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Assessing MAX employees on NABH & training them.

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A PROJECT REPORT ON

Assessing M AX employees on NABH & training them

in partial fulfilment for the award of the degree of

MASTER OF BUSINESS ADMINISTRATION(MBA)


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Acknowledgements

I would like to express my deepest respect and most sincere gratitude to my guide, M s. Shi ell y Pahwa Bahl , Senior Training Manager, MAX Hospital, for the patient guidance,encouragement and advice he has provided throughout my time as his student. He has extendedhis magnanimous moral support through all the phases of my work. I have been extremely luckyto have such a supervisor, who cared so much about my work, as well as for providing necessaryinformation regarding the project and who responded to my questions and queries so promptly.His constructive criticism and comments from the initial conception to the end of this work ishighly appreciated. No words of acknowledgement would be adequate to fully express mygratitude and I shall remain highly indebted to him forever.

I would also like to express my heartfelt thanks and sincere gratitude to M r. Amrish Kumar,Human Resource M anager for giving me the opportunity to do my summer internship at Max Hospital; , a prestigious organization where I was able to learn, grow anddevelop.

I also take the opportunity to thank all the members of staff of personnel at Max Hospital for their kind cooperation and who helped me in my supervisors absence.

I am indebted to all the respondents who took out time from their busy schedule and filled myquestionnaire, gave valuable insights and suggestions, leading to the successful completion of the

project.

I would also like to express my heartfelt gratitude to my college mentor, M rs. Radhika Batra who has always been there to guide me and gave her feedback all through.

It has been a memorable experience and I am sure what I have learnt in the past two months willcome handy in many years to come.


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Executive Summary

Need Of The Study

The project deals about the Training Requirements By The Front Office Staff for Getting The Accreditation.

Due to the shortage of time and limitation of resources the study is confined to the trainingrequirements by the Front Office department only .

The project revolves around various facts and aspects such as:

What is front office? Why does a medical institution needs front office staff? What is an Accreditation certificate? What certificate MAX wants to apply for? What are the functions of HRM?

The Project would highlight things such as

General survey done through questionnaire to check the understandingof front office staff about their basic yet important duties.

The findings in terms of percentages. The suggestions The way outs to weed out the budding problems.

The Project would also highlight the Human Resource Departments role in

training the Front Office staff for the type of Accreditation applied for .

Contents


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Chapter -1

Introduction

Introduction


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Abstract

Front Office

Front office is a business term that refers to a company's departments that come in contact withclients, including the marketing, sales, and service departments.

The job of front office is to welcome guests, greet them, organizes the reservations, allocatingcheck in and out of rooms, organizing porter service and other security arrangements, passing onmessages to customers and settling the accounts.

Hence Front Office can b e called as Organizations Face. The only SPOC ( Single Point O f Contact) of an organization.

Need Of Front Office

In todays competitive world every organization regardless of its field likes to be an edge over others, a hand upper than everybody so as to ensure its long term venture in the market and huge

profit earning ratio, which can only be achieved by attracting as many buyers as they can for their products and services. Therefore the first step towards a successful journey for anyorganization is by employing exceptionally good FRONT OFFICE staff as they are the Face of the Organization.

Front Office staff is employed by various organizations such as:

1) Hospitality Industry

2) Medical Industry

3) Education Industry

4) Entertainment Industry

5) Aviation Industry

6) Service Industry

7) Railways

Medical & Health Care Organizations, Whatdoes it all mean?


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Medical organizations support the field of medicine , which is the branch of

health science , concerned with maintaining or restoring human health through thestudy, diagnosis, treatment and possible prevention of disease and injury .

Health Care Organisations The prevention, treatment and management of illness and the preservation of mental and physical well-being through the services offered by the medical and alliedhealth professions.

Health care organizations uses research, evaluation, and enhanced management and

communication strategies to effectively provide high quality care for special populations.Activities that focus on provider education, enhanced data applications, and consensus buildinginside and outside the organization are only some of the means by which health plans can

achieve improved outcomes for persons with special health care needs.

Moving Beyond Healthcare: The Role of Healthcare Organizations inCreating Healthy People in Healthy Communities in a Healthy World

In recent years, responding to the evidence on the determinants of population health and to the broad strategic vision of health promotion, hospitals and other healthcare organizations haveincreasingly defined their mission as improving the health of the community or population thatthey serve. In the United States, the Healthcare Forum has stressed the important role thathospitals can play in creating healthier communities. In this and subsequent articles and relatedcase studies in Hospital Quarterly , we will explore the role that healthcare organizations can

play in achieving the goal of healthy people in healthy communities in a healthy world. But firstit is important to discuss the philosophical and practical limitations to that role, in order tounderstand what healthcare organizations might really be able to contribute.

The Role for Leaders of Health CareOrganizations in Patient Safety We review what leaders of health care systems, including chief executive officers and boardmembers, need to know to have patient safety literacy and do to make their systems safe. Highreliability organizations produce reliable results that are not dependent on providers being

perfect. Their characteristics include the commitment of leadership to safety as a system
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responsibility, with a culture of safety that decreases variability with standardized care and doesnot condone at-risk behavior. A business case can be made for investing resources intosystems that produce good outcomes reliably. Leaders must see patient safety problems as

problems with their system, not with their employees. Leaders need to give providers

information to make and monitor system progress. All medical errors, including near misses, and processes associated with all adverse events may provide information for system improvement.Improving systems should produce better long-term results than educating workers to be morecareful .

