will increase
customer satisfaction for services received. Instead of less
less-quality
quality goods would
damage the overall customer satisfaction
Customers
ustomers consider price as an indicator of the quality of a service, especially for
services whose quality is difficult to detect prior to services in consumption. This is
related to the fact that the nature of the services that have a risk level is high eenough

38
compared to the product form of goods and services to be purchased, the customer
tends to use price as the basis for expected quality of a product/service. Customers
usually tends to assume that higher prices would reflect the high quality (Barsky &
Solomon, in Dwi Suhartanto, 2001).
Environmental or situation factors affecting the level of personal satisfaction with the
services consumed. Situation factors, such as; conditions and circumstances will lead
the consumer experience to come to a service provider, this will affect the
expectations or the expectations of the goods or services to be consumed. The same
effect occurs because the influence of personal factors such as emotional consumer
(Zeithaml & Bitner, 2001: 59-60).
Customer satisfaction occupies a strategic position for the company's existence,
because a lot of benefits to be gained: First, many researchers agree that a satisfied
customer tends to be loyal (Anderson, et al., 1994; Fornell, et al., 1996). Satisfied
customer will also tends to buy back into the same manufacturer. The desire to buy
back as a result of this satisfaction is the desire to repeat the good experience and
avoid a bad experience. Second, satisfaction is a factor that would encourage
communication by word of mouth communication are positive.
Form of communication through word of mouth delivered by people who are satisfied
this could be recommendation to other potential customers, encouraging colleagues to
do business with the provider where the customer was satisfied and said things good
about the service provider where he was satisfied. Third, the effect of customer
satisfaction tends to consider the content providers are able to satisfy the first
consideration if you want to buy products or similar services (Solomon, in Dwi
Suhartanto, 2001).

4.3 TIME STUDY

Generally this technique is used to determine the time required by a qualified and well
trained person working at a normal pace to do a specified task. The result of time
study is the time that a person suited to the job and fully trained in the specific
method. The job needs to be performed if he or she works at a normal or standard
tempo. This time is called the standard time for operation. This means the principle
objectives of stop watch time study are to increase productivity and product reliability
and lower unit cost, thus allowing more quality goods or services to be produced for
more people. The importance and uses of stop watch time study can be stated as
under:
39
  Determining schedules and planning work
 Determining standard costs and as an aid in preparing budgets
 Estimating the costs of a product before manufacturing it. Such information is
of value in preparing bids and determining selling price.
 Determining machine effectiveness, the number of machines which one person
can operate, and as an aid in balancing assembly lines and work done on a
conveyor.
 Determining time standards to be used as a basis for labor cost control.
 Helps to know the Labour productivity, Labour efficiency, Labour
Performance and overall time required to perform the task.
 Helps to improve the process of operation.

Procedure for conducting stop watch time study:

Generally, the following procedure is followed in conducting stop watch time study:
1. Selection of task to be timed:
Select the task or job that needs to be timed for study purpose. There are various
priorities on the basis of which task or job to be studied is selected such as
bottleneck 104 or repetitive jobs, jobs with longer cycle time, to check correctness
of existing time, comparison of two methods etc.
2. Standardize the Method of Working:
To achieve performance standard accuracy it is necessary to record the correct
method of working.
3. Select the operator for study:
Select the consistent worker whose performance should be average or close to
average so that observed times are close to normal times.
4. Record the details:
The following information is recorded on observation sheet: Name of labour,
task/job performed, department, section of work activity, general information
about activity performed etc
5. Break the task into element:
Each operation is divided into a number of elements. This is done for easy
observation and accurate measurement.
6. Determine number of cycles to be measured:
It is important to determine and measure the number of cycles that needs to be
observed to arrive at accurate average time. A guide for the number of cycles to be
timed based on total number of minutes per cycle is shown below in

40
 7. Measure the time of each element using stop watch:
The time taken for each element is measured using a stop watch. There are two
methods of measuring. viz., Fly back method and Cumulative method. The time
measured from the stop watch is known as observed time.
8. Determine standard rating:
Rating is the measure of efficiency of a worker. The operator„s rating is found
out by comparing his speed of work with standard performance. The rating of an
operator is decided by the work study man in consultation with the supervisor.
Various rating methods used are speed rating, synthetic rating and objective rating

4.4 KEY VARIABLES

“Parasuraman et al. (1985) identified 97 attributes which were found to have an
impact on service quality. These 97 attributes were the criteria that are important in
assessing customer’s expectations and perceptions on delivered service” (Kumar et
al., 2009, p.214). These attributes were categorized into ten dimensions
(Parasuraman et al., 1985) and later subjected the proposed 97 item instruments for
assessing service quality through two stages in order to purify the instruments and
select those with significant influences (Parasuraman et al., 1988, p.13). The first
purification stage came up with ten dimensions for assessing service quality which
were; tangibles, reliability, responsiveness, communication, credibility, security,
competence, courtesy, understanding, knowing, customers, access. They went into
the second purification stage and in this stage they concentrated on condensing scale
dimensionality and reliability. They further reduced the ten dimensions to five which
were;

TANGIBLES
RELIABILITY
RESPONSIVENESS
ASSURANCE
Competence
Courtesy
Credibility
Security
EMPATHY
Understanding/knowing the customer.

