Ots 24 Oac30-51 3mainbod

Time & Motion study of out patients, Shree Krishna Hospital
I
INTRODUCTION
1.0 Backdrop
Shree Krishna hospital is a 500-bed, well-equipped general hospital with most of the medical
facilities available under the same roof. The average daily utilisation of the 12 OPDs is 435. The
OPDs remain open from 9 a.m. to 1.30 p.m. and special OPD operates in the afternoon hours
from 2:30 to 5 pm. Because most of the patients are treated in the respective OPDs in the
morning hours there is often a queue. Also there are approximately 15% (table 11 gives the
details) cases of the patients being referred to another department and many more in addition to
this for diagnostic tests like X-ray, Pathological tests, Sonography, CT-scan, ECG etc. The total
time spent by each patient is higher than a private nursing home. The time taken is also perceived
to be more by the patients because they have to wait at various departments to get all the
treatment needs fulfilled, which is a daunting and monotonous task when done at a stretch. If the
same patient would have gone to a private clinic and would have been referred to some other
laboratory or specialist the time spent by him would be in different slots hence it seems to be
less. Delay can also result from inconvenient layout and location of departments or facilities
and/or due to delay from the service providers like the staff at registration or pharmacy counter,
doctors and paramedical staff.
The orientation of the study was not only to investigate the extent of delay and reasons for it but
also to understand what effect it has on the overall operations, competitive advantage and
reputation of the organisation. Because in the course of receiving service there is high
involvement of the patient with the service provider, so it is imperative to design every facet of
such services around the customers need and therefore the operations are planned, designed,
controlled and managed with the paramount objective of delivery of quality services. Hence the
impact of delay on the quality of service was also analysed.
1.1 Nature of the Problem

Waiting is inherent to services because services are perishable and intangible hence cannot be
stored. At the same time nobody likes to be kept waiting, be it a hospital or any other place. High
1 Rakesh, Rupanwita (IRMA)

waiting time and delays may result in uncertainty, uneasiness, unsettledness, anxiety, annoyance,
irritation, anger and frustration. All these lead to poor rating of overall service quality.
Even if the actual time taken is not very high but the customers perceive or feel that they have to
wait for a long time then also it will result in customer dissatisfaction. In studying and analysing
waiting problems the perceived delay plays an important role only next to the actual delay.
Perceived waiting time depends on the time perception, the psychological and economic cost of
waiting and value of consumer’s time. These factors determine the acceptability of waiting. The
subjective waiting time shows a higher correlation with irritation about waiting compared to the
objective waiting time.1
Therefore in addition to objective measurement and evaluation, the subjective evaluation of

waiting time or delay is also important for the service organisations. One solution to waiting
problems can be by reducing the actual/objective waiting time. At the same time the overall
quality of service delivery can be improved by pacifying or sweetening the subjective waiting
time.
1.2 Objective
1. To measure and assess the average time taken by an out door patient during each visit in
various OPDs and to find out areas where delay takes place.
2. To study the patients’ perception regarding delay/waiting in the hospital.
3. To suggest measures to reduce the waiting time at various steps of treatment of the
outdoor patients.
1.3 Scope of study

Study was done only for out door patients in the morning session from 9 am to 1.30 pm. The
afternoon OPD hours were not studied because in the afternoon the traffic is very low and so is
the queuing. Though there are 12 OPDs we decided to omit 3 OPDs, namely the departments of
2
TB and Chest, Psychiatry and Trauma and Emergency Care. Despite Trauma and Emergency
Care being an OPD was not taken into the purview of the study because for these patients the
1
Pruyn and Smidts, 1993.
2
Preliminary study and analysis of the previous 2 year traffic in the different departments revealed that average traffic is 6 and 8
patients per day in TB & Chest and Psychiatry. These departments have very low number of cases per day and insignificantly
small amount of delay made the study unnecessary in these departments.

principle of first come first served is not followed. So the following departments and support
services were studied.
TABLE – 1
Departments studied
Departments Departments Support services
Ophthalmology (Eye) Surgery & Anaesthesia Pharmacy
ENT(Ear, Nose, Throat) Orthopaedics Registration
Obstetrics & Gynaecology Skin & Venerology Pathology
Dental Paediatrics Radiology
Medicine
Various private clinics, nursing homes and diagnostic laboratories in Anand which directly or
indirectly compete with Shree Krishna Hospital by sharing the same patient base were also
studied to get an idea of the competitive advantage they have. With regard to this we also tested
the sated hypothesis in section 1.4 to reach to an objective conclusion.
In time study of each patient time spent the patient was recorded till the treatment received or
medicine purchased if any and not till he/she finally goes out of the hospital.
1.4 Hypothesis
Null hypothesis: There is no significant difference across the different causes which lead to delay
in service providing to a patient in Karamsad vis-à-vis a private nursing home.
Research hypothesis: There is a significant difference across the different causes which lead to
delay in service providing to a patient in Karamsad vis-à-vis a private nursing home.
1.5 Definition of Terms
1.5.0 Technical terminology

1. Process layout: Layout where people and equipments performing the same type of
functions are grouped in the same area.
2. Cycle time (C.T.): The time that elapses between one person finishing a process and the
next person finishing.
3. Value added time (VA): The time that actually adds value to the patient journey.

4. Changeover time (C/O): The time taken to switch from undertaking one type of process
to another. Record each process individually when undertaking different investigations
with one machine.
5. Available working time (AT): The available working time of staff on a shift minus breaks
etc.
6. The Lead time (LT): The time it takes for a patient to move all the way through a process
or value stream.
7. Bottleneck: Part of the journey with the smallest capacity relative to the demand
8. SERVQUAL: Standards for service quality, and is a standard process which measures the
gap between what customers expected and their perceptions of the service provided.
1.5.1 Medical and related terminology

9. Residents: a medical graduate engaged in specialized practice under supervision in a
hospital
10. Interns: recent graduate or advanced medical student living in a hospital and acting as an
assistant physician or surgeon
11. Ben: a Gujarati term for the lady care taker much like a nurse
12. Ophthalmology: Study of the eye
13. Gyaenacology: the science and medical speciality of the physiological functions and
diseases of women and girls, esp. affecting the reproductive system
14. Dermatology and Venerology: pertaining to skin disease and disease contracted by sexual
intercourse respectively
15. Paediatrics: branch of medicine dealing with children and there diseases

II
METHODOLOGY AND PROCEDURE
2.0 Methodology
In order to undertake service improvement in any dimension it is necessary to use a standard
method that enables us to understand the current process, determine the desired changes and
thereby improve it. Here the study was to handle waiting and delay problems and improve the
temporal aspect. The methods used in the study are discussed as follows.
2.0.0 Methods-engineering approach3

It involved the following steps:
1. Determining the objective
2. Studying the present condition for a detailed understanding of the problem, the interactions
of various components and possible causes and effects of conditions relating to the
problem.
3. Planning possible solutions to find out as much alternatives as possible
4. Evaluation of possible solutions to choose the alternative with little or no expense without
compromising with quality.
5. Recommendation of action.
The 6th and 7th step i.e. follow-up and Check results respectively were not part of the project
and was left entirely under the discretion of management of the organisation.
2.0.1 Pareto’s 80/20 law:

The law states that 20% of the root causes account for 80% of the results. For instance 20% of
patients generate 80% of the workload. Also 80% of the delays are because of 20% reasons.
Therefore identifying the critical few and looking at these areas will deliver improvements in the
majority. Those critical or vital few needs to be focused on rather than diverting attention to the
80% trivial many. So we focused on medicine OPD which handles 25% of the total patient
everyday. Similar effort was made for selecting few vital responses from the patients’ survey.
3
Annexure-13

2.0.2 Perceived service quality4

Apart from the actual nature of the service the patient’s perception of service quality determines
the success of a hospital. Personal need for the service provided by the hospital, word of mouth,
past experience if any and the 5 dimensions (listed below) together decides the expected service
whereas the same 5 dimensions play the single most influential role in perceiving the service.
These two added determine how patients perceive this hospital’s services and the role of inflated
cycle time (degree of responsiveness) in the entire scenario.
Figure - 1
Perceived service quality
Word of Personal Past

Mouth Needs Experience
Dimensions of Expected Perceived service quality

service 1. Expectations exceeded
service quality*
Reliability ES<PS (Quality surprise)
Responsiveness 2. Expectations met
Assurance ES=PS (Satisfactory quality)
Empathy 3. Expectations not met
Tangibles Perceived ES>PS (Unacceptable quality)
service
* Reliability: the ability to perform services as promised, both dependably and accurately.
Responsiveness: willingness to help customers promptly.
Assurance: knowledge and courtesy of employees, as well as their ability to convey trust.
Empathy: caring and individualized attention.
Tangibles: the appearance of physical facilities, equipment, and personnel, as well as other
facilities affecting the sense.
To measure these five dimensions “The SERVEQUEL instrument” was used. (Annexure-7)
4
SOURCE: Journal of marketing, published by the American marketing association, A. Parasuraman, V.A. Zethhaml, and L.L. Berry, “A
CONCEPTUAL MODEL OF SERVICE QUALITY AND ITS IMPLICATIONS FOR FUTURE RESEARCH,”

2.1 Sampling plan

2.1.0 For time study of the patients
A sample size of 180 was taken which included 20 patients from each of the9 OPDs through
random selection of patients. For 9 of the OPDs for which the study was conducted, though the
average number of patients is different in each of these departments a sample of 20 was taken
from each department to ensure proper representation of all the departments. The procedures and
referrals vary in each OPD and accordingly the total time taken varies. But all the outpatients
have to stand in a common queue at support services like registration, pharmacy, pathology,
radiology etc. hence it was assumed that ample number of patients will be there for the study for
each of these and hence no separate sample was taken.
TABLE - 2
Sample for time study of patients
No. OPD Average patient/day Sample size
1 Medicine 118 20 Source: MIS Records for two year
2 OB & G 36 20 (The total figure is for whole day
3 Surgery 49 20 OPD)
4 Ophthalmology 37 20
5 ENT 40 20 2.1.1 For patients’
6 Orthopaedics 53 20
survey
7 Paediatrics 33 20
8 Skin & VD 43 20 100 patients selected at
9 Dental 25 20
random were surveyed
TOTAL 435 180
to study the subjective
and behavioural aspects of waiting problems. Also 30 patients were surveyed with the
SERVQUAL questionnaire to collect insights about people’s perception regarding service quality
of the hospital. Those 30 patients were selected randomly and it was ensured that all of them be
outpatients only.
2.1.2. For doctors’ survey

15 doctors from various departments were surveyed to get an idea of the service provider view of
the waiting and delay problem.
2.1.3. For students’ survey

Students, interns and residents of the Pramukhswami medical college attached to the hospital
were surveyed as they also remain present in OPDs as a part of their education. The residents aid
the doctors in treating the patients and even run the entire OPD at times in absence of doctors.
TABLE - 3
Sample for students’ survey
Faculty Sample size
MBBS 2nd year 30
MBBS 3rd year 30
Physiotherapy 25
Nursing 15
Interns 25
Residents 20
TOTAL 145
2.2 Instruments and tools used

2.2.0 Process chart: for mapping the patient’s journey in detail (annexure-1)
2.2.1 Questionnaires
• for the patients (annexure-3)
• for students/residents/interns (annexure-5)
• for doctors (annexure-4)
2.2.2 SERVQUAL form (annexure-6)
2.2.3 Fishbone (Cause and Effect) diagram (annexure-7)
2.2.4 Flow Charts
2.2.5 Statistical tools (Mean, Standard deviation, t-test, factor analysis)
2.2.6 Monte Carlo simulation
2.3 Procedure followed

The study was conducted from two dimension, objective measurement and subjective evaluation.
The time study was the first step in the process of objective assessment of the situation. It was
conducted for 180 patients in SKH and 60 patients in private nursing homes, through a process
chart shown in the annexure 1. After that simple mathematical and statistical tools were used to
derive the mean time and there standard deviation. The earlier stated hypothesis was also tested

using t test for the difference of means. These quantities were used to analyze the situation and
derive insights in order to give recommendations.
The recommendations were also simulated in order to find out the reduction in the waiting time
once they were implemented and thus to decide whether to opt for the suggestions or not. For
this purpose Monte Carlo simulation technique was used.
The cases of the patients differ from each other so also the requirements. A hospital must be
flexible enough to accommodate a variety of types and sequences of treatments. For this reason it
is important to arrange various departments like out patient departments, operation theatre,
radiology, pathology, emergency care rooms, patients’ rooms, doctors’ rooms, pharmacy,
cafeteria, administration etc. in process layout which will allow efficient operation by better
arrangement of departments, service providers and equipments. The reasons for placing one
department next to the other depends on multiple criteria like sharing the same equipment or
personnel, logical movement of patients, better communication, safety, and contamination etc. so
simplistic options like that of load distance analysis in deciding the layout do not serve the
purpose. Therefore any change in layout was critically studied and qualitatively analysed. In
addition to present layout of that department the routes and connection to other department to
which there is frequent cross departmental movements was also studied.
The subjective evaluation of the delay problems mostly focused on the patient’s psychology on
waiting and delay. Their opinion regarding the promptness of the service delivery and the way
people respond to these delays was collected. 11 possible reasons for delay were identified and
through factor analysis they were categorized into 4 factors on light of which priority of
improvements were decided. Frequency counting was done for responses to some other
questions. To determine the importance of time in treatment and the impact of delay in patients
overall idea of service quality, SERVQUAL instrument was used. From the analysis of results,
the gap or difference between the patients’ expectations and perception was found out. This gave
an idea of where the organisation is placed in their mind at present and which dimensions of the
services needs to be improved.

Doctors were surveyed to understand the problem from the service provider’s perspective. Also it
helped in knowing the present level of perceived capacity5 available with the hospital which was
an important factor while suggesting improvements. It was obvious to find difference in
perspectives of doctors, the service providers and the patients, the service recipients. To see
another side of the situation from a relatively neutral point of view, the students, interns and
residents were surveyed.
2.4 Assumptions
1. While doing comparative study of other private clinics vis-à-vis SK hospital it was
assumed that those clinics are single speciality clinics offering specialized treatment like
only ENT, Gynaecology, Dental, Skin and VD etc. also they do not have the diagnostics
facility like SK hospital and send their patients to other Laboratories/X-ray clinic for the
same.
2. It was assumed that the time taken at the private clinics is the benchmark and comparison
was made. The purpose of comparing the time taken for services at SKH with that of the
private clinics (instead of comparing it with some normal time) was these are the set of
choices offered to a patients and he/she makes comparison among these.
3. The study was based on the assumption that the morning to afternoon OPD patient traffic
is 80:20.
4. It was assumed that actual waits and delays are functions of how the system is designed.
The only way to reduce them is to alter the system design.
5. Apart from the actual delay perceived delay affects the patients’ psychology. Even if
actual time taken is reduced to solve the perceived delay one has to pacify the negative
impacts of delay and make it appear more acceptable.
2.5 Limitations
1. The study was conducted during June-July for 7 weeks. Thus only one season was
studied whereas the morbidity pattern and incidence of diseases changes significantly in
different seasons. Also this time being the rainy season rural population (which accounts
5
Since doctors are the operating core and main service providers, their perception of the present workload will decide their
willingness to take up additional responsibility or acceptability of any change implemented since the changes has to be
operationalised by them only.

for 60% of the traffic in the hospital) remains quite busy in agricultural activities which
may distort the findings to some extent.
2. The study was only for the out patients. But while surveying the patients, doctors and
students it was difficult for them to answer strictly on the basis of OPD experiences. The
responses were influenced to a great extent by their IPD experiences too.
3. In depth interviews with the patients would have yielded some more useful insights but
because of the time constraints only questionnaire administration was done.
4. The motion of the patient outside the premises of the private clinic to avail of other
support services was not studied rather the study was limited to only time of service and
waiting in the clinic.
III
FINDINGS AND CONCLUSIONS
3.1 PROCESS DESCRIPTION

The typical processes that a patient undergoes are shown in the form of a process flowchart n the
next page. As soon as the patient enters the hospital the first requirement is to go to the
registration counter and get the case paper. For the ones who have already visited the hospital
this is not a problem and they straightaway reach the registration counter. But the patients
coming for the first time, having no idea about the procedures of the hospital tend to either ask
someone what to do or directly reach the OPD where they are explained to first get the case
paper first from registration and then come back. At the registration counter there are two
queues, one for the old cases and the other for new ones. The old cases are generally the follow-
up cases and most of the time the queue there is longer. At the counter the patient is asked about
which OPD he/she needs to go for treatment and the ones having no idea regarding this are asked
about their problem so that their case is made for the appropriate OPD. During the peak hour one
social worker remains present to inform the patients about the routes to the required OPD. But
apart from that 1 hour in the morning there is no one to direct/inform the patients. Either the
patients ask at the 2 helpdesks (of which 1 is deserted most of the times) or at reception (where
the operator is already too busy sending and receiving calls) or anyone else whom they get hold
of.
After getting the case paper the patient goes to respective OPD and submits the case to the Nurse
and waits for his/her turn. In OPDs like Medicine, Gynaecology and Paediatrics case submission
is followed by routine weight check-up. Here the Nurse or Ben also plays a major role in
regulating the flow of patients.
Figure - 2
Flow chart of patient’s movement

To the Y
Enters the Knows Registration Wait
Queue in
Hospital procedur counter
Y
N
Asks others Reaches the Gets the case
where to go OPD paper (Rs. 20)
Knows
Gets way to
informatio that OPD?
n to go to
Registratio
N
Asks someone else or tries to
find out the OPD on own Y
Waits Gives case Reaches the

for his
paper to Nurse OPD
To the IPD
Y
Admitted Receives Referred
in IPD? treatment to other
Y Y Wait
Goes to
Queue in Gets medicine
pharmac
N
N
Exits
*The bold lettered words indicate the steps where the patient gets some value addition.