The accountable care organization has been a model for health care reform, yet its modestsuccess has been limited to a handful of health care systems across the country. However, theaccountable care organization model has recently taken on far greater significance since being

introduced as one of Medicares pilot programs across the medical worl

What is the Role of the Front Desk Staff at aMedical Office?

The staff that works the front desk in a medical office is the first point of contact between thatoffice and its patients. Depending on the size of the practice, there may be multiple peopleworking the front desk or just one. Medical office front desk job duties include generaladministrative tasks as well as duties specific to working in a medical facility.


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General Administrative Duties

Clerical duties assigned to the staff at a medical front office include answeringtelephones, routing calls, taking messages, greeting visitors and patients, handling

correspondence, scheduling appointments and dealing with bookkeeping and billingtasks. The staff members also take payments and make outbound calls to remind patientsof upcoming appointments. In general, the staff members work to keep the medical officerunning efficiently by keeping everything organized and handling transactions and

paperwork in a time-sensitive manner.

Medical-Specific Duties

The front office workers are responsible for updating and filing patient medical records,so they need to have a general understanding of medical terminology and processes. Theyalso help patients fill out insurance forms and might arrange for laboratory services or

hospital admittance. Office staff members may answer general medical questions or refer patients to someone who can answer their questions.

The members of a medical front desk staff work indoors in an office environment. Theyspend a significant amount of time on the phone and computer, and they interact with

people regularly. The job can be stressful due to working with people who are ill or concerned about health issues. In general, medical front desk workers keep a 40-hour workweek within normal business hours, though some medical facilities are open onweekends or during the evenings to accommodate patient needs. In some cases, medicalfront desk workers have part-time schedules.

Types of Accreditations required by a Medical Organizationto be called as HEALTH CARE ORGANIZATION

List of international healthcare accreditation organizations:

Saudi Arabia :o Dr. Sulaiman Al -Habib Medical Group is not an accreditation organization,

however it is an accredited one. India :o National Accreditation Board f or H ospitals & H ealthcare Providers (NABH )[1]

USA :o Joint Commission I nternational

United Kingdom :
http://en.wikipedia.org/wiki/Sulaiman_Al-Habibhttp://en.wikipedia.org/wiki/Sulaiman_Al-Habibhttp://en.wikipedia.org/wiki/NABHhttp://www.qcin.org/nabh/index.phphttp://en.wikipedia.org/wiki/Joint_Commission_Internationalhttp://en.wikipedia.org/wiki/Joint_Commission_Internationalhttp://www.qcin.org/nabh/index.phphttp://en.wikipedia.org/wiki/NABHhttp://en.wikipedia.org/wiki/NABHhttp://en.wikipedia.org/wiki/Sulaiman_Al-Habib


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o QHA T rent Accreditation

Australia :o Australi an Council on H ealthcare Standards In ternational (ACHSI) [2]

New Zealand :o Quality H ealth New Zealand (QHN Z)

QHNZ quality standards are based on those used in Australia and Canada. QHNZ is accredited by the international umbrella organization, the International Society for Quality in Healthcare(ISQua).

Why does a hospital needs an Accreditation?

In a recent interview conducted by Times Of India with the Chairman, Quality Council of India

(QCI), Girdhar G Gyani feels that Hospital accreditation is directly related to patient

As per Mr. Girdhar Few years ago, quality in health care was not an issue. Access was a bigger compulsion. But now that there are facilities, its high time to think about quality.

This Project talks about Health care Organizations in India thatneed Accreditation (NABH) which serves as a major Quality Check Control.

Q: How does a patient gain, when a hospital gets accredited?

A: The entire system is directly related to patient well being. In fact 67% of the parameters and standards a hospital needs to fulfil to get itself accredited are fromthe clinical side. We got a survey done and found that the hospital stay in anaccredited hospital had come down to 4.7 days as compared to 5.3 days in anordinary hospital. Things get systematised in the process, turning concepts of informed consent, protocol or evidence based treatment, a reality which is in theinterest of the patient.
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Q: What does an NABH accreditation mean to a hospital?

A: It is an open challenge. Achieving the certificate is the first step, maintainingthe standards is a bigger goal. It is surely a feather in the hospital's cap. The

particular case of RML hospital is a precedent of sorts. Some of its departmentsalso have the potential to become a state of the art tertiary care centre. I suggestformation of a state-level body/agency to monitor, coordinate and build capacityfor the hospital holding or eying the QCI certificate.

National Accreditation Board forHospitals & Healthcare Providers (NABH)

National Accreditation Board for Hospitals & Healthcare Providers (NABH) is a constituent board of Quality Council of India, set up to establish and operate accreditation programme for healthcare organizations. The board is structured to cater to much desired needs of the consumers andto set benchmarks for progress of health industry. The board while being supported by all stakeholdersincluding industry, consumers, government, have full functional autonomy in the operations.


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International Linkage

NABH is an Institutional Member as well as a Board member of the International Society for Quality in Health Care (lSQua).

NABH is a member of the Accreditation Council of International Society for Quality in HealthCare (ISQua).

NABH is on board of Asian Society for Quality in Healthcare (ASQua).

Mark of Excellence

VisionTo be apex national healthcare accreditation and quality improvement body, functioning at par with global benchmarks.

Mission
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To operate accreditation and allied programs in collaboration with stakeholders focusing on patient safety and quality of healthcare based upon national/international standards, through process of self and external evaluation.