41
TANGIBLES

The appearance of physical facilities, equipment, personnel and information

material
RELIABILITY

The ability to perform the service accurately and dependably

RESPONSIVENESS

The willingness to help customers and provide a prompt service

ASSURANCE

A combination of the following

Competence - having the requisite skills and knowledge
Courtesy - politeness, respect, consideration and friendliness of contact staff
Credibility - trustworthiness, believability and honesty of staff
Security - freedom from danger, risk or doubt

EMPATHY

A combination of the following:

Access (physical and social) - approachability and ease of contact
Understanding the customer - making the effort to get to know customers and
their specific needs

42
 CHAPTER 5
METHODOLOGY OF THE STUDY

43
5.1 INTRODUCTION:

POPULATION CHARACTERISTICS
Sample was taken from different department in the hospital. Time moment of the file
from different department was analyzed through questionnaire .Different department
were :-
 Nursing Department
 Discharge Summery Department
 Pharmacy Department
 Billing Department

Research Methodology is a purely and simply the frame work or a plan for the study
that guides the collection and analysis of data. Research is the scientific way to solve
the problem and it’s increasingly used to improve market potential. This involves
exploring the possible methods, one by one, arriving at the best solution considering
the resource to the disposal of research.

5.2 METHODOLOGY:

5.2.1 AREA OF THE STUDY

KIMS Healthcare and Management Limited , Kochi

5.2.2 PERIOD OF THE STUDY

The project was done for the period of two months from June to July 2014

5.2.3 RESEARCH DESIGN

A research design is the specification of methods and procedures for acquiring the
information needed. It is the overall operation pattern or framework of the project that
stipulates what information is to be collected from which source by what procedure. It
is also refer to as blueprint of the research process. This project work is descriptive in
nature.

44
KEY ISSUES OPTIONS
Research Design Descriptive
Data Primary Data
Research Survey Method
Research Type Observation Method

5.3 TYPE OF SAMPLING DESIGN

Convenient sampling technique is used, in which the respondents get directly
approached, to get answer from them to the several questions.

SAMPLE SIZE

The sample size for the survey was 68 patients

SAMPLING AREA

Sampling area of the study is the KIMS hospital inpatients departments.

5.4 SOURCES OF DATA:

1. Primary data

The primary data refer to those data which do not exist already in records and
publications. The researcher has to gather primary data fresh for the specific study
undertaken by him. The primary data are explicitly gathered for a specific research
project at hand. The primary data is collected with the help of questionnaire from the
patients

Means of obtaining primary data

Questionnaire

Questionnaire is a special type of questionnaire used for collecting data for service
quality analysis. It includes questions concerning different aspects of the subject for
study. Like questions are arranged under 5 different essential dimensions of service
quality. It is used in such cases where the subject of study is very wide and direct
observations are not possible. Questionnaires may be sources of information only
when the informers are well educated and prepared to cooperate with the research
worker.

45
2. Secondary data

Secondary data include those data which are collected for some earlier research work
and are applicable in the study the researcher has presently undertaken.
In this study the researcher used many of secondary data such as;
a) Hospital journals
b) Books
c) Internet.

5.5 DATA ANALYSIS AND INTERPRETATION TOOLS

The primary data collected from the respondents are analysed using statistical tools.
The data of analysis were collected from 68 patients who were inpatients of
department of , KIMS Hospital. Data is collected under different dimensions of
service quality . For analysis part Microsoft excel is used.

46
DISCHARGE PROCESS

Discharge Advice

Staff nurses prepares nurses notes File sends to OP

Prepares discharge summary

File sends to IP Billing Medicine Indenting Process

Prints D/s Summary & get signed IP Pharmacy takes D/S medicines

Final Bill Settlement D/s Medicine sends to concerned ward.

Staff nurses explains D/S Summary and D/S Medicine

Patient Check out

FIGURE – 5.1 – Discharge process

47
 CHAPTER 6
DATA ANALYSIS &INTERPRETATION

48
6.1 INTRODUCTION

The data collected has to be processed and analyzed in accordance with the outline
laid down for the purpose of developing the research plan. This is essential for a
specific study and for ensuring that we have all relevant data for many contemplated
comparisons and analysis. Technically processing implies editing, coding,
classification and tabulation of collected data. Analysis is the process of breaking a
complex topic or substance into smaller parts to gain a better understanding of it. The
term analysis refers to the computation of certain measures along with the searching
for patterns of relationship that exist among data groups.