In the OPDs the patients are given choice to decide which doctor they want to consult. Apart
from the probabilistic arrival pattern, this is one of the reasons why the queue builds up at times
and at other times there is no one to avail the services. If the patient is required to undergo
further tests like X-ray or pathological tests the doctor prescribes it in the case paper and for this
a receipt has to be made from the cashier by depositing the required charges. For pathological
tests one can directly go to the laboratory and get the receipt there at the counter. Since all
computers in hospital are LAN connected there is no hassle in getting the receipt from cashier or
at the laboratory. If the patient is referred to any other OPD then the similar cycle continues.
After treatment in the OPD if the patient has to be admitted in the wards as in-patient then again
another process starts but that is beyond the scope of this study. Otherwise as a last step the
patient decides whether to purchase medicine from the hospital pharmacy store or to exit. To
purchase medicine one needs to go to the pharmacy counter and stand in a queue if any and
finally exit from the hospital. So during treatment the services are availed at various stations and
searching and waiting at each station for a number of times at a stretch leads to a greater
perceived. Whereas in private clinics and other small nursing homes the patient directly goes to
the doctor and gets treatment. For X-ray or pathological tests they have to go to other nearby labs
or clinics. For medicine purchase also they go to nearby medicine stores. Thus the services
stations are disjoint rather than inter-connected like SK hospital. Also many clinics have the
appointment facility which is more convenient and saves time of the patients. But in SK hospital
everyone has to be in the same queue for any service.
The process of this OPD discussed is similar as far as the general procedures are concerned. But
here for some patients the need to dilate the pupil and keep eyes shut for 30 minutes becomes a
major reason of delay. Also the residents frequently consult the doctor. There are routine tests
done at 2 equipments. After that for further examination if required there is one equipment. If the
doctor is examining a patient for routine test and at the same time there is need to see a patient
for further examination one of the two patients has to wait. If the nurse is not available to take
case or apply drop there will be delay so also when residents make the patient wait while
consulting to the doctors. From the process chart it can be seen that at most of the value addition
steps consultation of doctors is needed. This also happen in other OPDs. Instead of making the
14
operator move from one equipment to another if he stays continuously at one place the waiting
can be reduced. Hence the responsibility of the doctors and residents is to be clearly specified.
Instead of serving the same patient throughout if for all the patients’ residents do some steps like
initial diagnosis and writing the case history and then doctors do rest of it i.e. detailed
examination it would save time.
3.2 HOSPITAL LAYOUT

The figure on the next page shows the layout of the entire hospital, location of the departments
and sources of information present in the hospital. Also it shows the flow of patients from one
point to other. The bright red arrows show the routes which are most convenient. However the
tendency is more to reach the open hall type central area and then walk through the outer passage
whereas the entrance to the OPDs is from the inner passage. Thus the thick blue lines indicate the
misleading ways and the green stars shows the areas where patients frequently loose track. One
such place is the central hall at the main entrance, where no signage is provided. There is no
passage from orthopaedics from the inner side since it is closed at trauma care and the outer one
is the only way to X-ray where many patients are referred from orthopaedic. Also the corners of
the octagonal arrangement where we have connecting corridors to the inner passage and staircase
to the first floor and basement are common points where patients find themselves lost. All four
sides look alike from the OPDs because the garden obstructs the complete view and it becomes
difficult even to find out the exit point.
15
Figure – 3 Hospital layout
atric
ecol
aedi
ogy
yna
Son
G
o
s
tal
y
n
-ra
De
X
Surgery
age
ashi
yna
Pass
er
G
C
c
Trauma & emergency

Dressing Room
Courtyard
TB&
Chest Courtyard
Medicine
Ortho
ECG
Courtyard
Courtyard
Diet
Clinic
Pathology
hi
ption
Rece
Offi
offic
yc
LIF
s
an
ce
P ry
&
sc T
T
at o
th C
Entrance hall
in Or
Sk
Regis
tratio
n
macy
Phar
Eye
EN
T
Signage Staff (as source of information)
Help desk Frequent way lost
Misleading and frequently used ways convenient ways
16
The gynaecology and paediatrics departments are easy to find though they are at a distance from
the registration as the straight pathway via the courtyard acts as an easy connector. But for the
departments placed inside and at corners it is difficult to find ways. In the diagram, Eye and ENT
OPDs which are located on the first floor are also shown and have been separated by a dotted
line. The Eye department is easy to locate as it is just at the end of the staircase and similarly the
signage for ENT also makes it convenient to reach. But the cashier counter 21 and pathology are
not only distantly located from the staircase well designed signage is also missing, so patients
find them difficult to access. Medicine, the OPD with the highest traffic is also not easy to find.
The red circles indicate the signboards or written help for finding routes. But as it can be seen
they are not at the spots where actually help is required. The signboards are placed parallel to the
walls so are visible only when one reaches them, moreover the height at which they are placed,
the font size and the number of departments written on a single board makes them less user
friendly.
All the four help desks are concentrated at the same place and are of hardly any help to the
patients at other places in the hospital.
The blue circles indicate the places where staff remain present throughout the day and can be
simultaneously used as help desks also. Those spots are the 2 security staff at two entrances,
nurse at orthopaedics, the man at dermatology, reception, tea stall, the cashier and the man at X-
ray counter. These people can very well cover the 3 sides. But the fourth side where medicine,
surgery and dental OPDs are there no one is available. Since workload and traffic is quite high
in those areas, someone has to be appointed for this purpose. This will be taken care of by a
slight change in the arrangements of the medicine department which will be discussed in the next
chapter on recommendations.
17
3.3 FINDINGS FROM OBJECTIVE STUDY

TABLE-4
Summary table of the time spent by a sample of patients in receiving OPD service
DELAY SERVICE TRANSPORTATION

Source: Time Study
Departmen
by G Pa Ra Su Or Re Ph S Di M De E E Pa by G Pa Ra Su Or Re P Sk Di M D E E Pa G Pa Ra Su Or Re Ph S M D E E P
t be ya ed di rgi th gis ar k ab ed nt N y th be ya ed di rgi th gis har in ab ed e N y th ya ed di rgi th gis ar k ed e N y at
n/ en iat ol cal op tra m i ete ici al T e ol n/ en iat ol cal op tra mac ete ici n T e ol en iat ol cal op tra m i ici n T e h
nu ac ric og ae tio ac n s ne og nu ac ric og ae tio y s ne t og ac ric og ae tio ac n ne t ol
rse ol y di n y y rse ol y di n a y ol y di n y a o
og c og c l og c l g
y y y y
G
yaen 23 35 4. 1
ac 6 12 99 15 27 36 56 27 2 33 5 52 3.7 6 19 37 43 2 2 13 1 2
4 3
12 1 4 1 9 3 8.
Eye 18 49 1 76 9 9 12 15 22 18 20 7 1 15 20 7 2 2 3
2
Dent 11 12 11 5 3
istry 15 0 0 68 0 25 18 19 34 19 3 3 11 17 3 9
M
edici 82 1 3 11 22 1 1
ne 13 76 89 0 8 4 2 19 5 19 34 6 7 4 40 11 24 2 54 3 3 0
3 1
15 0 2 6 1 3 8.
ENT 4 22 8 34 0 6 26 17 17 18 10 4 2 22 14 3 5 1 3
Surg 24 12 18 1
ery 16 95 2 20 33 6 86 4 44 8 32 8 10 29 36 26 6 18 14 49 3 5 20 2 1
Orth 14 24 14 9. 1.
o 9 9 94 32 6 19 19 7 32 10 25 9 33 5 40 7
Paed
iatric 35 11 28
s 20 6 17 74 6 12 6 9 17 19 35 5 17
Skin 1
& 10 19 3 1
VD 7 18 0 8 9 38 24 11 17 21 20 96 23 1 1 4 11 9 2
Departments that had no entries have been deleted, like TB and Chest, Sonography, CT Scan etc.
Time in nearest minutes
This integrated table has three broad divisions which have been further disintegrated for detailed analysis later in this chapter. Along on the Y Axis we have
the 9 OPDs under study while on the X Axis we have shown the three broad heads which will divide the total time spent by a patient into Delay, Service
time and Transportation time. Each of these three broad categories have as there sub heads all the possible service centres for which waiting, service, and
transportation can take place.
18
3.3.1 Distribution of total time spent by a patient in availing any of the OPD service
Table 5 indicates total and average time taken by patients coming for OP services in Shree
Krishna Hospital. The high values for the standard deviation indicates highly dispersed data
points implying that patients can get treatment either too early or too late than what is indicated
by the mean value. This reflects the peculiar nature of services with high customer contact with
the service provider and thus low level of standardized practices.
We see that the patients coming to medicine department have to spend maximum time followed
by those for ophthalmology. Skin and Venerology department offers quickest service followed by
dentistry.
TABLE – 5
Distribution of total time spent by a patient
Total Averag Std dev Waitin % of Servi % of Transpor % of Actual % of Transp % of
time e time g time total ce total tation total required total ortatio total
spent spent time time time time time transpor time n time
(for 20 by a spent spent spent tation spent delay spen
patients patient time t
per in the
Department dept.) OPD
Gyaenac 1090.66 54.53 15.60 481.23 44.12 534.6 49.01 74.87 6.86 44.41 4.07 30.46 2.79
Eye 1311.07 65.55 15.50 743.65 56.72 498.2 38.00 69.18 5.28 33.98 2.59 35.2 2.68
Dentistry 862.23 43.11 14.90 422.06 48.95 368.3 42.71 71.89 8.34 53.88 6.25 18.01 2.09
Medicine 1633.28 81.66 14.80 1162.1 71.15 364.4 22.31 106.85 6.54 38 2.33 68.85 4.22
ENT 889.98 44.50 13.00 569.33 63.97 259.8 29.19 60.86 6.84 43 4.83 17.86 2.01
Surgery 1121.39 56.07 15.80 664.83 59.29 352.2 31.40 104.40 9.31 66.86 5.96 37.54 3.35
Ortho 875.45 43.77 15.80 530.37 60.58 251.9 28.77 93.18 10.64 34.8 3.98 58.38 6.67
Paediatrics 982.31 49.12 16.30 583.08 59.36 342.4 34.85 56.86 5.79 44.41 4.52 12.45 1.27
Skin & VD 750.31 37.52 14.30 499 66.51 212.4 28.31 37.88 5.05 24 3.2 13.88 1.85
9516.66 52.87 18.10 5655.6 59.43 3184 33.458 675.94 7.10 383.3 4.03 292.6 3.07
Source: Time Study of 20 patients per department
When the time for which a patient is actually served was studied it was found that the department
of Gyaenacology is on the top offering a total of 534 minutes of service, averaging to about 27
min per patient, and is being closely followed by ophthalmology (Eye). For both these
departments the process of examination is very elaborate and takes a lot of time. Department of
Skin and Venerology is the one which offers the least service time of about 10 min per patient.
The study for the service time vis-à-vis the waiting time shows that the Gyaenac department is
the only one where on an average service time exceeds the waiting time (by 3 min per patient).
In the dental department the patient has to wait slightly more (3 min) than the time for which he
receives service. In the department of medicine this difference is maximum i.e. about 40 minutes.
19
For rest of the department the patient has to wait for about 12 to 16 minutes more than the
duration for which he is served.
With regard to the delay in transportation we see that a patient has to waste about 3 % of his total
time searching for departments. Medicine and Orthopaedics departments are the ones which
patient loose very often, despite the fact that they have a fairly advantageous location.
3.3.2 Composition of the total service time

The next table indicates the break up of the total service time between the different service
centres. For the ben/nurse the service time comprise of the entire routine work like registering
the patient at the department, taking weight, attending to telephone calls and controlling flow of
patients into the doctor’s room and ensuring discipline. It was seen that though the work
involved are same for the nurse in OB &G, medicine and paediatrics, the nurse in paediatrics
takes only half as much time as is taken by the one in OB &G. The department of medicine falls
somewhere in between. Again the routine work of the nurse in the ophthalmology, dentistry,
ENT, surgery, orthopaedics and dermatology is the same still, the nurse in surgery is far quicker
while in dental and Dermatology6 the service providers lag behind.
TABLE – 6
Distribution of the service time at different service centres
Service Mean standard by By Registrati Pharm Radiol Pathology Other
time for Service deviation ben/nu respective on acy ogy OPD
20 time/pat rse doctor
patients ient
Department
Gyaenac 534.56 26.73 9.30 26.56 351.92 52.00 3.74 0.00 37.35 62.99
Eye 498.24 24.91 6.20 15.36 390.93 21.70 18.26 0.00 15.00 37.00
Dentistry 368.28 18.41 3.80 25.32 252.74 18.53 34.45 18.26 19.00
Medicine 364.36 18.22 5.60 19.09 226.00 18.68 34.36 0.00 39.84 26.40
ENT 259.80 12.99 3.50 17.02 163.93 17.43 17.85 0.00 21.58 22.00
Surgery 352.16 17.61 6.30 7.89 187.58 29.05 35.69 31.54 18.00 42.00
Ortho 251.91 12.60 4.80 19.29 147.74 31.54 9.96 19.09 24.90
Paediatrics 342.38 17.12 4.90 11.54 286.43 17.02 18.68 0.00 8.72
Skin & VD 212.44 10.62 1.20 24.07 95.87 21.17 20.34 0.00 51.00
3184.11 17.69 7.20 165.92 2103.13 227.10 193.31 68.89 156.67 269.10
100 5.21 66.05 7.13 6.07 2.16 4.92 8.45
Source: Time Study
The service time by doctors in different departments varies from about 5 min per patient in Skin
and VD to about 20 min in Eye, followed by 18 min in OB &G. The high standard deviation in
6
The skin & VD department has a male attendant to do the routine tasks, no nurse is present.
20
the OB & G also indicates towards a highly dispersed service time and hence a probable need of
some standardised practices by the practioner. In ophthalmology there is too much dependence
on residents and interns who keep consulting the head doctor while treatment of a patient which
is one of the major cause of delay.
There are 3 registration and cashier counters where exclusively billing is done, the first one is the
main registration counter to get the case paper, the second one is the cashier counter near
department of paediatrics and the 3rd one is the counter number 21 at the department of
pathology on the first floor. The indicated registration time is the sum total of all these 3 service
centres. The department of eye demands frequent billing from counter 21 while in ENT such a
requirement is less frequent, hence a higher registration time for ophthalmology patients.
Similarly as OB &G, surgery and orthopaedic involves a lot of frequent billings for X Ray,
Sonography and other tests the time for registering for these OPDs are relatively higher.
The service at pharmacy is mostly availed by the patients from medicine, surgery and dentistry
while orthopaedics and OB &G patients are using the counter less frequently. Other departments
are on an average platform for pharmacy services.
The department of orthopaedics, surgery and dentistry are taking maximum service from the
radiology department while the department of pathology is kept busy mostly by cases from
medicine and OB &G department.
3.3.3 Composition of total waiting time

The table on next page indicates the distribution of the waiting time in the different departments
and other service centres. When the values of standard deviation are analysed, say in the case of
department of medicine, it can be inferred that about 95% patients will have to wait in between
27 to 89 min (+/- 2 standard deviations) and as the standard deviation for service time is quite
low (from table 6) such wide variation can be either due to very scattered patient arrival or
because of the fact that the first come first rule is being violated and so some are getting unduly
quick services at the cost of others who are waiting for a long time. This argument will be further
buttressed by the subjective part of the study.
TABLE – 7
21
Distribution of delay at different service centres

Waiting Mean Standard by At Registration Pharm Radiol Patholog other
time Waiting deviation ben/nu departme acy ogy y departme
time/pati rse nt nt
ent
Gyaenac 481.23 24.06 8.00 0.00 235.72 99.32 15.36 0.00 56.00 74.56
Eye 743.65 37.18 14.20 17.85 449.03 48.89 120.77 0.00 12.00 95.00
Dentistry 422.06 21.10 10.90 0.00 109.56 109.56 119.94 14.53 0.00 68.48
Medicine 1162.08 58.10 15.40 0.00 819.63 76.36 88.81 0.00 112.00 65.28
ENT 569.33 28.47 7.30 4.15 300.05 21.58 157.70 0.00 26.00 60.00
Surgery 664.83 33.24 11.20 15.77 241.53 32.79 125.75 94.62 44.00 110.15
Ortho 530.37 26.52 11.90 0.00 248.59 94.21 32.37 149.40 5.81 0.00
Paediatrics 583.08 29.15 14.90 19.92 355.66 74.29 116.20 0.00 0.00 17.02
Skin & VD 499.00 24.95 13.90 0.00 138.61 100.43 197.96 0.00 0.00 63.00
5655.61 31.42 14.40 57.69 2898.36 657.41 974.84 258.55 255.81 553.48
100.00 1.02 51.25 11.62 17.24 4.57 4.52 9.79
Source: Time study
We see that on an average more than half the delay is in the different OPDs while pharmacy is
also a major cause of delay, followed by registration. The department of medicine exceeds all in
the matter of delay followed be the ophthalmology. But the delay in the latter case is because of
the operation involved, i.e. waiting for some time for dilating the pupil with eye drops before the
patient can be treated but in the department of medicine delay can be attributed to high service
time, high traffic and certain avoidable delays like unfair queue, talking on cell/telephone by
service provider and certain layout issues.
Out of the 180 patients studied it was seen that about 49% of the patients take medicine from the
hospital pharmacy requiring a total of 193.31 minutes in getting serviced i.e. 6.07% of the total
service time for a patient (table 6), and a total of 974.84 minutes while waiting for being served
i.e. about 19.4%of the total waiting time for a patient (table 7). The average service time and the
average waiting time adds up to 11.8 minutes which is about 22% of the total time (52.87
minutes, from table 5) a patient spends on an average in any of the OPDs. The delay at pharmacy
will be dealt with in detail again in the chapter on recommendations.
The delay at radiology consists of two parts, first at place of taking the shot and secondly at place
where the report is generated.
In pathology the delay does not appear to be too much (it’s close to 23 min) but the number of
cases to pathology out of the sample studied was too small to predict the delays for the large
22
varieties of tests going on. Still we can compare the average time for some of the frequent tests
vis-à-vis private practioner. It was not very difficult to see from the perception study that this
department causes much unrest among patients as they are asked to collect reports at fixed
timings i.e. at 11 am, 1 pm and 4.30 in the evening or the next day, which may result in visit to
the hospital and this problem takes away the uniqueness of the hospital that it offers all services
under one roof.
3.3.4 Distribution of transportation time