Values Credibility: Provide credible and value addition services

Responsiveness: Willingness to listen and continuously improving service

Transparency: Openness in communication and freedom of information to itsstakeholders

Innovation: Incorporating change, creativity, continuous learning and new ideas toimprove the services being provided

Structure

Board Composition1. Chairman- Dr. Narottam Puri, Adviser-Medical, Fortis Healthcare Limited 2. Indian Medical Association3. Consumer Co-ordination Council4. Insurance Regulatory & Development Authority (IRDA)5. Indian Nursing Council


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6. Department of AYUSH7. Director General, Armed Forces Medical Services8. Directorate General of Health Services (DGHS), MoHFW9. Dean, Maulana Azad Medical College10. Ministry of Tourism11. Drugs Controller General of India12. Chair Health Committee CII13. Chair Health Committee - ASSOCHAM14. Chair Health Committee - FICCI15. Academy of Hospital Administration (AHA)16. Indian Health Care Quality Forum Academic partner 17. Chair Accreditation Committee NABH18. Chair Hospital Technical Committee NABH19. Chair Appeals Committee NABH20. CEO NABH Member Secretary

Benefits of AccreditationAccreditation

"A public recognition of the achievement of accreditation standards by a healthcare organisation,demonstrated through an independent external peer assessment of that organisation's level of performancein relation to the standards".

Accreditation benefits all stake holders. Patients are the biggest beneficiary. Accreditation resultsin high quality of care and patient safety. The patients get services by credential medical staff.Rights of patients are respected and protected. Patient satisfaction is regularly evaluated.

The staff in a accredited health care organisation are satisfied lot as it provides for continuouslearning, good working environment, leadership and above all ownership of clinical processes.

Accreditation to a health care organisation stimulates continuous improvement. It enables theorganisation in demonstrating commitment to quality care. It raises community confidence in the


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services provided by the health care organisation. It also provides opportunity to healthcare unitto benchmark with the best.

Finally, accreditation provides an objective system of empanelment by insurance and other third parties. Accreditation provides access to reliable and certified information on facilities,infrastructure and level of care.

Workshops

1. Quality Control & Awareness Program on Essential Standards for Medical TestingLaboratories

Mumbai; 17 August 2012

2. Healthex 2012 International

Exhibition and Conference on Hospital, Medical and Surgical Equipment, Drugs andDisposables and Allied Services.

; 7-9 Sept 2012

3.

Interactive workshops on Sterilization and Surgical Safety

4. Interactive workshops on Continual Quality Improvement : Tools and Techniques

Multiple Cities;


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5. 3 Day Training Programme on Implementation of NABH Hospital Standards

Multiple Cities;

6. Interactive Workshop on Legal Compliance

7. Interactive workshops on Management of Medication and Patient Safety

Chapter 2

I ndustry Prof i le


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Healthcare in India

Healthcare in India features a universal health care system run by the constituent states and territories of India . The Constitution charges every state with "raising the level of nutritionand the standard of living of its people and the improvement of public health as among its

primary duties". The National Health Policy was endorsed by the Parliament of India in 1983and updated in 2002.

Parallel to the public health sector, and indeed more popular than it, is the private medical sector in India. Both urban and rural Indian household tend to use private medical sector morefrequently than public sector, as reflected in surveys.

Health care industryThe health care industry , or medical industry , is a sector within the economic system that

provides goods and services to treat patients with curative, preventive, rehabilitative, palliative, or, at times, unnecessary care. The modern health care sector is divided into many sub-sectors,and depends on interdisciplinary teams of trained professionals and paraprofessionals to meethealth needs of individuals and populations.

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

Background

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

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

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

The Global Industry Classification Standard and the Industry Classification Benchmark further distinguish the industry as two main groups:

1. health care equipment and services; and2. pharmaceuticals, biotechnology and related life sciences.

Health care equipment and services comprise companies and entities that provide medicalequipment, medical supplies, and health care services, such as hospitals, home health care

providers, and nursing homes. The second industry group comprises sectors companies that produce biotechnology, pharmaceuticals, and miscellaneous scientific services.

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

Providers and professionals

A health care provider is an institution (such as a hospital or clinic) or person (such as a physician, nurse, allied health professional or community health worker) that provides preventive, curative, promotional, rehabilitative or palliative care services in a systematic way toindividuals, families or communities.

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

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

In 2003, health care costs paid to hospitals, physicians, nursing homes, diagnostic laboratories,

pharmacies, medical device manufacturers and other components of the health care system,consumed 15.3 percent of the GDP of the United States, the largest of any country in the world.For United States, the health share of gross domestic product (GDP) is expected to hold steady in2006 before resuming its historical upward trend, reaching 19.6 percent of GDP by 2016. In2001, for the OECD countries the average was 8.4 percent with the United States (13.9%),Switzerland (10.9%), and Germany (10.7%) being the top three. US health care expenditurestotaled US$2.2 trillion in 2006.According to Health Affairs, US$7,498 be spent on every woman,man and child in the United States in 2007, 20 percent of all spending. Costs are projected toincrease to $12,782 by 2016.

Delivery of services

The delivery of health care services - from primary care to secondary and tertiary levels of care is the most visible part of any health care system, both to users and the general public.There are many ways of providing health care in the modern world. The place of delivery may bein the home, the community, the workplace, or in health facilities. The most common way isface-to-face delivery, where care provider and patient see each other 'in the flesh'. This is whatoccurs in general medicine in most countries. However, with modern telecommunicationstechnology, in absentia health care is becoming more common. This could be when practitioner

and patient communicate over the phone, video conferencing, the internet, email, text messages, or any other form of non-face-to-face communication.

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

population.