Analysis of data in a general way involves a number of closely related operations,

which are performed with the purpose of summarizing the collected data and
organizing those in such a manner that they answer the research questions.

49
FISHBONE DIAGRAM

Possible reasons for discharge delay

FIGURE – 6.1 – Fishbone diagram

50
 6.2 CONSOLIDATED SUMMERY REPORT

AVERAG
AVERAGE TIME IN VARIOUS STEPS MIN MAX E
Time taken to reach the patient file to 0:04:0 1:25:0
NURSING the IP Billing 0 0 0:16:22
Time Taken for Discharge Summary 0:15:0 5:50:0
DOCTOR preparation 0 0 2:07:27
0:13:0 3:19:0
PHARMACY Time taken in IP Pharmacy 0 0 0:54:53
0:30:0 4:20:0
BILLING Time Taken in IP Billing 0 0 1:40:46
DISCHARGE Time Taken for Discharge medicine 0:06:0 3:00:0
MEDICINE delivery 0 0 1:09:55
2:26:0 9:59:0
TOTAL TIME 0 0 6:40:30

TABLE – 6.1 – Consolidated Summary Report

GRAPHICAL REPRESENTATION

AVERAGE
2:24:00

2:09:36

1:55:12

1:40:48

1:26:24

1:12:00

0:57:36 AVERAGE

0:43:12

0:28:48

0:14:24

0:00:00
NURSING DOCTOR PHARMACY BILLING DISCHARGE
MEDICINE

FIGURE – 6.2 – Graphical Representation

r 51
6.3 TIME TAKEN FOR DISCHARGE
MIN TIME :- 02:26:00 HRS
MAX TIME :- 09:59:00 HRS
AVERAGE TIME TAKEN :- 06:40:30 HRS

This is the total time taken for a patient to get discharged from the
hospital. From the data analysis we can see that the minimum time taken for a patient
to leave the hospital is within 02:26:00 hrs and the maximum time is 09:59:00 hrs. So
there is delay in certain department, from the data analysis its clear that discharge
summery and discharge medicine indenting is taking more time. If these two aspects
can be controlled the patient waiting time can be minimised and thus patient
satisfaction can be attained.

6.4 TIME TAKEN IN NURSING DEPARTMENT.

MIN TIME :- 00:04:00 HRS

MAX TIME :- 01:25:00 HRS
AVERAGE TIME TAKEN :- 00:16:22 HRS

This step is performed by the nursing staff. After the doctor has
advice the patient to get discharge the nurses should enter their nursing notes in the
hospital software about the meditation given and nursing care provided to the patient.
Then only the patient file will be transferred to doctors OPD for entering discharge
summery and discharge meditations and review date.

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6.5 TIME TAKEN FOR DISCHARGE SUMMARY
PREPARATION

MIN TIME :- 00:15:00 HRS

MAX TIME :- 05:50:00 HRS
AVERAGE TIME TAKEN :- 02:07:27 HRS

This step is performed by doctors. After the nurses completes there nursing notes the
patient file is transferred to doctors OPD by the attendees. The doctors enter the
doctors notes in the hospital software and discharge medicine is mentioned in the
discharge summery report. This process is taking maximum time since the doctors
will be busy within the department so the discharge summery may delay if OPD
patients are more.

6.6 TIME TAKEN IN IP PHARMACY

MIN TIME :- 00:13:00 HRS

MAX TIME :- 03:19:00 HRS
AVERAGE TIME TAKEN :- 00:54:53 HRS

This step is performed by pharmacy staff. After the doctor prepares

discharge summery and discharge meditation the document and file is transferred to
pharmacy were in medicine returns are taken and discharge medicine are billed and
transferred to nursing station by the attendees . Delays happens in the step mainly
because the pharmacist will be having confusion regarding certain medicine that
doctors prescribe so they will need a further clarification which delays in pharmacy.

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6.7 TIME TAKEN IN IP BILLING

MIN TIME :- 00:30:00 HRS

MAX TIME :- 04:20:00 HRS
AVERAGE TIME TAKEN :- 01:40:46 HRS

This step is performed by the IP BILLING Staffs. The patient file is

transferred to IP billing. The billing staffs makes sure all the billing is correctly done
and does billing if not billed and the consultation, pharmacy, room rents,
investigations, minor procedures, major procedures. All these clinical and non clinical
billing are checked and billed correctly.