From the following table it can be noted that the department of orthopaedic has the highest
standard deviation because, those who are familiar with the department reach very fast as it is
closest to the registration counter while those who take a wrong route take a lot of time in
reaching the department, so the data set had a higher range of values.
TABLE – 8
Distribution of transportation time among different service centres
Total time spent in mean standa Time spent Radiology Registration Pharmacy Pathology
transportation while time/pati rd in that
availing services in a ent deviati particular
particular department on dept.
Gyaenac 74.87 3.74 0.60 49.56 12.9 12.5
Eye 69.18 3.46 1.60 41.37 19.5 8.3
Dentistry 71.89 3.59 1.60 41.60 2.9 11 16.6
Medicine 106.85 5.34 1.80 72.40 24.5 9.9
ENT 60.86 3.04 0.40 38.86 13.7 8.3
Surgery 104.40 5.22 1.70 53.97 14.1 5 20.3 11
Ortho 93.18 4.66 2.00 33.00 9.1 9.5 39.8 1.6
Paediatrics 56.86 2.84 1.40 40.26 16.6
Skin & VD 37.88 1.89 0.60 23.09 4 10.8
675.94 3.76 1.70 394.1 26.1 29.5 174.7 51.6
100 58.30 3.86 4.36 25.85 7.63
Source: Time study
We see that the time spent in moving towards any out patient department is on an average close
to 6%(394 min for 9 departments), towards radiology 4%, registration 4 %, pathology 8% and a
maximum of 26%for pharmacy. So the department with highest traffic should be made well
known and thus delay can be avoided to a maximum possible extent. So we see that if we
consider a motion of 100 min by a patient in the hospital on an average we can expect him to
move for 26 min towards the pharmacy. So the patients should be conveniently guided towards
pharmacy and moreover as it is the last service centre and the patient is already exhausted so any
23
trouble in finding Pharmacy will guide him towards the exit and the hospital will loose an
otherwise sure customer.
TABLE – 9
Distribution of transportation time among different service centres
Total Total time Gyae Paedi Radio Surgical Orthopae Regist Pharmac Skin Medicine Denta ENT Eye Pathol
Departm time spent in nacol atric logy dic ration y l ogy
ents spent transportation ogy
while availing
services in a
particular
department
1090.
Gyaenac 7 74.9 43.2 1.5 4.15 12.9 0.75 12.5
Eye 1311.1 69.2 19.5 7 2 32.4 8.3
Dentistry 862.2 71.9 2.91 10.8 16.6 3 38.6
1633.
Medicine 3 106.8 10.8 24.5 1.66 53.9 3 3 9.96
ENT 890.0 60.9 13.7 3 34.9 1 8.3
Surgery 1121.4 104.4 14.1 48.97 3 4.98 20.3 2 11
Ortho 875.5 93.2 9.13 33 9.55 39.8 1.66
Paediatrics 982.3 56.9 35.3 4.98 16.6
Skin & VD 750.3 37.9 1 1 4 10.8 19.1 2
9516.
7 675.9 43.2 35.3 26.1 56.45 51.9 29.3 175 20.8 69.7 40.6 39.9 36.4 51.7
100 6.4 5.2 3.9 8.35 7.68 4.3 25.8 3.1 10.3 6.0 5.9 5.4 7.6
Source: Time study
This above table further closes down our option regarding required changes on a priority basis
for few of the out patient departments and brings forth the details of transportation time
regarding individual departments, from which we can see that people are moving for a longer
duration towards the Medicine and Ortho department despite the fact that these are not the most
distantly located departments, indicating need of better signage system.
3.3.5 Delay in transportation

The table-10 on the coming page indicates the time spent by the patients in moving for different
services when they come to a particular department for treatment. For example the 73.04 minutes
for Gyaenacology implies that the 20 patients who came for treatment in Gyaenacology spent
about 73 minutes till they received all the concerned services to their treatment, including
interdepartmental motion.
TABLE - 10
Delay in finding Departments
Gyaenac Actual time taken 73.04
Ideal time 44.41
Delay 28.63
24
Eye Actual time taken 59.76

Ideal time 26.98
Delay 32.78
Dentistry Actual time taken 67.2
Ideal time 51.88
Delay 15.32
101.2
Medicine Actual time taken 6
Ideal time 36.79
Delay 64.47
ENT Actual time taken 56.44
Ideal time 41.09
Delay 15.35
Surgery Actual time taken 89.64
Ideal time 56.86
Delay 32.78
Ortho Actual time taken 83
Ideal time 28.22
Delay 54.78
Paediatrics Actual time taken 56.44
Ideal time 44.41
Delay 12.03
Skin & VD Actual time taken 29.88
Ideal time 20.75
Delay 9.13
616.6
6 351.39 265.27
Source: Time study
The department of Gyaenacology and Paediatrics have a unique layout advantage and that is they
have a straight pathway, taking the patient directly from the entrance of the hospital into these
departments, so even though they are distantly placed the transportation time is relatively lower.
Though ophthalmology is far closer than ENT from the registration counter, the patient’s profile
is the major cause of delay for eye department, i.e. many patients to Eye are of old age and they
take time climbing up the stairs to first floor, while those to ENT department are of diverse age
group, are relatively agile. Secondly the test frequency is higher in Eye and patient have to move
many a times to counter 21 for billing of the test and this counter is placed even ahead of ENT.
Again, though the traffic is much higher in department of medicine it is placed ahead of
Dermatology and Psychiatry. Adding to the problem is the intermediate passage which creates a
maze for the patients who keeps loitering fro quite some time before he reaches the department
of medicine. On the other hand Dermatology which has very low number of patients as
25
compared to medicine is placed ahead and this location can be easily indicated by the person at
reception and is also accessible easily as it has a simple rectilinear path with no passages in
between.
Though the department of Orthopaedics is similarly placed as the department of Dermatology it

does not have the advantage in transportation because it is on the other side of registration
counter and despite the fact that patients are told the department number the patient has a
tendency to move towards the reception and thus move on a wrong path and take a round path
towards the department instead of a much simpler straight path.
3.3.6 The cross departmental traffic

The following table shows the average number of cases per day and the number of referral cases
in each of the OPDs out of the 20 patients who were timed. The department for which the
number was insignificantly small or for which our results didn't tallied with what the nurse had
to say have not been tabulated.
TABLE – 11
Inter department traffic
The number of referred Average No. of
cases for the 20 cases Cases in morning Average number of Frequently referring
Department studied in T & M OPD* referral cases** departments***
Gyaenac 2 29 3 Surgery, Medicine
Eye 5 30 8 Medicine, ENT
Dentistry 3 20 3 Medicine
Medicine 2 95 11
ENT 3 32 5 Medicine
Surgery 5 40 10 Medicine, Ortho
Ortho 2 42 3
Paediatrics 0 27
Skin & VD 6 34 10 Medicine, Ortho, Surgery
Source: Time Study and Medical Records
*From data of 2 years and under assumption that morning OPD constitutes 80% of total OP.
**From T & M
***Only those dept. for which the T & M tallies with information from nurse in respective dept.
The following figure shows the interdepartmental traffic. The department of Eye, E.N.T. and
Pathology shown beyond dotted line indicates location of those departments on the 1st floor. All
other departments are on the ground floor. The arrows indicate the routes and direction of
interdepartmental traffics. The red coloured arrows show the inflow to pharmacy and the blue
26
ones show out flow of patients from registration to OPDs. The green arrows indicate flow from
OPDs to Pathology or X-ray. The purple lines show the flow in between the 9 OPDs. The high
number of arrows indicate the delay due to availing more than one facility which is absent in
case of private clinics.
Figure – 4
Inter departmental traffic
Gynaecology Paediatrics
Cashier
Dental
X-ray
Surgery
Pathology
Medicine
Orthopaedics
Skin & VD
Pharmacy Registration
Eye ENT
It can be noted that all the OPDs have flows from registration and to pharmacy. Also patients
from most of the departments go to X-ray and Pathology. For getting services from these
departments one needs to go through the cashier for the receipt. Hence any delay in any of these
will act as a bottleneck except pharmacy which is the last phase of service. Until and unless the
report is generated from pathology, treatment at the referring department cannot proceed.
Similarly when a patient goes from skin OPD to medicine etc he/she has to join the queue of that
27
OPD and delay takes place. This gives us insight of increasing speed at those common facilities
like registration, pharmacy, pathology, radiology and cashier. Also there can be provision of a
special doctor for referral cases at the departments to which many referrals go like medicine,
surgery and orthopaedics but the same is not required for dermatology though it has high number
of referred case because it is already having under utilized capacity.
3.3.7 Study of SKH vis-à-vis private clinics

The following table gives the status of mean time taken by patients while availing services from
SKH in comparison to those using private clinics. When standard deviation was analysed it was
found that not only the mean time taken is less in private clinics but also the standard deviation
values are much smaller, which implies less uncertainty for the patients regarding when they will
get the services which results in the low psychological and economic cost of waiting. The
important thing to note is that the service time is also showing small standard deviation meaning
that the practioner is taking more or less same amount of time in treating his patients, which
indicates standardised practices, less interruptions while examining patients and high degree of
professionalism.
TABLE – 12 Distribution of the total time spent by a patient vis-à-vis private clinic
Averag Std Average Std dev Mean Std Average Std Mean Std dev Averag Std dev
e time dev time Waiti dev waiting dev Servic e time
spent spent at ng time in e time spent at
by a private time Private at private
patient Clinic at clinic SKH Clinic
in the SKH
Department OPD at
SKH*
Gyaenac 38.27 15.60 22.78 5.54 16.75 8.0 9.23 4.55 21.52 9.3 13.55 3.07
Dental 25.79 14.9 17.53 4.63 10.96 10.9 7.43 2.42 14.83 3.8 10.01 3.78
Medicine 57.99 14.80 26.6 8.53 44.8 15.4 19.05 7.16 13.19 15.4 7.5 4.03
ENT 26.21 13.00 21.9 6.3 16.29 7.3 13.93 .54 9.92 7.3 7.97 3.22
Ortho 27.01 15.80 18.58 6.41 17.14 11.9 11.5 5.79 9.87 11.9 7.08 2.18
Skin & VD 19.01 14.30 17.28 5.46 11.95 11.2 11.6 5.29 7.06 13.9 5.68 1.06
(Source: Time study at SKH and Private Clinics)
*Transportation Time, Radiology, Pathology and outside services not included
The table below is the summary of the test of differences of mean waiting time, the service time
and the total time. We see that the total time taken is significantly higher for department of
Gyaenacology and medicine while other departments though take more time than the
counterparts the statistical difference could not be established.
TABLE – 13
Test of difference of means alpha level = 0.05 t-critical for degree of freedom 28 =1.024
28
Total time Service time Waiting time

t- null t- null null
Department SKH Clinic value hypothesis SKH Clinic value hypothesis SKH Clinic t-value hypothesis
38.2 16.7
Gynaecology 7 22.78 2.44 Rejected 21.5 13.55 1.07 Rejected 5 9.23 1.31 Rejected
25.7 10.9
Dental 9 17.53 0.91 Fail to reject 14.8 10.01 0.92 Fail to reject 6 7.43 0.92 Fail to reject
57.9
Medicine 9 26.6 1.61 Rejected 13.2 7..5 1.24 Rejected 44.8 19.1 1.73 Rejected
26.2 16.2
E.N.T. 1 21.9 0.45 Fail to reject 9.92 7.97 0.54 Fail to reject 9 13.9 0.21 Fail to reject
17.1
Orthopaedics 27 18.58 0.88 Fail to reject 9.87 7.08 0.80 Fail to reject 4 11.5 0.32 Fail to reject
19.0
Skin & VD 1 17.28 0.24 Fail to reject 7.06 5.68 0.74 Fail to reject 11.95 11.6 0.08 Fail to reject
When service time alone was compared it was also found to be higher for all the departments but
statistical difference could be observed only for Gyaenacology. Similarly an insignificant
difference can be seen for waiting time for all the departments except Gyaenacology and
medicine.
3.4 FINDINGS FROM SUBJECTIVE EVALUATION OF WAITING AND DELAY

As mentioned earlier the people’s perception of time is as important as the actual time taken. So
the patient’s responses were taken through a survey of 100 patients using a questionnaire. 11
possible reasons for delay at various points in the hospital were identified and patients were
asked to identify which all reasons they feel contribute towards delay. To reduce the number of
variables and categorize them into a few types factor analysis was done. This also helped in
clubbing together the closely related variables showing multi-collinearity.
3.4.0 The identified factors for delay

Four factors were identified together which explains 68.34% of the variability in the data set.
Details of the factors are given in the table below.
TABLE-14
Factors for delay as perceived by the patients
No. Name of factors Variables % of Cumulati
variance ve %
explained
1 TRANSPORTA b. Searching for department
29
TION DELAY j. Cross-departmental movements 21.923 21.923

k. Personal reasons like resting, waiting for
friends
2 DELAY DUE c. Medicine purchase
TO QUEUE d. Queue in OPDs 15.870 37.793
I. Waiting for doctor/nurse if absent
3 NON f. f.The doctor is busy in something else and takes
RESPONSIVE longer time to see the patients 15.602 53.394
STAFF h. Nurse is busy elsewhere; doesn’t pay
attention
4 DELAY AT a. At registration counter
SUPPORT e. For pathological tests 14.943 68.337
FACILITIES g. In radio-diagnosis
Source: Patient survey
Patients feel that searching for the departments, moving from one department to other (mostly in
cases where the patient is required to undergo diagnostic tests or to another OPD) and for other
personal reasons like resting, waiting for attendants, going to toilet etc together accounts for
maximum of the delay. It was found out from the time study that the actual time spent in
transportation is only 7.1% but the patients feel it very important reason of delay because of the
inconvenience and helplessness caused by this. Any improvements done to reduce this time will
have more impact on the patients.
The next reason for delay identified was the queue for the services at various facilities. In some
of the OPDs like Dental, Skin & VD, Psychiatry etc. the queue is not very long and there is
hardly any queue after 12 pm. But traffic is more in Medicine, Orthopedics and Gynecology
OPDs so the patient has to wait there. At times the nurse informs the patients about how much
time they have to wait but most of the time the patients are told to sit and wait till their turn
comes. They are never told of any unexpected reason for waiting. This creates a sense of
uncertainty and uncomfortable feeling which makes the wait seem longer than actual. Absence of
nurse or doctors delays the procedures and treatment and the patients have to wait for longer
time. And at the same time the dissatisfaction of not to find the service provider increases the
feelings of lateness. However absence of doctors in OPD is not a frequent phenomenon and is
mostly when the doctors have to attend to any operation or emergency case. Also that time
residents take charge of the OPDs.
30
83% of the respondents said that one of the major reasons for delay is due to the long queue at
pharmacy counter for medicine purchase. Though the pharmacy counter remains open for 24
hours the peak hours are from 10 am to 1 pm when most of the outpatients come. Also at this
time since the treatment which is the main service that the patients come for is over any delay
after that seems less tolerable. The patients have the alternative of buying the medicine from
private druggists and thus they seem less compromising. For solving problem related to queues
either the actual time could be reduced by increasing efficiency of operations and service
delivery speed and/or pacifying the feelings of uncertainty, irritation and inconvenience resulting
from waiting.
Next to queue and waiting the non-responsiveness of the staffs like doctors and nurses makes the
patient feel the services in the Hospital is not prompt. If the doctor is busy in something other
than treating patients like talking on mobiles, talking to interns/students, discussing with
someone else other than the patients about topics not relevant to the patient, then the patient
starts feeling that the doctor is not giving him proper attention and not responding to their
problems. Similarly when the nurse is too busy to attend to the patients coming to OPD or
respond to any query rather spend time in gossiping etc the patients immediately gets a feeling of
slackness in services and feels this delay could have been avoided. Though the delay due to these
reasons may not be very significant in absolute terms of time but the degree of dissatisfaction
created in peoples mind lead to poor perceived service quality. Such behavioral issues if taken
care of and staff become more responsive, empathetic and give personal attention the patient will
be more satisfied though there is apparently no change in the treatment.
The last factor of delay is related to the delay at various support facilities like pathology and
radiology. Not all the outpatients receive services there whereas all of them go to registration
counter. Services at registration are pretty simple, short and quick. But at pathology there is
fixed time slot for getting the diagnosed report. For the samples taken before 11am the reports
are given after 11, for tests after 11 am the report is generated after 1 pm. Patients going for tests
after 2.30 have to wait till 4.30 for the report and by that time no doctor is available in the OPDs.
So the patient has to come again the next day. In radiology there is no such predetermined time
and promptness of services depends on the number of cases. Also for these diagnostic tests there
is additional hassle of getting receipt from cashier which enhances the delay.
31
Thus we conclude that the improvements have to be focused on reducing the patients/attendants
perception of delay due to transportation and followed by reducing the delays resulting from
queues at various locations. Responsive staffs and attention towards the patients makes the delay
more acceptable and also creates favourable feeling in patient’s mind. The support facilities like
diagnostics should not be bottlenecks and rather be aligned with the OPD services.
3.4.1 Some qualitative response to waiting problems