The structure of health care charges can also vary dramatically among countries. For instance,Chinese hospital charges tend toward 50% for drugs, another major percentage for equipment,and a small percentage for health care professional fees. China has implemented a long-termtransformation of its health care industry, beginning in the 1980s. Over the first twenty-five yearsof this transformation, government contributions to health care expenditures have dropped from36% to 15%, with the burden of managing this decrease falling largely on patients. Also over this
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period, a small proportion of state-owned hospitals have been privatized. As an incentive to privatization, foreign investment in hospitals up to 70% ownership has been encouraged.

Medical tourism

Medical tourism (also called medical travel, health tourism or global health care) is a terminitially coined by travel agencies and the mass media to describe the rapidly-growing practice of traveling across international borders to obtain health care.

Such services typically include elective procedures as well as complex specialized surgeries suchas joint replacement (knee /hip) , cardiac surgery, dental surgery, and cosmetic surgeries. However, virtually every type of health care, including psychiatry, alternative treatments,convalescent care and even burial services are available. As a practical matter, providers andcustomers commonly use informal channels of communication-connection-contract, and in suchcases this tends to mean less regulatory or legal oversight to assure quality and less formal

recourse to reimbursement or redress, if needed.
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Chapter 3

Company Prof i le

About Max Hospital


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With over 930 Beds and 12 hospitals in the network,(9 hospital in Delhi&NCR,2 hospitals in Punjab and1 hospital in Dehradun) and over 1500 physicians and 3500 support staff, Max Healthcare is one of theleading chain of hospitals in India. Our state-of-the-art infrastructure is one of the best in Delhi, with over 275 ICU beds and most advanced technologies makes us one of the best hospitals in India. Our specialties

are Cardiology and Cardiac Surgery , Oncology, Minimal Access Metabolic & Bariatric Surgery, Neurology and Neuro surgery, Orthopaedics and Joint replacement, Renal transplant, Bone MarrowTransplant, Aesthetic & Reconstructive surgery and many more.

M ax Healthcare I nstitute is a healthcare institute based in New Delhi, India. The Institute is awholly owned subsidiary company of Max India Limited. Established in 1985, Max IndiaLimited is a Public Limited company listed in the Bombay Stock Exchange and National Stock Exchange of India with more than 37,000 shareholders .[1]

The institute operates eleven centers in Delhi, NCR and neighbouring Punjab region, providinghealth care services in more than 30 disciplines .[2] The company provides patient servicesincluding nuclear medicine and cardiac imaging, labs, scans, interventional cardiology, cardiac

pacing and electrophysiology, neurosciences, orthopedics, gynecology and obstetrics, pediatrics, maternity services, diagnostic services, pediatric ophthalmology, neurophthalmology, internalmedicine, general surgery, urology, nephrology, gastroenterology, mental health and behavioralsciences, rehabilitative services, and pulmonology .[3] Dr. Ajay Bakshi is the CEO of MaxHealthcare.

History

Max Super Specialty Hospital

Max India Limited was founded in 1988. The first Max healthcare centre was opened as MaxMedcentre in Panchsheel Park, New Delhi with OPD facilities and day care surgeries in 2000 .[5]
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In 2002, Max Hospital was opened in Pitam Pura. Dedicated to mother and child care, MaxHospital, Noida was opened in 2002 with services including non-invasive cardiology,orthopedics, ENT, ophthalmology, nephrology etc. Max Heart and Vascular Institute wasestablished in 2004 with advanced cardiac life support and air evacuation service in Saket .[6]

Max Hospital in Patparganj was founded in 2005. In the same year, Max Eye and Dental Carecentre was opened at Panchsheel Park, New Delhi. Max Super Specialty Hospital in Saket wasfounded in 2006 and Max Hospital, Gurgaon was opened in 2007.

Hospitals

Max Super Speciality Hospital, Saket Max Super Speciality Hospital (A unit of Devki Devi Foundation), Saket

Max Super Speciality Hospital, Patparganj Max Hospital, Pitampura Max Hospital, Noida Max Medcentre, Panchsheel Park Max Hospital, Gurgaon Max Super Speciality Hospital, Shalimar Bagh Max Super Speciality Hospital, Mohali, Punjab Max Super Speciality Hospital, Bathinda, Punjab [7]

Chairman

Analjit Singh is the Founder & Chairman of Max India Limited, Chairman of Max New York Life Insurance Company Limited; Max Healthcare Institute Limited and Max Bupa HealthInsurance Company Limited.

He has been awarded the Padma Bhushan Award .[8]

He is presently an Executive Board Member of the Board of Governors, Indian School of Business( ISB), Hyderabad, where he is jointly funding a new campus at Mohali, Punjab andactively facilitating it as the Chairman, Mohali Campus Advisory Board, ISB. He has also

recently taken on the role of the Chairman of the Board of Governors, Indian Institute of Technology, Roorkee. In addition, he is the Chairman, Board of Governors, The Doon School, Dehradun .[9]

Analjit Singh is an alumnus of Doon School, Dehradun; Shriram College of Commerce,University of Delhi; School of Management and the Graduate School of Management, BostonUniversity, Boston, USA .[10]
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Specialty Centres at Max Healthcare

Max Heart and Vascular Institute is a 220-bed cardiovascular facility located at Saket, inSouth Delhi. This institute was opened in 2001.The services available at this institute are alltypes of Coronary, Carotid, Renal & Peripheral Angiographies, all types of Coronary, Carotid,Renal & Peripheral Angioplasties and Stenting, Balloon Mitral, Aortic and PulmonaryValvuloplasty, Rotational and Directional Athrectomy, Intravascular Ultrasound (IVUS) andThrombectomies .[11]