6.8 TIME TAKEN FOR DELIVERY OF DISCHARGE

MEDICINE
MIN TIME :- 00:06:00 HRS
MAX TIME :- 03:00:00 HRS
AVERAGE TIME TAKEN :- 01:09:55 HRS

Patient discharge process ends with delivery of discharge medicines.

The attendees are the person who takes medicines from the pharmacy and deliver to
the corresponding nursing station. The availability of the attendees is an issue
altogether. If the attendees are not available at the right time this will contribute to
patient waiting time.

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 CHAPTER 7
FINDINGS, CONCLUSION &
SUGGESTIONS

55
7.1 FINDINGS

 Average time taken for discharge seems to be 06:40:30 hrs.

 Average time taken for preparing the discharge summary and indenting
discharge medicine after recommending the patient for discharge seems to be
02:07:27 hrs
 Average time taken for sending patient file to IP billing seems to be 16:22
minutes.
 Average time taken in IP billing is 02:05:46 hrs
 Average time taken in IP Pharmacy is 54:53 minutes.
 Average time taken for reaching discharge medicine to concerned nursing
stations is about twenty 01:09:55 hrs.

 From the discharge process study, it is found that the main reason for delay in
discharge process is the delayed summary authorization and discharge medicine
indenting.

 The pharmacy staff needs to clarify the doubts regarding medicine intends in most
-of the cases. In some case, even after clarification, they have to wait more time to get
the confirmation regarding it. This happens because the junior doctors who put the
medicine indent may not be available at that time.

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7.2 SUGGESTIONS

 At least, In case of insurance patients, it will be better if there is system of

sending discharge files to IP billing before 12:00pm. So that the bill can be
generated as soon as possible and can be send it to the insurance company for
the approval. After sending the bill to the insurance company, it will take more
than four hours for the approval.

 Normal Patients Discharge Advice should be given in the previous day

Evening Rounds. Discharge Medicine can also given at that day. Here doctors
will be able to prepare discharge summery day before discharge itself.

 Movement of IP File from department to department is also taking more time

this can be reduced by Improved by the Availability of Attendees in Time.

 We can make the patients to get discharge medicine through OP Pharmacy. if

it done this 2 hr delay can be avoided. This procedure is currently followed in
Most of The Hospitals. But there should be necessary manpower in OP
Pharmacy.

 Introduce a MOBILE TABLET synchronized with hospital software so that

right the moment the doctor finish consulting the patient in the room discharge
summery authorization can be done at the same point itself this will save much
more time.

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7.3 CONCLUSION

The study has been carried out with the primary objective of to study the “Discharge
Delay Analysis in Hospitals”. As competition increases in the health sector and
environmental factors become ever more complex, concern about the patient
satisfaction grows. From the study conducted in KIMS Healthcare and Management
Limited we can conclude that Discharge Delay play an important role in the
satisfaction of super specialty patients. Discharge Delay analysis not only influences
patient’s satisfaction but also create certain behavioral intensions, such as willingness
to return and willingness to recommend a provider to friends and family.

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BIBLIOGRAPHY

59
8.1 WEBSITES:

 http://en.wikipedia.org/wiki/healthcare

 http://www.kimsglobal.com

 http://en.wikipedia.org/wiki/World_Health_Organization

8.2 ARTICLES AND JOURNALS:

 A study on service quality and customer satisfaction of selected Private

hospitals of Vadodara City. Pacific Business Review International Volume 6,
Issue 11, May 2014. Dr. Darshana R. Dave, Reena Dave.

 Redefining Health Care: Creating Value-Based Competition on Results-

Michael E Porter and Elizabeth Olmsted Teisberg.

 Parasuraman, A., Berry, L. L. & Zeithaml, V. A. (1985). A conceptual

model of service quality and its implications for future research. Journal of
Marketing Research, 49 (4), 41-48.
http://dx.doi.org/10.2307/1251430

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APPENDICES

61
 QUESTIONNAIRE

KIMS HOSPITAL, KOCHI.

DISCHARGE PROCESS STUDY

To be filled by Process Details/Time

Nursing Discharge Date

Nursing Patient Name

Nursing MR.No

Nursing Doctor

Nursing Nursing Station/Level -

Nursing Discharge Advice Time

Nursing File from Nursing to OPD

To be filled by Process Time

Nursing ANM File at OP

Nursing ANM File send to IP Billing

Nursing ANM /
Billing Staff Discharge Summery Authorization

To be filled by Process Time

Billing Staff Files at IP billing Section

Billing Staff Dis Summary Printed &signed

Billing Staff Med/Bill ready -Call from Pharmacy

Billing Staff Completion at IP billing

Billing Staff Discharge time (from system)

62