To achieve better patient satisfaction and loyalty their reaction and responses to waiting and
delay is to be understood apart from the reasons of delay. So the patients were asked questions
about their perception of the promptness of service delivery in this hospital and reaction to
waiting problems.
When asked about promptness with which services are delivered in this hospital, maximum
response was in the category “late” followed by normal and very late (table 15). Only 2% and
18% answered that the services are very prompt and prompt respectively. 24% i.e. nearly one
fourth feel that time taken here is normal; otherwise 56% i.e. more than half feel that the services
are delayed.
TABLE -15
Responses about promptness of services of hospital
Responses %
a. very late 24
b. late 32
c. normal 24
d. prompt 18
e. very prompt 2
Source: patient survey
Also most of the “late” and “very late” responses were from departments like Medicine,
Orthopaedics, Surgery, Eye and OB&G whereas respondents from Dental, Paediatrics,
Psychiatry and Skin told that the services are prompt or normal. However this cannot be directly
correlated to the departments as the perception gets influenced by the time spent in support
services like pharmacy, registration, pathology and radiology etc. A patient tends to feel the
32
services are late if he/she had to wait for quite some time in Registration or Pharmacy even
though he got prompt treatment in the respective OPDs.
TABLE – 16
Before service and after service perceived time
Before service % After service %
Less than 30 minutes 7 Less than 30 minutes 0
30 minutes -1 hour 27 30 minutes -1 hour 11
1-2 hour 39 1-2 hour 28
2-3 hour 15 2-3 hour 37
3-4 hour 9 3-4 hour 17
more than 4 hours 3 more than 4 hours 7
The above table shows that most of the respondents came with an anticipated time of 30 minutes
to 2 hours (66%) and as few as 3 came with estimation of more than 4 hours. When asked about
actual time taken, maximum (37%) response was for 2-3 hours followed by 28% for 1-2 hours.
This time is what the patients perceive they have spent in the hospital whereas from time study it
was calculated that on an average a patient spends about 52 min. Most of the patients come with
the anticipation that the services will be over within 1 to 2 hour.
TABLE – 17
Difference in actual and anticipated time as perceived by the patients
Difference (Delay) %
Less than 30 minutes 20
30 minutes -1 hour 41
1-2 hour 32
2-3 hour 5
3-4 hour 2
more than 4 hours 0
Perceived Delay
30 minutes -1
However it’s the patient’s time sense and perception that matters more than the actual time taken.
45 hour, 41
40
Frequency
1-2 hour, 32
Also most of them feel that the difference between their anticipated and actual time was 30
35
30 Less than 30
25 minutes, 20
minutes to 1 hour and 1 to 2 hours. This means if they expected that the treatment will be over in
20
15
10 2-3 hour, 5 more than 4
5 3-4 hour, 2
hours, 0
0
Tim e
33
1 hour, they felt that it took them extra 1 hour or so. The next frequent response (20%) was in the
category of “less than 30 minutes”. The perceived difference exceeded above 2 hours only in
case of 7 respondents. These figures give an idea about the time sense of people but do not truly
throws light on the patient’s feelings. For some a difference of 1 hour is acceptable whereas some
other patients may get highly dissatisfied by a delay of 15 minutes. Balking and reneging is high
for the less tolerable patients. Also the threshold level of bearing delays is person specific. So the
next task was to understand the tolerability towards delay.
Many patients and/or attendants said that waiting is a very common phenomenon in life and
especially in places like hospitals and when one comes to cure him then no point in grumbling
about the delay. So they accept waiting and being in queues as a part of life and try not to get
irritated by this.
TABLE – 18
Reaction about delays in a hospital
Responses %
a. irritates extremely 20
b. somewhat irritates 14
c. undecided/ never thought 16
d. acceptable 46
e. never mind delays 4
undecided
Response to delay somew hat
irritates 16%
14%
irritates
extremely
20% acceptable
46%
never mind
delays
4%
34
However apart from the 46% people who said so there were around 35% of the respondents who
find waiting irritating including 20% who find it extremely irritating. Some complained that once
they took leave from a day’s work and came to the hospital and it could not be finished on that
day, they had to take leave of one more day. A woman had been waiting for more than 30
minutes but could not go to the toilet because of the apprehension that in the mean time if her
turn comes and she is not present then she will have to wait longer. Respondents even said that
though they are very irritated by waiting for a long time they will keeps coming here as the OPD
rate is only Rs. 20/- whereas private doctors at Anand charge as high as Rs. 100/- to Rs. 150/-.
On the other hand some prefer paying Rs.100/- so as to avoid the hassles of waiting. Also people
have other choices like Government dispensary/hospital or doctors whose charges are flexible
and fall within range of Rs. 10 to Rs. 30.
The patients coming here usually feel that the systems in this hospital is well organised and
though they have to wait in a queue their turn comes up in due course of time. The patients seem
to be quite satisfied with the fairness with which the patients are treated in queues. 85% of the
respondents feel that one has to be in queue for treatment and no one breaks the queue to get the
treatment faster.
TABLE – 19
Responses about the fairness of the sequence in which patients are treated
Responses %
a. extremely
a. extremely unfair 4 e. extremely fair unfair b. unfair
b. unfair 11 17% 4% 11%
c. normal 30
d. fair 38
e. extremely fair 17 c. normal
d. fair 30%
38%
However some patients complained that though they had been waiting for more than 2 hours
they were not called in and people coming just half-an-hour back got treated earlier. In such
cases the major grievance was directed towards the Nurse/Ben who sorts case papers and calls
patient’s name serially and send s them to the doctor’s room. And some respondents from
35
villages also told that as they are illiterate they have no idea whether they have been called in
sequence or someone else is being called earlier than them.
But when asked whether they were informed about the cause and duration of waiting, a
significant number i.e. 79% said they were informed by the nurse that they have to wait after
submitting their case paper till their turn comes in the queue. Still 21% said that they had no idea
about why they had to wait, they were just told to sit/ wait outside without being informed about
the reason.
TABLE – 20
Information about cause and duration of wait
Informed about YES NO
Cause 79 21
Duration 14 86
86% of them denied being informed about the probable duration of wait. Whereas a meagre 14%
replied that they were informed about the approximate time of waiting. The irritation was less in
cases where they were informed about cause and duration of waiting. Also many told that if they
were informed about the duration of the delay they, in the mean time could have finished some
other work. Some told that if in some cases an uninformed patient tries to get into the doctors
room straightaway after giving the case paper or if someone else out of curiosity and impatience
is peeping into the doctors’ room, the person is scolded badly by the nurse. Especially the
patients coming for the first time who do not have ant idea about the procedures in the hospital
were worst victims of such incidences. Also in some of the OPDs the nurse usually does not
respond favourably to queries of the patients regarding their turn or the duration of waiting. This
increases the anxiety and restlessness of the patients. Even a rustic who has no idea of the
sophisticated procedures can understand the verbal and nonverbal communication of the doctors
and other staff. Empathetic behaviour of the staff instils confidence in the patient.
The sources of information also play a major role in directing the patients to various OPDs.
Those who have been coming for quite some time know the routes to some departments. If a
patient keeps on wandering and is still not able to get the right place the annoyance and
helplessness caused is much more than the delay at the OPD or at other places because of queue.
36
Given the profile of most of the patients, the non user friendly signage and a general human
tendency asking instead of reading notices, helpdesks appear to be preferable to the patients
rather than sign boards.
TABLE - 21
Source of information to find routes
Responses %
a. already knows the routes 22
b. ask someone from the staff or at counters 12
c. ask other people coming here 17
d. try to find out on own 49
Still for those who have to find out the way extensive and easy system of signage is required. At
present, for the illiterates there is absolutely no pictorial or other clue provided to find the way.
Some of those who read the signage still find it hardly of any help.
The waiting atmosphere has an important role in people’s reaction to waiting. Uncomfortable and
boring atmosphere make delay feel longer than actual. It frequently reminds of the fact that they
are waiting and heightens impatience. 32% respond neutrally to the waiting atmosphere of SK
hospital. For them it is as normal as other places. 14% respond positively saying that for them
this atmosphere is not boring. Many of them said they did not have to wait for a long time and
some others were so involved in the proceedings that they did not gave it a thought. Also the tea
and refreshment available adjacent to registration (and also from mobile cart) were appreciated.
TABLE – 22
Patient’s perception of the waiting atmosphere at SK hospital
boring 54
normal 32
not boring 14
However more than half i.e. 54% of the patients find the waiting
atmosphere boring compared to other clinics and hospitals. Many private nursing homes have
good aesthetics, TV, and reading material which make waiting feel a bit shorter and bearable.
Also as most of the private hospitals and clinics are located in the heart of the city people have
there own ways to spend there time. Also theatre, shopping, visiting nearby friends and attending
37
to other small engagements creates a sense of better utilisation of the waiting time and people do
not have to sit counting minutes for their turn to come.
It is important to know the patient’s feelings about the appropriateness of time taken for their
treatment in respective OPDs and all other support facilities. Here also the responses were of
mixed kind. But the maximum of them felt that it could have been in lesser time and there was
unnecessary delay which was a reason for their annoyance. And still some other told that though
it took a bit longer than what ideally it should take that much time taken was acceptable.
TABLE – 23
Reaction about the time taken at various departments/counters
Responses %
a. It could have been done in lesser time. 31
b. there was delay but this much time taken is acceptable 26
c. cannot say anything 9
d. there is no delay, this much time is needed for treatment 20
e. the services were delivered promptly and earlier than expected 14
Those who do not perceive any significant negative effect, any improvement in waiting time are
less likely to satisfy them more than they are at present. However if the problem is not taken care
of the hospital is likely to lose goodwill and reputation to some extent because of those 31% who
could not receive the services according to their expectations. And since word of mouth plays an
important role in such kind of services the loss may be manifold and cumulative.
After taking the patients’/attendants’ response about delays and waiting etc. the effect of such
delays on choice of availing the services of SK hospital was probed. Surprisingly the delay does
not play very important role in deciding whether to avail the services of the hospital or not. Only
8% of the respondents said they would never come to this hospital and 12% would prefer to go
somewhere else. But they also disclosed that the time factor is not the only reason for this. There
are other considerations like reputation and ability of the doctor, satisfaction in the treatment and
accessibility etc.
38
TABLE –24
Intention of revisiting SK Hospital
Responses %
a. never come here again 8
b. prefer to go somewhere else 12
c. cannot say 8
d. still consider coming here 36
e. definitely come here only 28
Effect on customer base
still consider
coming here
definitely come
39%
here only
30%
cannot say never come here

prefer to go
9% again
somew here else
13% 9%
As many as 64% of the respondents said they would visit this hospital out of which 28% would
definitely come here only. Some of them are loyal to this hospital and have been visiting this
place for years. The major concern of the respondents was not how much time it takes to get
treated in a place but the quality of treatment they receive. They were ready to wait some extra
time to get treated from a doctor they believe to be good and skilled. In some of the OPDs like
Paediatrics and Medicine 3 doctors sit at the same hours. There is long queue for one particular
doctor and the patient prefers to wait instead of getting treated from the doctor who is free at that
time. Also some of them answered that longer queue for a doctor indicates the popularity and
ability of the doctor.
Hence it could be concluded that though most of the patients perceive there is delay in this
hospital, it does not play significant role in their decision regarding whether to avail health care
services or not. For the patients who come from distant place (like Khambat) delay of an hour or
two does not matter much as they have already forgone their livelihood for that day, what is more
39
important is that such customers are dissatisfied when made to wait for another day for test
reports etc. Affordability, accessibility, trustworthiness of the doctor and availability of facilities
etc comes into picture in addition to the time taken for treatment and all these factors together
decides a patient’s choice of the hospital. Patients come to the hospital time and again if they
perceive they are satisfied with all these dimensions of SK Hospital. Hence if improvements be
made on the waiting problems without considering rest of the factors the overall perception of
the patients will not change significantly.
Since patients repeatedly emphasized on quality of the services as very important concern in
choosing a hospital, an effort was made to measure the patients’ perception of the service quality
of SK hospital with help of the SERVQUAL model (Annexure-6). This model has
responsiveness as the embedded time dimension. On the 7 point scale (Annexure-13), the
maximum score that could have been given to any question is 7 i.e. strongly agree and minimum
was 1 i.e. strongly disagree which will result in a maximum gap score of six and if the
perceptions matches the expectations then the score will be close to zero. The lesser gap between
expectation and perception the better is the delivery of quality health service by the hospital. So
the best situation will be when the gap is close to zero for the individual five dimensions and also
for the overall average.
Table – 25
Service quality of SKH along different dimensions as perceived by the patients
GAP Unweigted Weighted

TANGIBLES 0.96 0.96
RELIABILITY 2.49 3.12
RESPONSIVE 2.44 2.14
ASSURANCE 2.72 2.04
EMPATHY 3.02 3.40
TOTAL 2.33 2.32
Source: SERVQUAL survey
The analysis shows that when all dimensions were attached equal weight, the gap is maximum
for empathy and assurance. This indicates the patients feel that the staffs are neither very friendly
nor caring. For both the weighted and unweighted scores the gap is highest for empathy followed
40
by reliability. The score for empathy is more when weightage is considered which shows that
people think empathy and individual attention is important for a hospital. Though the reaction to
promptness and responsiveness was quite high in case of unweighted score i.e. 2.44, it is only
2.14 for weighted score which shows that the time factor is not very important in overall quality.
But as such a gap of 2.14 in the promptness of service is not a satisfactory score and there is need
of improving it.
For tangibles the gap is lowest and equal in both cases. Hence the patients are satisfied with the
physical facilities and equipments present in the hospital. Also some of them do not have trust in
treatment here as they had to come more than once for the same problem. Because the patients
have choices of going to government hospital or private clinics there will be tendency to
compare all the alternatives. Also most of them (24 out of 30) attached maximum weightage to
this reliability factor; therefore the gap became 3.12 from 2.49 when weights were considered.
This shows that while going to a place for treatment the reliability and trust on the service
provider is the major deciding factor.
3.5 FINDINGS FROM DOCTORS AND STUDENTS SURVEY
The doctors and students (including residents and interns) responses were taken and presented as
below. However only the question related to promptness of service delivery was of direct intrest
to the study and rest of the questions were used only to remove bias. The responses were in %
and in a scale as follows:
• 1-20 very poor
• 21-40 poor
• 41-60 normal
• 61-80 good
• 81-100 very good
TABLE – 26
Perception of doctors and students
41
doctors students interns residents

services of hospital 69.3 95.6 92 87
charges 53.3 56.8 62.7 71
patients perception 68.0 64.4 70.7 76
promptness 73.3 76.8 89.3 84
promptness
100.0
80.0
60.0
40.0
20.0
0.0
doctors students interns residents
Here we can see that the doctors and students are of the overall opinion that services of the
hospital are prompt whereas patients’ feelings are different than this. If the supplier side feels
that the services are as such prompt than they do not see any reason or scope for improvement.
This mismatch between the demand and supply side can be an important reason of slacked
services from the staff and unfulfilled expectation of the patients. If this bias is not removed the
probability of implementing any suggestion for improvement will be weak.
Also to explore whether the doctors and other staff can take up additional responsibility it was
necessary to study their perceived present workload. It was found out that at present there is no
department where the workload of doctor is very high. The indices are given in the following
table and plotted in the graph below it.
TABLE - 27
Workload indices
42
Doctors Support staff

Medicine 0.695 Surgery 0.640
Paediatrics 0.645 Orthopaedic 0.630
Surgery 0.627 EYE 0.610
Orthopaedic 0.610 medicine 0.600
ENT 0.610 ENT 0.590
EYE 0.610 Pathology 0.590
Skin 0.600 Dental 0.587
OB&G 0.600 OB&G 0.587
Dental 0.587 Radiology 0.587
Pathology 0.573 Paediatrics 0.573
Radiology 0.563 Skin 0.565
Source: Doctors’ survey
Thus it was concluded additional responsibility can be given to the staffs and that also can be
eased by staggered work scheduling. Therefore shaping the demand can be possible here.
3.6 PRIORITISATION OF AREAS OF IMPROVEMENT