Max Institute of Neuro Sciences is fitted with Novalis Tx, Rapid ARC, PET CT andBrachytherapy. The procedures performed here include Spine Surgery, Brain tumour surgery,Disk replacement surgery, Endovascular Neurosurgery and more .[12]

Max Institute of Orthopaedics & Joint Replacement Surgery is a tertiary care centre located

in South Delhi. This institute works on the concept of early mobilization, minimal discomfortand provides treatments like Knee Replacement Surgery, Hip Replacement Surgery, SpineSurgery, Sports Injury treatment or any other orthopaedic surgery .[13]

Max Cancer Centre uses technologies like Novalis Tx Radiosurgery, Intensity ModulatedRadiation Therapy (IMRT), Image Guided Radiation Therapy (IGRT), Stereotactic Radiosurgery (SRS), Radiation Therapy (SRT), and Stereotactic Body Radiation Therapy (SBRT).

Max Institute of Minimal Access, Metabolic & Bariatric Surgery has been accredited as theInternational Centre of Excellence (COE) by the Surgical Review Corporation, USA under theleadership of Vice Chairman and Director Pradeep Chowbe y[14] . This is the first institute in India

to get this award .[15]

Max Institute of Obstetrics and Gynaecology has been established to provide world-classhealthcare to women. The team of experts contains gynaecologists, sonologists, radiologists, and

psychological counselors .[16]
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Max Institute of Paediatrics

Max Institute of Paediatrics is a dedicated childcare center in the country and meets all thehealthcare needs of babies, children, and teenagers. It provides a wide range of child careservices that include general paediatrics including immunisations, paediatric and neonatalsurgery, neonatal care and numerous paediatric sub-specialities such as paediatricgastroenterology, nephrology, endocrinology, developmental paediatrics and adolescentmedicine.

Max Institute of Aesthetic & Reconstructive Surgery is located in Saket and equipped withthe Delhi's first ever VASER Lipo Technology. The list of medical services available hereinclude Face Lift, Hair Restoration Surgery, Breast Lift, Buttock/Thigh Lift, Liposuction, Tummy Tuck, and Arm Lift.

Max Eye Care is a super-specialized centre for eye surgery in Panchsheel Park, South Delhi.This centre provides a wide range of services including Opthalmology, Photo-Dynamic Therapy,Aesthetic Plastic Eye Surgery, Glaucoma surgery, small incision cataract surgery (SICS),

Neurophthalmology, and many more .[17]

Max Dental Care

Department of Mental Health & Behavioral Sciences

Department of Endocrinology, Diabetes and Obesity

Department of ENT

Department of Physiotherapy & Rehabilitation

Physiotherapy and Rehabilitation Department

Department of Nuclear Medicine
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Accreditation

The Max Institute of Minimal Access, Metabolic & Bariatric Surgery has accredited as acentre of Excellence for providing state-of-the-art Clinical Services and Surgical Training

Programmes for Abdominal Wall Hernia Surgery.

Max Super Specialty Hospital, Saket was awarded FICCI award for OperationalExcellence in Healthcare Delivery.

FICCI awarded Max Super Specialty Hospital, Patparganj with the Healthcare award for Operational Excellence in Environmental Conservation.

In the inaugural edition of FICCI Healthcare Excellence Awards, Max Super SpecialtyHospital, Saket was acknowledged one of the Best Hospitals for Excellence inHealthcare Delivery.

Max Healthcare was awarded the prestigious DL Shah National Award on 'Economics of Quality' from Quality Council of India.

The Blood Bank at Max Healthcare was awarded the 'NABH Accreditation for BloodBank'.

Max Super Specialty Hospital and Max Devki Devi Heart & Vascular Institute at Saket,the two tertiary care hospitals of Max Healthcare, are the first two hospitals of NorthIndia to have received the prestigious accreditation from National Accreditation Boardfor Hospital & Healthcare Providers.


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HRM Role in Max

The hospital ha s a well defined set of rules and conditions thatthe HR department needs to adhere to.

The HRM(NABH) has a structured and a well written literaturethat they need to follow in training the employees.

Hereunder is the HRM literature that explains the HR practicesand trainings that need to be followed in theOrganization(MAX) and for the employees (Front Office Staff).

Introduction

Human resources are an asset for effective and efficientfunctioning of a hospital.


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Human resource management is concerned w ith the peopledimension in management.

The goal of human resource management is to acquire, provide,retain and maintain competent people in right numbers to meetthe needs of the patients and community served by theorganization.

1. Their is documented system of planning the humanresource.

Human resource planning supports the organizationscurrent and future ability to meet the care, treatment andservice needs of the patient.

This is done in a structured manner keeping in mind thescope of services, healthcare needs of the society .

It shall match the strategic and operational plan of theorganization.

It is hence an annual exercise. The organization has to maintain an adequate number of

staff to meet the care, treatment and service needs of the

patient. The job specifications and job description are well

defined for each category of staff.


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The qualifications, skills and experience required for performing the job should be clearly stated by thehuman resource department.

The job description should commensurate with thequalification.

The organization has to verify the antecedents of thepotential employee with regards to criminal background.

This can done from where the employee has servedearlier and/or from the previous employer.

In case of a doctor or a nurse, a Good standingcertificate has to be obtained .

2. The organization has to follow a well documentedprocedure for recruiting employees and training them to theenvironment of the organisation.

There is a documented procedure for recruitment.