In any service marketing the customer evaluates the service from the beginning to end of its
deliverance but each step do not have equal influence and since the service delivery is a
continuous process, usually the later parts are most influential step in determining overall
satisfaction. Satisfied and pleasing experience at the end tends to pacify the annoyance at earlier
steps and gives a lasting effect. Hence any improvement taken should be prioritised for the steps
with greater impact on patient’s psychology. In SKH the final step of service is the medicine
purchase at pharmacy or prescription from the doctor (for those who buy medicine from outside).
When we analysed the services of the hospital with this premise it was observed that 55% of the
patients (out of 180) avail the services at the Pharmacy facilities where they have to wait a lot. At
times there is long queue at registration counter but the delay is not as much as at the Pharmacy
counter. Even at the peak hours at Registration counter i.e. from 9 am to 10 am most of those
standing in old case queue get service within 10-15 minutes. Moreover some delay there does not
affect patient’s perception significantly as he/she undergoes many other services after that and
the effect of that 10 minute delay will hardly have any impact till the end. Thus the OPDs and the
pharmacy are the priorities for improvements. Among the 9 OPDs the departments with
maximum traffic will be the ones to be improved first. Similarly if the patient is referred to
43
pathology for some test and there told to come next day to collect the report then also the
irritation is more as effectively he/she has to spend two days for the same treatment. So
pathology is also another concern for reducing the delay.
IV
44
RECOMMENDATIONS
The recommendations given are discussed department wise to highlight the specific problem in
each department and solution to it. Later the recommendations applicable to all the departments
have been stated.
4.0 DEPARTMENT WISE RECOMMENDATION
4.1 Medicine OPD
4.1.0 Change in layout and operations
The following figure indicates the present layout of the medicine department. There are four
cabins for four doctors in which every day two doctors sit by turn while one or both of the
remaining rooms are taken up by the residents as according to the number of patients waiting. At
times when the doctors go for emergency services, even more residents take charge.
Now as the number of patients increases so increases the commotion just outside the doctor’s
cabin. This leads to the blockage of the main passage as well as the door of the doctor’s cabin
leading to unnecessary noise and delay.
At present many a times the BP and even case history of the patients are taken by the doctors.
These tasks can be handed over to the residents thus saving the more valuable time and energy of
the doctors. This will reduce the service time as well as the patient dissatisfaction created when
they are exclusively treated by a resident (a student!).
Figure – 5 THE PRESENT LAYOUT OF DEPARTMENT OF MEDICINE
45
The changed
setup engages
one nurse
solely to take
care of the
motion of the
patients and
guiding the
patient to the
required
doctor. She
will also see
that no more
than 8 patients
are waiting just outside the doctor’s cabin. The others including attendants should wait in the
waiting space outside the department. Again, two residents will sit just outside the doctor’s cabin
and they will take the BP and listen and write down the history. The nurse will guide the patient
from here to the concerned doctor’s cabin.
The changed procedures should not be an obstacle in the learning process of the students,
residents and interns. Thus the residents and interns job will be on a rotation basis so that they do
not lose the opportunity to observe doctors and also treat patients.
Figure – 6
THE PROPOSED LAYOUT OF DEPARTMENT OF MEDICINE
46
4.1.1 Reducing the hassles and service time
From our preliminary study it was found that the morning OPD is being utilized by 83 patients
on an average. The frequency distribution of these 83 patients indicates that the patient turn up
mostly during the early hours. As discussed earlier the service time taken by the doctors in
private nursing homes varies between 4 to 11 min with the mean value 7.5 min and the standard
deviation is 4.03. Not only do the doctors at SKH take longer time in treating a patient vis-à-vis
private nursing homes (statistically significant at 95% level of confidence) but it was also
observed that on an average 11 min are spent in telephonic, cellular and other conversations. The
patients loose on an average 18 seconds due to the hustle outside the doctors room while leaving
and entering the cabin. We assumed that these wastes will be at least reduced by 50% if not
totally eliminated and we also assumed this will be done along with the hastening of services by
doctors by only 10 % which will reduce the service time from an average 11.3 min per patient to
10.17 min, still 36% higher than their private counterparts.
47
Using this reduced service time we reconstructed a frequency distribution as indicated below.
Then Monte Carlo simulation was used to determine the actual reduction in the net waiting time
per patient. It was found that the waiting time drastically falls by 54% by a simple reduction in
service time by 1.45 minutes {.5(11/28 + 18/60) + 1.13} per patient. The average queue length is
3.57 patients per channel of the service providers.
The simulation has been done under the empirical assumption that arrival rates are different in
the session between 12 to 1:30 pm when only 25% traffic is expected in general.
TABLE - 28
Frequency distribution after reduction in service time by 1.45 min And assuming the traffic to divide into 3
channels of 28 each
INTER ARRIVAL TIME SERVICE TIME
Cum. Rnd. No. Time Cum. Rnd. No.
Time(min.) Frequency Probability Prob. interval (In min.) Frequency Probability Prob. interval
0.07
1 1 0.048 0.048 000-48 2 2 0.071 1 000-71
0.10
2 2 0.095 0.143 49-143 3 1 0.036 7 72-107
0.21
3 1 0.048 0.191 144-191 5 3 0.107 4 108-214
0.28
4 2 0.095 0.286 192-286 6 2 0.071 5 215-285
0.32
5 1 0.048 0.334 287-334 7 1 0.036 1 286-321
0.35
6 1 0.048 0.382 335-382 8 1 0.036 7 322-357
0.50
7 1 0.048 0.43 383-430 9 4 0.143 0 358-500
0.57
8 2 0.095 0.525 431-525 10 2 0.071 1 501-571
0.64
9 2 0.095 0.62 526-620 11 2 0.071 2 572-642
0.67
10 2 0.095 0.715 621-715 12 1 0.036 8 643-678
0.71
11 2 0.095 0.81 716-810 13 1 0.036 4 679-714
0.75
12 1 0.048 0.858 811-858 14 1 0.036 0 715-750
0.85
13 3 0.143 1 859-1000 15 3 0.107 7 751-857
0.89
21 1.000 16 1 0.036 3 858-893
0.92
15 4 0.571 0.571 000-571 17 1 0.036 9 894-929
1.00
16 2 0.286 0.857 572-857 18 2 0.071 0 930-1000
17 1 0.143 1 858-1000
7 1.000 28 1.000
TABLE - 29
SIMULATED SERVICE AND ARRIVAL :
48
ARRIVAL TIME SERVICE TIME Waiting Queue

S No. Rnd. No. Time O’ Clock Rnd. No. Time Begins Ends Time length
1 847 12 9:12 275 6 9:12 9:18 0 1
2 189 3 9:15 764 15 9:18 9:33 3 3
3 985 13 9:18 586 11 9:33 9:44 15 3
4 755 11 9:29 716 14 9:44 9:58 15 3
5 750 11 9:40 459 9 9:58 10:07 18 4
6 968 13 9:53 647 12 10:07 10:19 14 4
7 603 9 10:02 417 9 10:19 10:28 17 4
8 312 5 10:07 198 5 10:28 10:33 21 4
9 682 10 10:17 443 9 10:33 10:42 16 4
10 461 8 10:25 80 3 10:42 10:45 17 4
11 230 4 10:29 514 10 10:45 10:55 16 3
12 529 9 10:38 788 15 10:55 11:10 17 6
13 424 7 10:45 224 6 11:10 11:16 25 5
14 877 13 10:58 417 9 11:16 11:25 18 5
15 334 5 11:03 376 9 11:25 11:34 22 6
16 283 4 11:07 366 9 11:34 11:43 27 5
17 149 3 11:10 746 14 11:43 11:57 33 5
18 850 12 11:22 580 11 11:57 12:08 35 5
19 618 9 11:31 176 5 12:08 12:13 37 4
20 38 1 11:32 68 2 12:13 12:15 41 4
21 838 12 11:44 472 9 12:15 12:24 31 3
22 218 15 11:59 669 12 12:24 12:36 25 3
23 554 15 12:14 418 9 12:36 12:45 22 2
24 850 16 12:30 732 14 12:45 12:59 15 2
25 950 17 12:47 898 17 12:59 1:16 12 2
26 552 15 1:02 511 10 1:16 1:26 14 2
27 781 16 1:18 459 9 1:26 1:35 8 2
28 483 15 1:33 314 7 1:35 1:42 2 2
Total 270 536 100
Average waiting time = 536/28=19.14 Average Queue length = 3.57 per channel
Average service time = 270/28=9.64
Present waiting time = 819/20 = 41 % reduction = (41-19)/41*100 =54%
4.2 Department of OB & Gynaecology
In this department the nurse sits inside the long corridor like area and from there the patients
waiting in the outside chairs can not be seen. Outside chairs face towards opposite of the OPD
towards the garden and patient sitting there feel more anxious as they cannot see the doctor or
nurse and have no idea about when their turn would come. The patients sitting inside the corridor
feel more assured as they can see that treatment of patients is going on and it gives them a
feeling of being in-process. The Ben also sits in a similar position from where it is not possible
to know how many patients are waiting inside.
49
Figure - 7
Also most of the patients are examined in Room 1 and whenever assistance of nurse is needed
she has to go to room 1 either by crossing the doctor’s room or room 2. While the nurse is in the
examination room the waiting patients are left as such and there is no one to attend to the
incoming patients. And she loses track of the sequence of incoming patients. So at times cases of
patients coming later are taken first than those who had come earlier are still waiting. This
creates a feeling of unfair treatment.
Most of the patients coming to this department are accompanied by some male member and no
male accompanier is allowed inside the OPD. To make the patients assured it is necessary to give
them the idea about what is going on inside and what is their waiting number. So, give the traffic
if 10 chairs are kept inside it will be sufficient to accommodate all the patients 7 inside. All
7
The average traffic is 38 patients per day
50
attendants male or female will be seated in the outside chairs. Separating these two categories
will reduce the perceived length of queue and the patients can easily understand their serial
number in the queue.
The Ben’s seat will be shifted towards the main entrance of the OPD so that she can allow the
patients with case paper to enter, and send those without case paper to get registered first. The
nurse will seat in the usual position, will do the routine jobs of writing the case, taking weight
and sending patients one by one to the doctors room. Whenever she has to leave her desk for any
assistance in the examination room, the Ben will temporarily take care of those responsibilities.
The residents will see the patients first and record the case history. Then the doctor will examine
and prescribe medicines. This will reduce the service time to some extent and also will save
doctor’s time.
4.3 Department of Dentistry

At present the morning OPD utilization for dental is only 20 per day (annexure 8&9). It was also
found from the nurse in this OPD that the department’s utilization has fallen since the third
doctor in the department left. At that time there were 2 sets of equipments in the department.
Now that the equipments have increased to 3 the doctors are only two. So a clear mismatch can
be seen. However the sets take time to be sterilized and be ready to be used for another patient so
an extra set saves time during the rush hours. Despite the fact that the workload is only 10
patients per doctor for the entire 4.5 hour OPD span, the waiting time at the department is 25%
of the entire delay in availing complete dental services in the hospital. The following principles
of motion economy8 were used to reduce the service time and doctor’s fatigue. Emphasis on
motion economy should be given in order to eliminate Class IV or V motions.
4.4.1 Reducing service time through motion economy

To improve motion economy at chair side, consider the following suggestions:
1. Decrease the number of instruments used for a procedure by maximizing the use of
each one for multiple functions.
2. Position the instruments on a preset tray/cassette in the sequence that they will be
used.
8
Annexure-14
51
3. Position instruments, materials, and equipment in advance, whenever possible.

4. Place the armamentarium on a mobile cart as close to the patient as possible.
5. Place the patient in a supine position.
6. Seat the operating team as close to the patient as possible.
7. Use operating stools that promote good posture and provide back and abdominal
support that adjusts vertically and horizontally.
8. Provide work areas that are 1 to 2 inches below the elbow.
9. Minimize the number of eye movements between the close and brightly lit operating
field and more distant objects in the treatment room with lower illumination.
10. Use smooth continuous motions and avoid distracting zigzag movement.
11. Reduce the length and number of motions made by the operator and the dental
assistant to accomplish routine and repetitive tasks, by following strategies of four
handed dentistry.
4.4.2 Strategies to ensure effective Four-handed Dentistry

4.4.2.1 Teamwork: To effectively implement the four-handed dentistry concept each member of
the dental team must assume individual as well as team responsibilities. The team must be aware
of each other's needs, recognize the need to reposition the patient and operating team, as
necessary to reduce strain, improve access and visibility, and reduce unnecessary movement by
transferring instruments only within the transfer zone.
4.4.2.2 Strategies for the Operator: The dentist/operator must develop a standardized routine for
basic dental procedures, a non-verbal signal denoting a need to exchange an instrument, and
when necessary, give advance distinct verbal direction to communicate a need for a different
instrument or material. Additionally, the operator must maintain a working position within the
operator's zone, avoid legs interfering with the static or assistant's zone, confine eye focus to the
field of operation, and confine hand and arm movement to the transfer zone. To reduce stress
and strain the dentist/operator must avoid twisting and turning to reach instruments by relying on
the assistant to change burs and to transfer needed instruments, exchange instruments only in the
transfer zone, and avoid removing instruments from the preset tray by returning instruments to
the assistant.
52
Figure 8
Four handed dentistry
4.4.2.3 Strategies for the Dental Assistant: The clinical assistant must develop a thorough
understanding of the procedure, recognize the patient's needs, anticipate the operator's need, and
recognize any change in the procedure. During the procedure the assistant should be seated as
close to the patient as possible with legs parallel to the long axis of the patient's body. The
assistant must maintain the order of both the instruments and dental materials according to their
sequence of use. When transferring a dental instrument to the operator, orient the working end of
the instrument so it is pointing up for maxillary functions and down for mandibular functions.
The assistant should work with the operator to establish and follow a safe, standardized, and
predictable instrument transfer protocol. When practical the dental assistant should change burs
in the hand piece, maintain a "ready position" for delivery of the hand piece, remove debris from
instruments before returning them to the preset tray, and maintain a clean work area at all times.
53
So, the need in our case is proper availability of a trained assistant who is perfectly in tune with
the operator (the doctor) and her needs so that time and energy can be saved and waiting for
service at the department can be reduced.
4.4 Department of Ophthalmology
In this OPD the elaborate treatment procedure poses certain unavoidable delays. The detail
process has been discussed in the chapter on findings and conclusion. Still the following
changes can help in waiting time. These are some general suggestions which are applicable to all
the other departments also to some extent and the only objective they will achieve is bringing
some standardization in the process.
Figure 9
Department of Ophthalmology
• The Ben will take the case paper, make entry and send patients inside.
• The nurse will apply drops, keep track of time and regulate flow of those patients
only.
• Two interns will be present at the two routine eye test machines. The one at routine
test 1 will be accompanied by a doctor. The same doctor will take care of the special
examinations. Another doctor will also be in charge of special examination but will
mainly take care of any additional work.
54
• The third doctor will be there for cataract examination and other minor surgery. If
required the 2nd resident will consult this doctor only in case of any confusion. After
the patient is done with the routine check-up and case history, he will be taken care of
by this doctor. Thus there will be only flow of patients not of service providers.
4.5 Pharmacy
4.5.0 Change in lay out and operations
The present system existing at pharmacy counter is depicted as below. There are four service
counters. The first one for billing, second one is for payment and the third and fourth one are for
dispensing the medicines. As the customer comes, he stands at the counter 1 for a computerised
billing and then he moves in a queue towards the second counter for payment and then finally to
the 4th counter for collecting the medicines. There is no different queue at each counter instead an
integral queue exists from first to last. There is a systematic and fair queue for the 1st counter but
for subsequent 2nd, 3rd and 4th counters there is lot of commotion.
Figure 10
Also the
long queue
at the 1st
counter is
discouraging and the tendency is either to not join the long looking queue or reneging. People
coming from towards the Medicine OPD tend to gather at the counter nearest from that side i.e.
counter 4 which is actually for collecting medicines, the last phase of service. The two rows of
waiting chairs placed at present are inadequate to seat all the people. People sitting in one row of
chairs (facing the pharmacy help desk) can neither view the counters nor the TV kept adjacent to
4th counter. They have to stand throughout the waiting since the chairs face opposite to the
55
counters and nobody from the queue sits there as that may result in their position in queue taken
over by someone else.
In the new set up as shown below the entire traffic will be split into two queues. Billing and
payment will be done at the 1st counter and from that queue patients will join the queue at 2nd
counter to collect their medicine. Similarly for the patients coming from the Surgery/Medicine
OPD side will stand in the queue at 4th counter to make payment and bill and subsequently
collect medicine from 3rd counter. This will break the entire waiting population into two parts
thus reducing the queue length at both the lines. The chairs facing the help desk are to be shifted
and placed facing the counters so that they can see the happenings at the counters and even can
take rest if the queue is long. Additional 10 chairs are to be placed adjacent to the wall to
accommodate extra people. From the new set up people can also watch TV.
Figure 11
Pharmacy: proposed layout
4.5.1
Strategic
changes at
pharmacy
and
registration
It is observed that the traffic during the early hours (9:00-10:00 AM) is less at Pharmacy while
there is a lot of rush at the registration counter. But, the number of customers at Pharmacy builds
up as the day passes and the same at registration counter eases.
In order to decrease the waiting time at Pharmacy and registration we propose the transfer of one
operator from Pharmacy to registration from 9 to 10 am and similarly transfer of one staff from
56
registration to pharmacy from 10 O’clock onwards. As an extra operator arrives at Pharmacy and
he is given the simple task of pasting labels on the medicine strips and write the dosages on it
then also we find that he will reduce the medicine dispensing process by a minimum 30 seconds.
So under this conservative assumption also if we change the frequency distribution of arrival
time and service time which was constructed from three days readings of patients coming to the
pharmacy we get the distribution as shown in table 28.
4.5.1.0 Testing the new model

The plan was simulated for 120 patients using Monte Carlo simulation and the total time spent at
the pharmacy was found to have come down to 10.68 minutes per patient which is 18.6% less
then the present value of 13.12 min.
In addition to this, similar benefits will accrue at the registration counter as the new operator
from Pharmacy provides his services during the morning rush hours.
TABLE - 30
Arrival and service rate frequency table from 3 days (Tuesday, Saturday and Monday) averaged values
INTER ARRIVAL TIME SERVICE TIME

Cum. Rnd. No. Time Cum. Rnd. No.
Time(min.) Frequency Probability Prob. interval (In min.) Frequency Probability Prob. interval
Arrival and service rate at pharmacy counter between 9:00 am to 10:00 am from three days averaged sample
1 4 0.174 0.174 000-174 1 3 0.130 0.130 000-130
2 3 0.130 0.304 175-304 2 7 0.304 0.434 131-434
3 6 0.261 0.565 305-565 3 5 0.217 0.651 435-651
4 4 0.174 0.739 566-739 4 4 0.174 0.825 652-825
5 4 0.174 0.913 740-913 5 4 0.174 1.000 826-1000
6 2 0.087 1 914-1000
Total 23 1.000 23 1.000
Arrival and service rate at pharmacy counter between 9:00 am to 10:00 am from three days averaged sample
Cum. Rnd. No. Time (in Cum. Rnd. No.
Time(min.) Frequency Probability Prob. interval min.) Frequency Probability Prob. interval
0 12 0.200 0.2 000-200 1 16 0.267 0.276 000-276
1 17 0.283 0.483 201-483 2 21 0.350 0.617 277-617
2 8 0.133 0.616 484-616 3 13 0.217 0.834 617-834
3 10 0.167 0.783 617-783 4 10 0.167 1 835-1000
4 9 0.150 0.933 784-933
5 4 0.067 1 934-1000
Total 60 1.000 60 1.000
Arrival and service rate at pharmacy counter between 12:00 am to 1:30 pm from three days averaged sample
Cum. Rnd. No. Time (in Cum. Rnd. No.
Time(min.) Frequency Probability Prob. interval min.) Frequency Probability Prob. interval
0 1 0.030 0.03 000-30 1 9 0.273 0.273 000-273
1 4 0.121 0.151 31-151 2 12 0.364 0.637 274-637
2 6 0.182 0.333 152-333 3 8 0.242 0.879 638-879
57
3 4 0.121 0.454 334-454 4 4 0.121 1 880-1000