The well performed recruitment process ensures an adequatenumber and skill mix of staff to provide the organizationsservices.


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Recruitment is to be undertaken in accordance with appropriaterequirements, where applicable.

Recruitment is based on pre-defined criteria.

This shall be done in a transparent manner.

Every staff member entering the organisation has to attend theInduction program

The organization shall determine as to when induction training shall be conducted.

There can be separate induction training at the organization level andfor the respective departments.

The content of this training should be provided in the form of booklet.

The induction training schedule includes orientation to theorganizations vision, mission and values.

The organizations staff including the outsourced staff should be aware of themission, vision and values of the organization


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The induction training includes awareness on employee rights andresponsibilities.

Training will help to employees in understanding their responsibilities

This should be conducted in a regular intervals.

The induction training includes awareness on patients rights andresponsibilities.

The employees should be able to identify and report violation of patients right as and when it occurs.

Confidential treatment of medical records

Can have copy Of Medical records

Receive information about:

Illness, treatment and prognosisMedicationsDiet

The induction training includes orientation to the servicestandards of the organization.

The employees should be trained to implement the service standardsof the organization.


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Every staff member is made aware of organizations wide policies andprocedures as well as relevant department/unit/service/programmespolicies and procedures.

The staff should correctly interpret the policies and operating procedures of the organization as well as his/her relevant department.

3. An ongoing program for professional training and developmentof the staff is to be arranged.

There is a documented training and development policy that exists for thestaff.

The training shall be for all categories of staff including doctors andoutsourced staff.

Training can be internal or external.

A training manual incorporating the procedure for identification of training needs, the training methodology, documentation of training,training assessment, impact of training and the training calendar should be prepared.

Feedback mechanisms are to be used for assessment of training anddevelopment program and the feedback is used to improve the trainingprogramme.

This includes both internal & external training.


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For external training it could be done either by the HCO itself or bythe external agency which organized the training.

4. Staff is has to be adequately trained on various safety-relatedaspects.

Staff is trained on the risks within the organizations environment.

Risk includes- patient, visitors and employee-related.

Staff members can demonstrate and take actions to report, eliminate /minimize risks.

The staff members should be able to take actions against these risks.

Staff members are made aware of procedures to follow in the event of an incident.

The staff must be properly trained to handle any adverse situation if happens.

Staff is trained on occupational safety aspects.


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Staff should know the preventive actions to avoid the risks.

5. A well stated appraisal system should be designed for evaluatingthe performance of the employees.

A documented performance appraisal system exists in the organization.

Performance appraisal is the process of evaluating the performance of employees during a defined period of time with the aim of

ascertaining their suitability for the job, potential for growth as well asdetermining training needs.

The performance appraisal should be properly documented.

The employees are made aware of the system of appraisal at the time of induction.

The performance appraisal procedure should be properlycommunicated to the staff at the time of induction.

Performance is evaluated based on the pre-determined criteria.

Performance appraisal should be done on the performanceexpectations described in job description.


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The appraisal system is used as a tool for further development.

The performance appraisal motivates the employee to do a better jobfrom the previous one.

This helps in the further development of the organization.

Performance appraisal is carried out at pre defined intervals and isdocumented.

This shall be done at least once a year.

Referred to Max Appraisal Policy

6. The organization has to have a documented disciplinary andgrievance-handling policies and procedures.

Documented policies and procedures exist.

The policies and procedures are known to all categories of staff of theorganization.

The staff should have the knowledge of all the policies & proceduresof the organization.

This could be in the form of service rules.


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The disciplinary policy and procedure is based on the principles of natural justice.

Natural justice implies that both parties (employee and employer) aregiven an opportunity to present their case and decision is takenaccordingly.

The disciplinary procedure is in consonance with the prevailing laws.

The procedure should be done according to the prevailing laws.

For e.g. labor laws and CCS (CCA) rules.

There is a provision for appeals in all disciplinary cases.

The organization shall designate an appellate authority to consider appeals indisciplinary

The redress procedure addresses the grievance.

Actions are taken to redress the grievance.

The changes should be communicated to every staff member.


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A Grievance is a sign of employees discontent with job and its nature. Theemployee has got certain aspirations and expectations which he thinks must

be fulfilled by the organization where he is working. When the organization

fails to satisfy the employee needs, he develops a feeling of discontentor dissatisfaction. Thus, grievance is caused due to the difference betweenthe employee expectation and management practices.

7. The organization must address the health needs of theemployees.

A pre-employment medical examination is conducted on all theemployees.

A pre-employment medical examination is conducted on all theemployees who are joining the organization.

This shall however be in consonance with the laws. For example, performing pre-employment HIV testing is illegal.

Health problems of the employees are taken care of in accordance withthe organizations policy.

Employee health checkup and health safety policy.

Regular health checks of staff dealing with direct patient care are doneat-least once a year and the findings/ results are documented.


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The results of the health checks should be properly documented in the personal file of the employee.

It is free of cost.

Occupational health hazards are adequately addressed.

Training should be given to staff on how to use personal protectiveequipments.

Occupational hazards are the hazards to which an individual isexposed during the course of performance of his job. These include

physical, chemical, biological, mechanical and psychosocial hazards.

8. The organisation has to maintain a documented personal recordfor each staff member.

Personal files are maintained in respect of all employees.

A personal file is maintained for all the employees.

The personal files contain personal information regarding theemployees qualification, disciplinary background and health status.


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The personal details of the employee are documented in the person

All records of in-service training and education are contained in thepersonal files.

Training records should also be documented in the personal file of theemployee.