4 5 0.152 0.606 455-606
5 8 0.242 0.848 607-848
6 5 0.152 1 849-1000
Total 33 1 33 1.000
Monte Carlo simulation

The following table indicates the entire simulation which has been done for three different time
slots for which frequency distribution as well as the probability and cumulative probability was
calculated. For each stage we have indicated the service time and waiting time as well as the total
queue length. The average waiting time in the first hour is approximately 5 min per patient, for
second slot of 10-12 am it is 12.8 min while for the ending session it is only 3.5 min for a patient.
The average queue length for the entire process is 4.925.
Table – 31
Monte Carlo simulation for 120 patients based on above frequency distribution
ARRIVAL SERVICE Waiting Queue
S No. Rnd. No. Time O’ Clock Rnd. No. Time Begins Ends Time Length
1 766 5 9:05 210 2 9:05 9:07 0 2
2 78 1 9:06 634 4 9:07 9:11 1 2
3 498 3 9:09 953 5 9:11 9:16 2 2
4 812 5 9:14 498 3 9:16 9:19 2 2
5 798 5 9:19 231 2 9:19 9:21 0 3
6 138 1 9:20 39 1 9:21 9:22 1 2
7 164 1 9:21 477 3 9:22 9:25 1 2
8 317 3 9:24 512 3 9:25 9:28 1 2
9 283 2 9:26 890 5 9:28 9:33 2 2
10 422 3 9:29 203 2 9:33 9:35 4 2
11 831 5 9:34 952 5 9:35 9:40 1 4
12 674 4 9:38 155 2 9:40 9:42 2 4
13 108 1 9:39 343 2 9:42 9:44 3 3
14 98 1 9:40 154 2 9:44 9:46 4 4
15 108 1 9:41 389 2 9:46 9:48 5 4
16 708 4 9:45 520 3 9:48 9:51 3 5
17 85 1 9:46 648 3 9:51 9:54 5 6
18 243 2 9:48 533 3 9:54 9:57 6 7
19 424 1 9:49 205 2 9:57 9:59 8 6
20 245 2 9:51 451 3 9:59 10:02 8 5
21 354 3 9:54 498 3 10:02 10:05 8 5
22 154 1 9:55 568 3 10:05 10:08 12 6
23 23 1 9:56 215 1 10:08 10:09 14 5
24 145 1 9:57 254 1 10:09 10:10 15 4
25 461 3 10:00 125 1 10:10 10:11 14 4
Total 66 122 95
58
Arrival and service rate changes as time slot changes to 10 am – 12 pm and as new operator joins
1 967 5 10:05 533 2 10:11 10:13 6 3
2 643 3 10:08 205 1 10:13 10:14 5 3
3 573 2 10:10 506 2 10:14 10:16 4 2
4 668 3 10:13 363 2 10:16 10:18 3 4
5 610 2 10:15 122 1 10:18 10:19 3 5
6 231 1 10:16 199 1 10:19 10:20 3 5
7 198 0 10:16 487 2 10:20 10:22 4 6
8 430 1 10:17 677 3 10:22 10:25 5 4
9 342 1 10:18 738 3 10:25 10:28 7 4
10 423 1 10:19 768 3 10:28 10:31 9 8
11 601 2 10:21 67 1 10:31 10:32 10 8
12 876 4 10:25 233 1 10:32 10:33 7 7
13 297 1 10:26 860 4 10:33 10:37 7 8
14 173 0 10:26 32 1 10:37 10:38 11 8
15 365 1 10:27 378 3 10:38 10:41 11 7
16 468 1 10:28 610 3 10:41 10:44 13 7
17 149 0 10:28 33 1 10:44 10:45 16 7
18 554 2 10:30 597 2 10:45 10:47 15 7
19 994 5 10:35 744 3 10:47 10:50 12 6
20 178 0 10:35 127 1 10:50 10:51 15 7
21 580 2 10:37 933 4 10:51 10:55 14 6
22 890 4 10:41 473 2 10:55 10:57 14 8
23 438 1 10:42 558 2 10:57 10:59 13 7
24 716 3 10:45 140 1 10:59 11:00 14 7
25 746 3 10:48 853 4 11:00 11:04 12 8
26 559 2 10:50 730 3 11:04 11:07 14 6
27 559 2 10:52 171 1 11:07 11:08 15 7
28 678 3 10:55 294 2 11:08 11:10 13 7
29 119 0 10:55 697 3 11:10 11:13 15 6
30 644 3 10:58 15 1 11:13 11:14 15 6
31 851 4 11:02 874 4 11:14 11:18 12 6
32 651 3 11:05 444 2 11:18 11:20 13 9
33 573 2 11:07 277 2 11:20 11:22 13 10
34 581 2 11:09 25 1 11:22 11:23 13 10
35 674 3 11:12 338 2 11:23 11:25 10 9
36 615 2 11:14 66 1 11:25 11:26 11 9
37 360 1 11:15 243 1 11:26 11:27 11 9
38 114 0 11:15 724 3 11:27 11:30 12 10
39 118 0 11:15 733 3 11:30 11:33 15 9
40 483 1 11:16 108 1 11:33 11:34 17 9
41 244 1 11:17 222 1 11:34 11:35 17 8
42 701 3 11:20 570 2 11:35 11:37 15 8
43 393 1 11:21 15 1 11:37 11:38 16 9
44 730 3 11:24 217 1 11:38 11:39 14 8
45 543 2 11:26 292 2 11:39 11:41 13 7
46 273 1 11:27 525 2 11:41 11:43 14 7
47 113 0 11:27 335 2 11:43 11:45 16 8
48 794 4 11:31 432 2 11:45 11:47 14 9
49 861 4 11:35 896 4 11:47 11:51 12 8
59
50 448 1 11:36 880 4 11:51 11:55 15 8

51 254 1 11:37 873 4 11:55 11:59 18 9
52 722 3 11:40 160 1 11:59 12:00 19 10
53 564 2 11:42 221 1 12:00 12:01 18 9
54 16 0 11:42 875 4 12:01 12:05 19 9
55 857 4 11:46 4 1 12:05 12:06 19 9
56 396 1 11:47 391 2 12:06 12:08 19 8
57 504 2 11:49 105 1 12:08 12:09 19 8
58 670 3 11:52 411 2 12:09 12:11 17 8
59 461 1 11:53 245 1 12:11 12:13 18 7
60 876 4 11:57 134 1 12:13 12:14 16 6
61 234 1 11:58 657 3 12:14 12:17 16 6
62 756 3 12:01 678 3 12:17 12:20 16 5
Total 128 792 454
Again arrival rate changes due to time slot 12-1:30 pm and service rate shows change probably because of factors like
fatigue etc
1 208 2 12:03 506 2 12:20 12:22 17 5
2 668 5 12:08 363 2 12:22 12:24 14 5
3 108 1 12:09 122 1 12:24 12:25 15 4
4 755 5 12:14 199 1 12:25 12:26 11 3
5 730 5 12:19 487 2 12:26 12:28 7 2
6 430 3 12:22 677 3 12:28 12:31 6 1
7 342 3 12:28 380 2 12:31 12:33 3 1
8 423 3 12:31 580 2 12:33 12:35 2 1
9 601 4 12:35 67 1 12:35 12:36 0 0
10 28 1 12:36 233 2 12:36 12:38 0 0
11 297 2 12:38 860 2 12:38 12:40 0 0
12 289 2 12:40 368 2 12:40 12:42 0 0
13 137 1 12:41 748 3 12:42 12:45 1 1
14 389 3 12:44 102 1 12:45 12:46 1 1
15 278 2 12:46 580 2 12:46 12:48 0 0
16 149 1 12:47 867 3 12:48 12:51 1 1
17 30 0 12:47 127 1 12:51 12:52 4 1
18 726 5 12:52 326 2 12:52 12:54 0 1
19 243 2 12:54 629 2 12:54 12:56 0 0
20 260 2 12:56 987 4 12:56 1:00 0 0
21 529 4 1:00 772 3 1:00 1:03 0 0
22 278 2 1:02 779 3 1:03 1:06 1 1
23 429 3 1:05 496 2 1:06 1:08 1 1
24 333 2 1:07 453 2 1:08 1:10 1 1
25 454 3 1:10 986 4 1:10 1:14 0 0
26 477 4 1:14 688 3 1:14 1:17 0 0
27 13 0 1:14 876 4 1:17 1:21 3 1
28 399 3 1:17 546 2 1:21 1:23 4 3
29 148 1 1:18 745 3 1:23 1:25 5 2
30 125 1 1:19 323 2 1:25 1:27 6 2
31 4 1:23 198 1 1:27 1:28 4 2
32 2 1:25 658 3 1:28 1:31 3 1
33 3 1:28 567 2 1:31 1:33 4 1
Total 74 114 42
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4.6 Department of Pathology

The time taken for the frequently referred tests in SKH and private clinics (given in annexure 17)
indicates that the laboratory at SKH is not operating efficiently. Absence of centralised control
and proper work culture is the major concern in this department. Hence the doctors have to play
major role here in controlling the operations and ensuring minimum wastage of time due to idle
staff and gossiping etc.
The figure below shows the layout of clinical pathology lab. The red dots indicate the ideal
position of doctor, trainee technicians and other work staff. The doctor needs to remain present
throughout to provide consultation to technicians, verify results and sign reports. One technician
each is needed for the following places:
1. At urine collection and test
2. At blood collection
3. At routine blood test
4. At haemoglobin counter
5. At each microscope i.e. total 3 at 3 microscopes
Figure – 12
The clinical Pathology Lab.
Apart from this two staff are needed for the 2 computers and one Ben is also needed to help and
regulate flow of patients. Hence 1 doctor, 7 technicians and 3 other staff are needed. But
61
presently there are always more than this at any point of time. The operator at haemoglobin
counter takes reading and dictates the Ben to write. The position of Ben reduces her use in any
productive work. Also the reports generated are collected by the patients not at the lab but at
room no 21 where the receipts are made for pathology. The Ben sitting there has to come to the
lab to take the reports and thus some patients have to wait there during her absence. The changed
operations will be as follows
• The Ben will sit near the main entrance to regulate patients flow and to give the reports at
room no 21 after they are checked by the doctors or else the patients can be asked to
collect the reports directly from the Ben at the lab not from room 21.
• Only one person at each of the equipments will be present as shown in the red dots unless
made necessary for the purpose of learning.
• Instead of push here pull strategy will be more effective. The operator at blood test will
not wait for the collector to deposit the sample rather would collect it from the collection
area itself. Similar flow at microscopes, haemoglobin counter and other areas. The
operator at haemoglobin counter will both observe and write.
• The doctor will check the operations and supervise the places more diligently and the
easy going mode of operations should be checked.
• Whenever there is need to do further tests at other labs the technician will go and deposit
the sample there and come back to his original place. Similar operations will continue at
other 2 labs.
• The Ben at the computer in room 21 should stay there only and never leave her desk.
Similarly in radiology there is absence of central regulation and command. There is often
confusions, delay and wastage due to repeat tests. The number of repeat tests can be reduced by
counting the slides used each day and the reports generated.
4.7 Registration Counter

As the time taken at registration is not very high it is not a bottleneck activity for the departments
with high traffic but improving efficiency here will definitely reduce the total time spent by the
patients in the departments where traffic is less. The old case line is usually longer than the new
62
case line, however study shows that the average time taken for each new case is 1.25 minutes
whereas that for old case is only 0.75 minutes. But in any case long queue is always discouraging
for the patients. There are 3 counters in all, first one is for KRUPA patients, second one for new
cases and last one for old cases. As the daily average count of Krupa patients is not more than
12-13 some of the patients from old case line can be transferred to the Krupa counter by the
social worker who stands there. Since the social worker will regulate the transfer of the patients
there will be no problem to a Krupa patient. Moreover one staff will be diverted from the
pharmacy to registration during the rush hours i.e. 8.30 to 10 am which will further hasten the
proceedings.
Providing elaborate signage at this place will help the patients in tracking route to the OPDs they
are referred. This is discussed in the next section of this chapter.
GENERAL RECOMMENDATIONS
4.8 Improvement on signage and information
4.8.1 To direct the patient towards the registration
In the hospital premises the way to emergency, registration, college and hostels should be clearly
and boldly indicated in straight and clear terms, for the few days a security personnel can be
made to indicate the required way. Out of the two entrances, a security guard always remain
present at the trauma care side entrance thus he can be effectively used to guide patients. At the
main entrance also one security guard is present. His job will be to explain that one needs to get a
case paper from registration and he should show the way to registration.
4.8.2 To direct the patient to the required OPD

At the registration counter one social worker will stay till 11 am. On the right side wall (adjacent
to outer garden) there will be names of OPDs indicated by symbols and letters, the floor on
which it is, room number and arrow marked direction. The two help desks at main entrance, the
receptionist and the kitchen staff at the registration selling tea/snacks should carry a “may I help
you” board by their side and will also properly guide the patients.
• Since the tendency to move towards the central open space near the statue and then to the
outer passage is more and departments are at the inner passage there is always confusion.
63
Use of a 4 direction arrow board in central hall near the statue showing way to all the
departments can help.
• Each room should have only one number and a relevant symbol, the number for assets in
each department should be changed to alphabets or any other code as it creates confusion.
The symbols will aid the illiterates and even for literates it is easier to follow route by
looking at the symbols rather than text. All the room numbers should be circulated to all
the staff and they should be made clear of most frequently used room numbers by them
and with every location in due course of time. Also at each helpdesk a list containing all
the room numbers should be available to answer the patients’ queries.
• Each staff should consider his duty to at least indicate the first direction towards the
destination of a patient whether asked for or not. Movement to a different floor should be
clearly mentioned and mentioned first of all. At places where staff is regularly present can
be additional helpdesks since the study shows that people tend to ask someone the way
rather than finding out by looking at the signboards.
• All the passages should have hanging sign board with relevant directions and with 3
closest departments boldly written in dark colour on a light background. The main
hanging sign board should be clearly visible from the other end of the passage. Gujarati
and English should be written side by side and not in a top-bottom manner. Writing less
reduces the cluttered and repulsive appearance and avoids confusion.
• Sign boards are to be placed on the outer side of the wall surrounding the central
courtyard or name of the OPDs should be painted on the wall itself. All such sign boards
can be seen from any of the three sides except from the side on which the plate is. For
that hanging signboards are to be placed in the outer corridor of each department. Thus
someone standing in the row of Medicine OPD can know that the Medicine OPD is in
that row by looking at the hanging board and also can locate the OPDs of rest three sides
by looking at the signboards placed at the wall adjacent to courtyard. All the present sign
boards placed on the side wall should be brought to a height not more than 7 feet and the
letter size should be increased to enhance legibility. The boards when kept perpendicular
the wall are visible from a distance.
• All the side sign boards which are visible only when one is 4 or 5 feet (because of
blocked vision) away from them should be taken to better location.
64
• The corners, intersections and passages should be the first choice for putting a sign board
since those are the most frequent way-lost points.
• Every department in order to be clearly distinguished should have the name, number and
symbol. If distinct pattern and colour should be used as background so that the
background can be indicator of the department it will offer a great aid for those who cant
read. The colour scheme9 of the departments will be indicated from the registration itself
and throughout the OPD areas. For example if red colour is assigned to medicine, then on
the walls a stripe of red colour can be painted including the letters “Medicine” showing
way to medicine OPD. Thus anyone following the red stripe can reach in medicine OPD
without any way lost in between.
• Counter number 21 for pathological and other tests should be clearly written and the
sign board should be visible from at least 3 different directions in the courtyard.
• Pharmacy should be give a special mark and its presence should be marked well on all
the relevant sign boards.
4.8.3 Anyone referred to another department including pathology, radiology or pharmacy should
be made clear with direction and location as well as room number if any by the Nurse/Ben of that
OPD.
4.9 Strategies to shape demand

Some of the strategies that serve to some degree to shape the demand pattern are discussed below
By which capacity can be more uniformly utilized. The feasibility of this suggestion has been
strengthened by the findings from the doctors and students survey.
4.9.1 Use of appointment system

Hospital services are typically characterised by low standardization and high complexity of the
service, arising because of high involvement of the customer. Hence the queuing pattern is
stochastic and at times the patients have to wait for a long time. Though little can be done to
smoothen out the patient arrival for the general OPDs, some of the patients can be given prompt
specialized services. This of course would be for a segment of customers since the less privileged
ones from rural area are less likely to avail facilities of telephonic booking. The appointment
9
Annexure-15
65
system will smooth out the utilization of the service centre and reduces the dependence on a
room full of patients who arrived at a time convenient to them. The patients taking appointment
may be charged a higher amount. Also the timing for appointments can be from 12 pm to 1.30
pm when in any case the OPD utilization is low so some existing idle facility can be diverted to
these patients without affecting those who are there in the normal queue.
4.9.2 Providing economic incentives for non peak demands

A price differential or verbal request from the nurse and residents, to come during off peak hours
will play a positive role in inducing the patient to come in a low traffic period when he comes
next. Then the patients by word of mouth may spread the message to visit the hospital during the
off peak slot in expectation of some discount or at least the benefit that one might get better
attention and more time of the consultant who is otherwise too pressed for time during rush
hours.
4.9.3 Staggered work staff schedule

Trend analysis can help to come upon a conclusion regarding the range of service time a patient
requires in a particular department. Part of it we have done. Again from the past trend traffic
during different hours during the OPD can be finalised. With a safe margin of error supply of
doctors and staff can be fixed on an hourly basis. This will save the doctors of unnecessary
sittings in the OPD. This will provide a better satisfaction level and a sense of autonomy to the
doctors. Also providing a break of 10 minutes in between the OPD hours will help in reducing
the doctors’ psychological length of working hours.
4.10 Reducing psychological waiting time