Personal files contain results of all evaluations.

It contains performance appraisals, training assessment and outcome of healthchecks.

9. The organisation has to maintain the strictness for credentialingand privileging the medical professionals, permitted to providepatient care without supervision.

Medical professionals permitted by law, regulation and the hospital toprovide patient care without supervision is identified.

The organization must have a proper credentialing. Credentialing is a process of obtaining, verifying and assessing the qualification of ahealth care provider.

The education, registration, training and experience of the identifiedmedical professionals is documented and updated periodically.


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Credentials of the medical professionals shall be properly documented& it should be updated properly.

After acquisition of new skills and/or qualification an updation should be done.

All such information pertaining to the medical professionals isappropriately verified when possible.

The credentials should be verified properly.

Medical professionals are granted privileges to admit and care of patients in consonance with their qualification, training, experience andregistration.

The requisite services to be provided by the medical professionals areknown to them as well as the various departments/units of theorganiszation.

Only can be done by internal communication.

Medical professionals admit and care for patients as per theirprivileging.

Medical professionals should ensure that they provide only thoseservices that they offer.

10. The organisation has to maintain the strictness for credentialingand privileging of nursing professionals, permitted to providepatient care without supervision.


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Nursing staff permitted by law, regulation and the hospital to providepatient care without supervision is identified.

Organization should assess each employee and figure out themaccording to their capability.

The education, registration, training and experience of nursing staff isdocumented and updated periodically.

After acquisition of new skills and/or qualification an updation should be done.

All such information pertaining to the medical professionals isappropriately verified when possible.

The credentials should be verified properly.

Nursing staff are granted privileges in consonance with theirqualification, training, experience and registration.

The requisite services to be provided by the nursing staff are known tothem as well as the various departments/units of the organisation.

Only can be done by internal communication.

Nursing professionals care for patients as per their privileging.

Nursing professionals should ensure that they provide only thoseservices that they offer.


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Privileging a right, advantage, favor, or immunity specially granted to one;esp., a right held by a certain individual, group, or class, and withheld fromcertain others or all others

Privileging denes a physicians scope of practice and the clinical serviceshe or she may provide. Privileging is based on demonstrated competenceand is a data driven process.

It should be done at proper timing and documentation should be kept in a personal file.

Chapter 4

Objective Of The Study


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Objectives of the Project

Every task is done with an objective without which it is incomplete, meaningless and baseless. The main objectives for undertaking this research are:

To view the employees understanding on their job profiles. To analyze their learning on the trainings given by the Human Resource Department. To analyze & rectify their learning about NABH To learn whether the employees are well versed with the hospital norms & conditions or

not. To learn about the steps taken by the Human Resource Management for training the front

office staff on NABH To identify the loopholes in the organization. To analyze the effectiveness of trainings taken by Human Resource Mangagement for

NABH for the employees.

To offer suggestions and recommendations for improving job satisfaction in the department

To suggest the management of the company to know about the actions to be taken to

increase the understandability level of the employees on NABH and its requirements


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Chapter 5

An I nsight about Research M ethodology


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RESEARCH METHDOLGY

Research methodology is a way to systematically solve the research problem. Research

Methodology comprises of two words, research and methodology.

Research is defined as human activity based on intellectual application in the investigation of

matter. And methodology can be defined as a particular procedure or set of procedures.

RESEARCH DESIGN

Research design is the conceptual structure within which research is conducted; it

constitutes the blue print of the collection, measurement and analysis of the data. As search

the design includes an outline of what the researcher will do from writing the hypothesis

and its operational implication to the final analysis of data.

Research Design can be categorized as

The present study is exploratory & descriptive in nature.

T he basic reason for carrying out descriptive research is to identify the cause of something that is

happening. It collects data in order to answer questions about the current status of the subject or

topic of study

Exploratory research is a type of research conducted for a problem that has not been clearly

defined. It often relies on secondary research such as reviewing available literature and/or data,

or qualitative approaches such as informal discussions and more formal approaches through in-

depth interviews, focus groups, projective methods, case studies etc. it can give some indication

as to the "why", "how" and "when" something occurs, it cannot tell us "how often" or "how

many".


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SAMPLE DESIGN

Sample Size: 50 respondents

Sample unit = Employees of MAX Super Speciality Hospital, Shalimar Bagh.

Sample area = MAX Super Speciality Hospital, Shalimar Bagh. New Delhi

DATA COLLECTION METHOD

The front office staff of the organization were put through a questionnaire & personal discussion for datacollection. Both primary & secondary data are used. Primary sources are original, uninterrupted and

unedited information, first-hand access to words, images, or objects created by persons directly

involved in an activity or event. Where as secondary sources interpret, analyze or summarize. In other

words, a secondary source is a work that interprets or analyzes an event or phenomenon well after the

fact.

PRIMARY SOURCES OF DATA COLLECTION

QUESTIONNAIRE

INTERVIEWS

SECONDARY SOURCE OF DATA COLLECTION

MAGAZINES

MANUALS

BROCHURES

In the present study, primary as well as secondary data has been used


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Chapter 6

Analysis & Interpretations

Parameter1. NEW HIRE INDUCTION PROGRAM

Q1. Have you attended the Induction program (NHIP)


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Analysis:

73% of the employees have attended the NewHire Induction Program.

27% of the employees havent attended anytraining like this.

Interpretation:

73% of the employees in the Front Office have attended theInduction Program.

Reasons for not attending the NHIP

Yes

No

Joined Late


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5%

15%

7%

Interpretation:

Since 5% of the staff joined late and 1 5% of the staff couldnt attendthe training because of lack of time and rest 7% were unable toattend the same because of early work pressure.