4.10.1 Reducing unoccupied time which seems longer than occupied time
If not at all the OPDs a central place can be chosen where some reading material can be offered
to the patients and their attendants like at the pathology department, medicine department, eye
OPD where the patients have to wait for longer time. Some posters and illustration on basic
health behaviour, first-aid and diet charts etc can be kept at the OPDs to engage people.
Demonstrations and video show through the social workers can also help. At pharmacy patients
from all OPDs converge and already there is provision of a television, the only need is to make it
66
operational. So these arrangements will also help beguile the pre-process and post-process
waiting which appears longer than in-process waiting.
Reducing anxiety which makes waiting seem longer

The nurses should be trained to make the patients feel comfortable and give an impression that
they are cared for. Simple acts like offering them a seat and answering sincerely to their queries
and doubts can give the patient an impression of attention and personal care. The entire process
of waiting is more traumatic if patients are left uncared for. Also if the chairs are placed in a way
from where patients can see the treatment going on or from where they can see the doctor busy
with a patient they will feel that there is something in progress and their turn will also come
soon.
Uncertain waiting is longer than known, finite waiting

When one knows how long the queue is and when is his turn, one has an option of spending it in
the manner he wishes instead of sticking to the chair in uncertainty and fear that his turn might
come anytime. The condition aggravates when the nurse is impatient to entertain people and tell
the case number in process. So a standardized method of writing the case number in progress can
make the patients feel more comfortable. This can be done by placing a board at each OPD.
Reducing the unexplained waiting time as it seems longer than explained waiting
The very reason for waiting after giving the case paper should be explained to the patients by the
nurse. If the patient has to wait for some unexpected reasons like the doctor suddenly moving for
some emergency service, or an important IPD case is given preference to the queue, then these
reasons should be explained and duly regretted.
Reducing unfair waiting

In no case any preference apart from what rules and policies state should be entertained. Once a
patient feels that such a thing is happening, he will let everyone around know, which will create
unnecessary unrest. The hospital administrator can ensure it during his surprise visits once in a
while.
67
Nothing is more irritating than seeing a person idle but not serving to people who are in queue.
Hence the staff should appear that they are doing their jobs sincerely and are interested in serving
the patients as nicely as possible.
Reducing physically uncomfortable waiting

The arrangement as well as their number of chairs is adequate in all the OPDs but almost
everywhere the fan is equitably distributed between two rows and so it cools none of the rows.
An arrangement of a fan affixed on the side walls or one of the pillars can adequately serve the
purpose. Keeping drinking water taps, one in between medicine and surgery OPD and another
between pathology and ENT can make waiting more comfortable.
4.11 Building social relationships

As social relationships are involved in delivering health services so customer contact cannot be
strictly limited to the time needed to deliver the actual service. It helps to avoid the provider
appearing abrupt or rude. As the doctors time is of higher value this role should be nicely played
by experienced and trained nurse who come in contact with the patient. The very disposition and
non verbal cues should be very friendly and amiable. There is no justification to a rude behaviour
towards an impatient patient who is eager to know his turn, that is his right and the service
provider should note that it is their duty and they should try to calm the anxiety of a patient,
otherwise that itself makes the wait more lengthy and troublesome. Also the personal attention
from the doctor while treating the patients instils faith and nullifies the effects of delay to a great
extent.
68
4.12 Analysis of the match between requirement and recommendations and prioritizing the
recommendations
These recommendations offer a solution for the waiting problems in some way or the other. But
some of the suggestions would address the problem in a better way than the others and thus the
outcome or results of it justifies putting our effort there. Thus the recommendations need to be
prioritised to choose the best possible preferences.
The patients’ requirements (R) at various steps of treatment in the hospital were identified and
listed as below in a random manner.
1. finding the departments and other routes
2. information on procedures
3. information on timings
4. minimum waiting at OPDs
5. quick service at support services
6. comfortable waiting
7. All treatments on the same day
Then the suggestions (S) which can meet these requirements were identified and listed.
1. change in layout
2. change in operations
3. improvement on signage and information
4. reducing psychological waiting time
5. appointment system
6. diverting demand to off peak hours
Then all the requirements (R) and suggestions (S) were put in a matrix form and the degree to
which each suggestion meets the requirements was written. The scores were given as
9 (strongly satisfy), 3 (somewhat satisfy) and 1 (weakly satisfy).
69
TABLE – 31
Match between requirements and recommendations
S 1 2 3 4 5 6
R
1 3 3 9 3 1 1 After obtaining the scores
2 1 9 3 9 1 1
3 1 3 3 9 9 the requirements were
4 3 9 1 3 9 9 prioritised according to
5 3 9 1 3 1 9
6 3 1 3 9 3 3 need and the ranks were
7 1 9 3 3 9 9 given in opposite order
which indicate the weightage of each requirement. Thus the most important need was given
the rank as 1 and weightage of 7.
1. Minimum waiting at OPDs
2. Finding the departments and other routes
3. Quick service at support services
4. Comfortable waiting
5. Information on procedures
6. All treatments on the same day
7. Information on timings
Those rank wise weightage were multiplied with the scores from previous table to obtain total
score. The suggestions were also ranked according to difficulty in implementation and feasibility
and that rank was multiplied with total score to get the overall score. The weighted scores are
given in the table in next page.
TABLE – 32
Weighted scores of recommendations
70
S weig 1 2 3 4 5 6
R hts
1 7 3 21 9 63 1 7 3 21 9 63 9 63
2 6 3 18 3 18 9 54 3 18 1 6 1 6
3 5 3 15 9 45 1 5 3 15 1 5 9 45
4 4 3 12 1 4 3 12 9 36 3 12 3 12
5 3 1 3 9 27 3 9 9 27 1 3 1 3
6 2 1 2 9 18 3 6 3 6 9 18 9 18
7 1 1 1 3 3 3 3 9 9 9 9 3 3
Total score 72 178 96 132 116 150
Technical difficulty 2 4 6 5 1 3
(rank suggestions )
Overall score 144 712 576 660 116 450
The suggestion with maximum overall score is the first to be implemented. According to that the
priority of the suggestions will be:
5. change in layout
But the suggestions are correlated with each other and hence their correlation score was
calculated. The scoring was done as degree of correlation as below.
++ Strong positive correlation (9)
+ Positive correlation (3)
0 Neutral or zero correlation (0)
- Negative correlation (-3)
- - strong negative correlation (-9)
TABLE – 32
Correlation scores amongst recommendations
No. 1 2 3 4 5 6
1 * * + 3 ++ 9 0 0 0 0 0 0
2 * * * * + 3 + 3 ++ 9 0 0
3 * * * * * * + 3 0 0 0 0
4 * * * * * * * * + 3 + 3
71
5 * * * * * * * * * * - -3
6 * * * * * * * * * * * *
Thus a strong correlation shows that implementing one recommendation will achieve the other to
a great extent and negative correlation imposes a choice between the two recommendations. The
scores for each suggestion are the scores that the particular suggestion gets from all other (5)
suggestions. Scores for each suggestion was thus calculated s follows:
1. 3+9+0+0+0=12
2. 3+3+3+9+0=18
3. 9+3+3+0+0=15
4. 0+3+3+3+3=12
5. 0+9+0+3-3=9
6. 0+0+0+3-3=0
Thus the changed preference of the suggestions will be as below which represents the best
possible priorities of the recommendations.
4. change in layout
The reduction of time by implementing these suggestions will be reflected in the overall service
rating of the hospital and satisfied patients.
V
REFERENCES
Books
1. Barnes, M. Ralph M. Motion and Time Study: Design and measurement of work. Sixth
edition John Wiley & sons Inc.
72
2. Chase, B. Richards, Jacobs Roberts F. and Aquilano J. Nicholas Operations management

for . competitive advantage. Tenth Edition, New Delhi: Tata McGraw-Hill Publishing
Company Ltd.
3. Levin I. Richard, Rubin S. David and Gardner S. Everette, Jr. Quantitative approaches to
management. McGraw-Hill international editions
4. Chance A. William Statistical methods for decision making. D. B. Taraporevala sons &
co. Pvt. Ltd.
5. Kotler Philip and Clarke N. Roberta Marketing for health care organizations. New Jersey:
Prentice Hall Inc.
6. Lovelock Christopher and Wright Lauren Principles of service marketing and

management. New Jersey: Prentice Hall Inc.
7. Gaither Norman and Frazier Greg Production and Operations Management. Eighth
edition. South western college publishing, 1999.
8. Kasper Hans, Helsdiggen V. Piet and Wouter de V. Jr. Services marketing management:
an international perspective. John Wiley & sons.
9. Dilworth James B. Production and Operations Management: Manufacturing and Services.

Fifth Edition, McGraw-Hill international editions.
10. Verma A.P Operations Research. Second edition, S. K. Kataria and Sons.
Websites
1. http://www.hsw.wales.nhs.uk/ipd/homepage.htm
2. http://www.cs.stir.ac.uk/courses/IT62/lectures/lec3_sim.pdf.
VI
ANNEXURES
ANNEXURE 1: SAMPLE PROCESS CHART

Process Flow
73
Present Method PROCESS CHART

Proposed Method
SUBJECT CHARTED: DATE
CHARTED BY
CHART No.
DEPARTMENT SHEET No.
Distance Time in CHART SYMBOL Process description
in feet min.
Total
ANNEXURE-2: TIME STUDY OF DEPARTMENTS
Date Time study of patients at department of……………………
Patient Referring Arrival Wait time/ Service Departure Others

No. OPD Time Delay Time Time
74
ANNEXURE-3: QUESTIONNAIRE FOR PATIENT PERCEPTION TEST
Department: Questionnaire no.

1. While coming here what time did you anticipate it will take for treatment and what was the
actual time taken?
Anticipated time Actual time
Less than 30 minutes Less than 30 minutes
75
30 minutes -1 hour 30 minutes -1 hour

1-1.5 hour 1-1.5 hour
1.5-2 hour 1.5-2 hour
2-2.5 hour 2-2.5 hour
2.5-3 hour 2.5-3 hour
3-3.5 hour 3-3.5 hour
3.5-4 hour 3.5-4 hour
4-4.5 hour* 4-4.5 hour
* The regular OPD time is 9-1.30 i.e. 4.5 hours per day
2. What do you feel about the time taken at various departments/counters?

a. It could have been done in lesser time.
b. there was delay but this much time taken is acceptable
c. cannot say anything
d. there is no delay, this much time is needed for treatment
e. the services were delivered promptly and earlier than expected
3. Services of this hospital are

a. very late b. late c. normal d. prompt e. very prompt
4. Rate the fairness of the sequence (queue) in which patients are treated
a. extremely fair b. fair c. normal d. unfair e. extremely
unfair
5. Were you informed about the cause of waiting? Yes / No
6. Were you informed about the duration of waiting? Yes / No
7. How do you locate a department if you do not know the route?

a. try to find out on my own
b. by reading the signage
c. ask someone else
8. What is your reaction about delays?
76
a. irritates extremely b. somewhat irritates c. undecided/ never thought

d. okay for me (acceptable as part of life) e. never mind delays
9. Where do you think maximum delays take place?

a. In queue at registration counter
b. Searching for departments
c. In queue in a department
d. Waiting for the doctor/ nurse if they are absent
e. Medicine purchase
f. Going from one department to another department
g. For pathological tests
h. In radio-diagnosis
i. The doctor is busy in something else and takes longer time see the patients
j. Nurse is busy in something else and does not pay attention
k. Personal reasons like resting, waiting for other friends/ relatives etc.
10. Provided this much time taken this time next when you need to see a hospital/doctor, you
a. never come here again b. Prefer to go somewhere else c. cannot
say
d. still consider coming here e. definitely come here only
11. How did you find the waiting atmosphere?
a. boring b. normal c. not boring
ANNEXURE-4: QUESTIONNAIRE FOR DOCTORS
ALL THE QUESTIONS ARE WITH REGARD TO OPDs only. Department …………
(1.) How do you perceive the workload of service providers for the under mentioned departments?
1. Very high 2.high 3.normal 4.low 5.very low
77
department doctors Support staffs department doctors Support staffs

gynaecology Pharmacy
Paediatric Skin
Sonography Diabetes
Radiology Cardiology
Surgical Medicine
Anaesthetics TB
Orthopaedic Dental
CT Scan ENT
Registration Eye
Pathology
(2.) How do you rate the services of this hospital? (Please tick.)
Very good good normal bad very bad
(3.) Please rate the charges for the services here vis-à-vis another private hospital.
Very low low at par high very high
(4.) How do the patients perceive the services in this hospital?

(5.) How do you rate the promptness with which services are delivered to patients?
(6.) Following are some of the reasons why the patient has to spend unduly high amount of total time in
receiving services, how well do you agree with these reasons? (Choose one out of following five)
1. Strongly agree 2. Agree 3. Undecided 4. Disagree 5. Strongly disagree
Reason Response Response
High time in searching for dept. Less number of nurses
Absence of staffs at various counters Under equipped pathology
Slow service at pharmacy counter Under staffed radiology
Less number of doctors Under equipped radiology
Slow service by nurse Slow service at Radiology
Slow service at pathology Understaffed pharmacy counter
Understaffed pathology Slow service by doctor
Relatively high time taken by Some time is lost by doctors while teaching &
residents/interns demonstrating before a patient
(7.) Please give your suggestion to reduce total time spent by a patient in receiving services here? ………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
……………………………………………………………………………………………………….
ANNEXURE-5: QUESTIONNAIRE FOR STUDENTS/INTERNS/RESIDENTS
ALL THE QUESTIONS ARE WITH REGARD TO OPDs only. Batch …………
(2.) What is the workload of doctors with regard to teaching and training?
Very high high normal low very low
78
(2.) What is the workload of doctors with regard to treating patients?

(3.) How do you rate the services of this hospital on a 10 point scale?
(4.) Please rate the charges for the services here vis-à-vis another private hospital.
Very low low at par high very high
(5.) How do the patients perceive the services in this hospital?

(6.) How do you rate the promptness with which services are delivered to patients?
(7.) Kindly give your opinion regarding the total workload of doctors? It’s ………….
(8.) What is your opinion with regard to workload of the support staffs? It’s………….
(9.) Following are some of the probable reasons of delay, how well do you agree with these reasons?
(Choose one out of following five)
1. Strongly agree 2. Agree 3. Can’t say 4. Disagree 5. Strongly disagree
Reason Respon Respon

se se
High time in searching for dept. Less number of nurses
Absence of staffs at various counters Under equipped pathology
Slow service at pharmacy counter Under staffed radiology
Less number of doctors Under equipped radiology
Slow service by nurse Slow service at Radiology
Slow service at pathology Understaffed pharmacy counter
Understaffed pathology Slow service by doctor
Relatively high time taken by Some time is lost by doctors while teaching &
residents/interns demonstrating before a patient
(10.) Please give your suggestion to reduce total time spent by a patient in receiving services here?
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
ANNEXURE-6: THE SERVQUAL INSTRUMENT
PROCEDURE FOR UNWEIGHTED SERVQUAL SCORE
79
Step1. Using the SERVQUAL instrument, first the score for each of the 22 expectation questions was
obtained. Next, score was obtained for each of the perception questions. The Gap Score each of the
statements was calculated. (Gap Score = Perception – Expectation).
Step2. An average Gap Score was obtained for each dimension by assessing the Gap Scores for each of
the statements that constitute the dimension and dividing the sum by the number of statements making up
the dimension.
Step3. In the TABLE 1 the average dimensions SERVQUAL scores (for all five dimensions) was
transferred from the SERVQUAL instrument. The scores were summed up and divided by five to obtain
the unweighted measure of service quality.
STEPS TO OBTAIN THE WEIGHTED SERVQUAL SCORE

Step1. The importance weights for each of the five dimensions constituting the SERVQUAL scale was
calculated.
Step2. In Table 2 the average SERVQUAL score for each dimension (from Table 1) and the importance
weight for each dimension were written. Then the average score for each dimension with its importance
weight was multiplied.
Step3. The weighted SERVQUAL scores for each dimension were added to obtain the overall weighted
SERVQUAL score.
THE SERVQUAL INSTRUMENT

EXPECTATIONS PERCEPTIONS
This survey deals with your opinions of Hospitals. The following statements relate to your feelings about the
Please show the extent to which you think hospitals Shree Krishna Hospital. Please show the extent to which
should posses the following features. What we are Shree Krishna Hospital you believe has the feature
interested in here is a number that best shows your described in the statement. Here, we are interested in a
expectations about institutions offering health services number that shows your perceptions about Shree Krishna
Hospital
Strongly Strongly Strongly Strongly
Disagree Agree Disagree Agree
1 2 3 4 5 6 7 1 2 3 4 5 6 7
Expected Perceived GAP

(E) (P) (E-P)
Tangibles Tangibles
E1. Excellent Hospitals will have modern P1. SK Hospital has modern looking
80
looking equipment. equipment.

E2. The physical facilities at excellent P2. The physical facilities at SK Hospital are
Hospitals will be visually appealing. visually appealing.
E3. Employees at excellent Hospitals will P3. Employees at SK Hospital are neat
be neat appearing. appearing.
E4. Materials associated with the service P4. Materials associated with the service are
will be visually appealing at an excellent visually appealing at an SK Hospital.
Hospital.
Average Tangibles SERVQUAL score
Reliability Reliability
E5. When excellent Hospitals promise to do P5. When SK Hospital promises to do
something by a certain time, they do. something by a certain time, they do.
E6. When a patient has a problem, excellent P6. When a patient has a problem, SK
Hospitals will show a sincere interest in Hospital shows a sincere interest in solving it.
solving it.
E7. Excellent Hospitals will perform the P7. SK Hospital performs the service right the
service right the first time. first time.
E8. Excellent Hospitals will provide the P8 SK Hospital provides the service at the
service at the time they promise to do so. time they promise to do so.
E9. Excellent Hospitals will insist on error P9. SK Hospital insists on error free records.
free records.
Average Responsiveness SERVQUAL score
Responsiveness Responsiveness
E10. Employees of excellent Hospitals will P10. Employees of SK Hospital tell patients
tell patients exactly when services will be exactly when services will be performed.
performed.
E11. Employees of excellent Hospitals will P11. Employees of SK Hospital give prompt
give prompt service to patients. service to patients.
E12. Employees of excellent Hospitals will P12. Employees of SK Hospital are always
always be willing to help patients. willing to help patients.
E13. Employees of excellent Hospitals will P13. Employees of SK Hospital are never be
never be too busy to respond to patients’ too busy to respond to patients’ requests.
requests.
Average Responsiveness SERVQUAL
Assurance Assurance
E14. The behavior of employees in P14. The behavior of employees in SK
excellent Hospitals will instill confidence in Hospital instills confidence in patients.
patients.
E15. Patients coming to excellent Hospitals P15. Patients coming SK Hospital feel safe in
will feel safe in treatments. treatments.
81
E16. Employees of excellent Hospitals will P16. Employees of SK Hospital are

be consistently courteous with patients. consistently courteous with patients.
E17. Employees of excellent Hospitals will P17. Employees of SK Hospital have the
have the knowledge to answer patients’ knowledge to answer patients’ questions.
questions.
Average Assurance SERVQUAL score
Empathy Empathy
E18. Excellent Hospitals will give patients P18. SK Hospital gives patients individual
individual attention. attention.
E19. Excellent Hospitals will have P19. SK Hospital has operating hours
operating hours convenient to all their convenient to all their patients.
patients.
E20. Excellent Hospitals will have P20. SK Hospital has employees who give
employees who give patients personal patients personal attention.
attention.
E21. Excellent Hospitals will have their P21. SK Hospital has their patient’s best
patient’s best interests at heart. interests at heart.
E22. The employees of excellent Hospitals P22. The employees of SK Hospital
will understand the specific needs of their understand the specific needs of their patients.
patients.
Average Empathy SERVQUAL scores
TABLE 1: CALCULATIONS TO OBTAIN UNWEIGHTED SERVQUAL SCORE

Average Tangible SERVQUAL score
Average Reliability SERVQUAL score
Average Responsiveness SERVQUAL score
Average Assurance SERVQUAL score
Average Empathy SERVQUAL score
TOTAL
AVERAGE (= Total / 5) UNWEIGHTED SERVQUAL SCORE
SERVQUAL IMPORTANCE WEIGHTS

Listed below are five features pertaining to hospitals and the services they offer. We would like to know
how much each of these features is important to the customer. Please allocate 100 points among the five
features according to how important it is to you. Make sure the points add up to 100.
The appearance of physical facilities, equipment, personnel, and communication materials.
______________ Points
The Hospital’s ability to perform the promised service dependably and accurately.
______________ Points
82
The Hospital’s willingness to help customers and provide prompt service.

______________ Points
The knowledge and courtesy of the staff and their ability to convey trust and confidence.
______________ Points
The caring, individual attention the Hospital provides to the patients
______________ Points
TABLE 2: SERVQUAL WEIGHTED SCORES
SERVQUAL Dimension Score X Importance Weight = Weighted
from Table 1 from Table 2 Score
Average Tangible
Average Reliability
Average Responsiveness
Average Assurance
Average Empathy
TOTAL
AVERAGE (= Total / 5) WEIGHTED SERVQUAL SCORE
83
ANNEXURE-7: CAUSE AND EFFECT DIAGRAM
Lack of Operations
information
Inconvenient Bottlenecks
Timings Search layout
departments
Elaborate
Procedures at Frequent examination
OPDs/counters Comes back to OPD movement
to ask dosage
MAKES THE
PATIENT
WAIT
Takes time Not present

to reach at desk
Busy in some
other task
Lengthy Lack of
conversation competency/slow
Personal reasons
with doctor service
wait for friends/ Teaching/
toilet demonstrating
Patients Service
related providers
84
ANNEXURE 8: OPD Statistics for the Financial Year 2002-03

OB & Ortho Skin TB
Months ENT Opth. Medicine G . Paed. Psych. Surgery & VD Chest Dental
3 3 3 6 3 1 5 4
April 939 6 798 1 2933 113 899 5 1547 0 957 7 501 9 1343 2 1054 1 167 6 963 37
3 2 3 5 2 1 4 4
May 932 5 765 9 2406 93 859 3 1524 9 757 9 433 7 1231 7 1108 3 151 6 750 29
3 3 10 3 5 2 1 5 4
June 881 4 771 0 2611 0 831 2 1514 8 661 5 477 8 1326 1 1076 1 144 6 624 24
4 3 12 4 7 4 2 6 5
July 1141 4 977 8 3325 8 1034 0 1861 2 1057 1 533 1 1596 1 1333 1 190 7 852 33
4 3 3 5 4 1 5 4
Aug 1090 2 877 4 2869 110 824 2 1405 4 1065 1 434 7 1359 2 1105 3 147 6 784 30
4 3 13 3 5 4 2 5 4
Sep 1138 4 889 4 3385 0 935 6 1480 7 1028 0 540 1 1427 5 1211 7 154 6 760 29
4 3 12 3 5 3 1 4 4
Oct 1040 1 830 2 3326 8 875 4 1352 2 783 0 387 5 1282 9 1277 9 152 6 650 25
3 2 10 3 4 2 4 3
Nov 824 2 630 4 2627 1 782 0 1073 1 729 8 232 9 1171 5 949 7 124 5 492 19
3 2 3 4 3 4 4
Dec 1021 9 759 9 2894 111 949 7 1187 6 803 1 225 7 1259 8 1033 0 160 6 587 23
3 3 10 3 5 2 1 4 3
Jan 995 8 810 1 2755 6 898 5 1319 1 664 6 471 8 1276 8 969 7 210 8 619 24
3 3 3 5 2 4 4
Feb 895 4 919 5 2958 114 783 0 1321 1 719 8 242 9 1287 9 1058 1 226 9 664 26
3 3 3 5 3 4 4 1
March 973 7 901 5 3053 117 965 7 1296 0 828 2 215 8 1226 7 1087 2 306 2 605 23
1063 1005 1326
11869 9926 35142 4 16879 1 4690 15783 0 2131 8350
***Considering a 26 days month
85
ANNEXURE-9: OPD Statistics for the Financial Year 2003-04

OB & Skin & TB
Months ENT Opth. Medicine G Ortho. Paed. Psych. Surgery VD Chest Dental
3 3 3 5 2 4 4 1
April 995 8 875 4 2861 110 883 4 1351 2 742 9 219 8 1097 2 1073 1 313 2 628 24
3 3 3 5 2 4 3
May 926 6 813 1 2916 112 836 2 1335 1 745 9 287 11 1227 7 1024 9 242 9 526 20
3 2 10 3 5 2 4 4
June 847 3 744 9 2783 7 876 4 1291 0 673 6 193 7 1215 7 1114 3 174 7 543 21
4 4 13 4 5 3 1 5 4
July 1085 2 1135 4 3602 8 1100 2 1543 9 938 6 251 0 1400 4 1242 8 180 7 592 23
4 4 13 3 4 3 4 4
Aug 1054 1 1243 8 3467 3 898 5 1246 8 952 7 190 7 1227 7 1277 9 217 8 573 22
5 5 14 4 5 3 5 5 1
Sep 1435 5 1319 1 3839 8 1089 2 1393 4 963 7 234 9 1486 7 1368 3 260 0 671 26
3 3 3 4 3 4 4
Oct 899 5 936 6 2967 114 792 0 1062 1 939 6 174 7 1059 1 1123 3 197 8 398 15
4 4 13 4 5 3 5 4
Nov 1122 3 1234 7 3418 1 1124 3 1382 3 985 8 199 8 1306 0 1150 4 203 8 650 25
4 5 13 4 5 4 5 4
Dec 1251 8 1400 4 3490 4 1242 8 1382 3 1060 1 219 8 1412 4 1056 1 202 8 605 23
4 4 4 4 3 4 3
Jan 1107 3 1203 6 3004 116 1070 1 1218 7 837 2 295 11 1069 1 983 8 170 7 545 21
4 4 4 4 3 4 3
Feb 1040 0 1205 6 2894 111 1037 0 1281 9 940 6 211 8 1165 5 927 6 198 8 666 26
4 4 13 4 6 3 5 4
March 1101 2 1273 9 3409 1 1061 1 1554 0 1015 9 154 6 1368 3 1054 1 231 9 698 27
1286
2 13380 38650 12008 16038 10789 2626 15031 13391 2587 7095
***Considering a 26 days month
86
ANNEXURE-10: AVERAGE NUMBER OF PATIENTS BEING TREATED BY A

DOCTOR PER DAY IN OPD IN 2002-04
Average number of patients being treated by a Doctor per day in OPD in 2002-04*
OB & Ortho Skin & TB
ENT Opth. Medicine G . Paed. Psych. Surgery VD Chest Dental
Mean1 38 32 113 34 54 32 15 51 43 7 27
Mean2 41 43 124 38 51 35 8 48 43 8 23
grand mean 39.5 37.5 118.5 36 52.5 33.5 11.5 49.5 43 7.5 25
Total Dr. 9 12 13 15 9 9 12 14 6 6 12
TotalDays 6 6 6 6 6 6 6 6 6 6 6
Dr./Day 1.5 2 2.167 2.5 1.5 1.5 2 2.333 1 1 2
Av. Patients /Dr. 26 19 55 14 35 22 6 21 43 8 12.5
**** 21 15 44 11 28 18 5 17 34 6 10
**** Assuming morning OPD to consist of only 80% of total OPD for the patient.
* Treatment by residents not included
87
ANNEXURE-11: FACTOR ANALYSIS TO SEGREGATE THE REASONS FOR DELAY

AS PERCEIVED BY THE PATIENTS
KMO and Bartlett's Test

Kaiser-Meyer-Olkin Measure of Sampling .680
Adequacy.
Bartlett's Test of Sphericity Approx. Chi-Square 182.376
df 66
Sig. .000
Rotated Component Matrix

Componen
t Extraction Method: Principal
1 2 3 4 Component Analysis.
a. REGNQUEU .470 .535 .302 -.235 Rotation Method: Varimax
b SEARCHDE .661 3.413E-02 .305 -4.028E-02 with Kaiser Normalization. a
c MEDPURC 2.826E-02 .165 5.731E-02 .806 Rotation converged in 6
d DEPTQUE 1.944E-02 .905 7.305E-03 8.195E-03 iterations.
e RADIOLOG .131 -2.101E-02 .104 .797
f DOCBUSY .428 .204 .752 8.060E-02
Total Variance Explained
g PATHOTES .451 -.208 .320 .468
Initial Extraction Rotation
h NURSBUSY -2.999E-02 8.733E-02 .907 .209
Eigen Sums of Sums of
i WAITDOC .224 .650 .159 .203
values Squared Squared
j INTDEPTL .799 9.527E-02 -7.681E-02 .310
Loadings Loadings
k. PERSONAL .772 .304 3.242E-02 .193
Componen Total % ofCumulativ Total % ofCumulativ Total % ofCumulativ
t Variance e % Variance e % Variance e %
1 4.168 34.734 34.734 4.168 34.734 34.734 2.631 21.923 21.923
2 1.717 14.309 49.043 1.717 14.309 49.043 1.904 15.870 37.793
3 1.193 9.941 58.983 1.193 9.941 58.983 1.872 15.602 53.394
4 1.122 9.354 68.337 1.122 9.354 68.337 1.793 14.943 68.337
5 .856 7.130 75.467
6 .729 6.076 81.543
7 .564 4.697 86.240
8 .476 3.970 90.210
9 .394 3.286 93.496
10 .354 2.949 96.444
11 .269 2.241 98.685
12 .158 1.315 100.000
Extraction Method: Principal Component Analysis.
88
ANNEXURE-12: METHODS-ENGINEERING
APPROACH
1
Determine problem or objective
Study conditions
2
3 Plan possible solutions
4 Evaluate possible solutions
5 Recommend actions
6 Follow-up
7 Check results
89
ANNEXURE-13: SHOW CARDS
SCALE 1 (For Questionnaires)
VERY GOOD
EXTREMELY IMPORTANT
5
GOOD
4 IMPORTANT
AVERAGE
3
CANNOT SAY
BAD
2
UNIMPORTANT
VERY BAD
1 EXTREMELY UNIMPORTANT
SCALE 2 (For SERVQUAL Instrument)
1 2 3 4 5 6 7
STRONGLY STRONGLY
DISAGREE AGREE
90
ANNEXURE – 14: PRINCIPLES OF MOTION ECONOMY & CLASSIFICATION OF

MOTION
Principles of Motion Economy

Motion economy refers to the manner in which human energy can be conserved while
performing a task. The following questions were asked to the concerned doctor.
• How many times do you turn your body or reach for an instrument?
• Does the assistant/nurse eliminate your stress by transferring the instruments and
materials to you as and when required?
• Does the assistant have primary responsibility for transfer of materials and instruments or
is the assistant often unoccupied while the dentist reaches for an instrument or changes a
bur?
• Are the hand pieces and instruments within a 21-inch radius of the assistant?
• Think about your daily activities and decide how you can modify the routine to reduce
motion. Plan ahead to ensure all materials are prepared in advance in a motion effective
environment.
Classification of motion
Motions can be classified (to understand what is to be done and what IS to be avoided) into five
categories according to the length of the motion as shown below:
• Class I: Movement of the fingers only when picking up something say a cotton roll.
• Class II: Fingers and wrist motion as used when transferring an instrument to the
operator, or manipulating a hand instrument.
• Class III: Fingers, wrist, and elbow as when reaching for a hand-piece.
• Class IV: The entire arm and shoulder as when reaching for supplies away from the work
area, or to adjust the operating light.
• Class V: The entire torso as when turning around to reach for equipment from adjacent
fixed cabinetry.
91
ANNEXURE - 15
COLOUR SCHEME OF DEPARTMENTS AND SAMPLE SIGNBOARDS
REGISTRATION
PHARMACY
DERMATOLOGY
PSYCHIATRY
EYE
MEDICINE
SURGERY
DENTISTRY
OB &
GYNAECOLOGY
PAEDIATRICS
X-RAY
EYE
ORTHOPAEDICS
PATHOLOGY
E.N.T. E.N.T.
92
ANNEXURE - 16: TIME TAKEN FOR PATHOLOGICAL TESTS IN SKH VIS-À-VIS

PRIVATE LABS.
Sr. No. TEST TYPE NORMAL TIME TIME TAKEN

Pathology SKH Private clinic
1 Histogram with TC, DC, 10min 30 min. 15min
Hb, MP Test each
2 ESR 45 min 1.2hr 1 hr
3 Blood group 10min 25 min 15 min
4 Stool examination 15min 1 hr 30 min
Microbiology
1 Culture & sensitivity 24-48min 36-48 hrs
2 Widal test 20min 45-60min 30 min
3 Stain sputum 15min 45min 30
4 Pregnancy test 15min 45min 30
Histopathology
1 FNAC Biopsy
Biochemistry
1 Lipid Profile 45min 1.5hr 1 hr
2 Biological fluids 30min 1hr 45 min
3 Urine analysis 15min 30min 30 min
4 Liver function test 30min 45min 45 min
5 Blood glucose 30min 1hr 30 min
6 Post prandial 15min 1.3hr 30 min
7 Random 20min 40min 30 min
8 Blood urea 15min 45min 20 min
9 Uric acid 20min 40min 30 min
93

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Time & Motion study of out patients, Shree Krishna Hospital

1.1 Nature of the Problem

1 Rakesh, Rupanwita (IRMA)

Therefore in addition to objective measurement and evaluation, the subjective evaluation of

1.3 Scope of study

2 Rakesh, Rupanwita (IRMA)

1.5 Definition of Terms

1.5.0 Technical terminology

3 Rakesh, Rupanwita (IRMA)

1.5.1 Medical and related terminology

4 Rakesh, Rupanwita (IRMA)

2.0.0 Methods-engineering approach3

2.0.1 Pareto’s 80/20 law:

5 Rakesh, Rupanwita (IRMA)

2.0.2 Perceived service quality4

Word of Personal Past

Dimensions of Expected Perceived service quality

6 Rakesh, Rupanwita (IRMA)

2.1 Sampling plan

2.1.2. For doctors’ survey

2.1.3. For students’ survey

7 Rakesh, Rupanwita (IRMA)

2.2 Instruments and tools used

2.3 Procedure followed

8 Rakesh, Rupanwita (IRMA)

9 Rakesh, Rupanwita (IRMA)

10 Rakesh, Rupanwita (IRMA)

3.1 PROCESS DESCRIPTION

11 Rakesh, Rupanwita (IRMA)

12 Rakesh, Rupanwita (IRMA)

Waits Gives case Reaches the

13 Rakesh, Rupanwita (IRMA)

3.2 HOSPITAL LAYOUT

Figure – 3 Hospital layout

Trauma & emergency

Signage Staff (as source of information)

Help desk Frequent way lost

Misleading and frequently used ways convenient ways

3.3 FINDINGS FROM OBJECTIVE STUDY

DELAY SERVICE TRANSPORTATION

3.3.2 Composition of the total service time

3.3.3 Composition of total waiting time

Distribution of delay at different service centres

3.3.4 Distribution of transportation time

3.3.5 Delay in transportation

Eye Actual time taken 59.76

Though the department of Orthopaedics is similarly placed as the department of Dermatology it

3.3.6 The cross departmental traffic

3.3.7 Study of SKH vis-à-vis private clinics

Total time Service time Waiting time

3.4 FINDINGS FROM SUBJECTIVE EVALUATION OF WAITING AND DELAY

3.4.0 The identified factors for delay

TION DELAY j. Cross-departmental movements 21.923 21.923

3.4.1 Some qualitative response to waiting problems

Source: patient survey

Source: patient survey

Source: patient survey

Source: patient survey

Effect on customer base

cannot say never come here

GAP Unweigted Weighted

Source: SERVQUAL survey