Parameter2. LIFE SAVING TECHNIQUES

Q2. Are you aware of the basic training of CPR (CardiacPulmonary Resuscitation).

Yes

Lack Of Time

Early work Pressure


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66%

44%

Interpretation:

CPR is a Must Know training for the front office staff , 4 and 66%of the employees are well versed with the training & 44% of theemployees dont know.

Reasons for not knowing the CPR

20%

No

Lack of enough trainingSessions.


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15%

9%

Interpretations:

20% of the staff hasnt got enough amount of t raining sessions forthe same, 15 % couldnt attend the training sessions so conducteddue to work pressures and rest 9% are out of practice due to lack of sessions.

Parameter3. INFORMATION ON VARIOUS THREATS

Q3 Are you aware of various codes of the hospital.

80%Yes

Work Pressures.

Lack Of Practice


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20%

Interpretation:

Codes are the indications of various threats like cardiac arrest,

bomb threat, external disaster and etc.80% of the employees working in the hospital are well aware of various Codes.

Q3(a) what does code yellow means?

90%

No

ExternalDisaster

NotAttempted


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10%

Interpretation:

90% of the employees know about Code Yellow ie. ExternalDisaster. However still 10% need to be trained.

Reasons of ignorance towards the Codes(threats) of the hospital

12%

2%

Lack of Knowledge due topoor ratio of trainingsession

Ignorance towards thenorms, as they areconfusing


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6%

Interpretation: 12% are ignorant due to lack of knowledge, 2% are

ignorant as the codes are confusing and rest 6% are ignorant due tolack of enough mock drill practices.

Parameter4. MAINTAINING PATIENT CONFIDENTIALITY

Q4 . Do you follow Patient Confidentiality clause

100%

0%

Always

Sometimes

Never

Poor mock drill practices for

the codes.


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0%

Interpretations:

The hospital maintains its decorum of keeping their patients identitya secret.

Parameter5. HANDS ON BASIC MEDICAL TERMINOLOGY

Q5. Have you attended any training on Medical Terminology

20%

80%

Interpretations:

Yes

No


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Only 20% of the employees have attended trainings related to theirmedical terminologies.

Reasons for not knowing the medical concepts and terminologies

25%

45%

10%

Lack of Knowledge

Irregular Shifts and abrupt job rotations

Lack of effective trainings


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Interpretation: 25% of the employees are ignorant due to lack of knowledge, 45% due to irregular shifts and job rotations and rest10% due to lack of effective trainings.

Parameter6. Hands on effective handovers

Q6.Do you inform the next shift staff about any follow-up that theyneed to do after your shift ends.

60%

10%

Yescompletely

YesPartially

No


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30%

Interpretations:

80% of the employees take care to do a proper follow up.

Reasons for not performing effective handovers

15%

10%

15%

Interpretations: 15% fail to do effective handovers as they arebogged down by the work pressures, poor work timings, 10% due to

Work Pressure / worktimings/

Lengthy reportingprocedures

Ineffective trainings


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lengthy and confusing handover procedures and rest 15% due toineffective training sessions

Parameter7. Awareness on hospitals infrastructure Q7. Are you aware of the Fire Exits in the hospital

66%

34%

Interpretations:

Fire Exits are a must know fact of the hospital to save lives at thetime of any Fire accident and still 34% of the employees arentaware of the Exits.

Yes

No


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If yes then please specify the Exits

40%

0

60%

Interpretations:

The Fire Exits are near Sagar Ratna, Emergency departmentand etc which was well answered by 60% of the employees.

Near Caf-area

2nd Floor

Near SagarRatna


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Parameter8: Respecting Time deadlines to revert to a complaint

Q8. Do you adhere to a limit to revert to a complaint.

20%

0%

80%

Interpretations:

Only 20% of the employees attempted the question and knew thetime limit to be adhered to and rest didnt attempt the questionwhich shows their ignorance towards the same. Such a loopholewould dampen the growth of the hospital in terms of good customercare.

Parameter9: Maintaining Loyalty as a staff

Q9. Do you ensure that you recommend patients Max branchesonly in case of non-availability of the services in the current branch.

Yes

No

Not

Attempted


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85%

25%

0%

Interpretations:

85% of the employees ensure and maintain their loyalty towardstheir branch and recommend Max sister branches only.

Parameter10:Basic knowledge on NABH

Q10. Do you know the full form of NABH

Yes Always

Yes

Sometimes

No I dont

Yes


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100%

0%

Interpretation:

The staff is well aware of NABH.

If YES please specify the full form

No

National Accreditation Board for Hospital and Healthcare Providers


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100%

0%

Interpretations:

The staff is well aware of the NABH full form which is a good signalto apply for the certificate.

National Accreditation Board for Hospitals


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Chapter 7 L imitations of the

study

LIMITATIONS OF THE STUDYLimitations of the study were:

An employee has a fear to reveal the unknown facts & aspects.

Due to scarcity of time, the study was limited to 50 respondents.

The information collected is based on the understanding of the respondents.

The study conducted with the front office staff of organization only.

Time was major limitation, which affected the study.

Some of the respondents were reluctant to share information with us due to lack of

knowledge.


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Data collected is based on questionnaire.

The number of employees in Max is more, but sample size is limited by 50. And it is

quite understood that sample size does not exactly represent the total population.

The information collected by the observation method is very limited.

The result would be varying according to the individuals as well as time.

The findings and conclusions are based on knowledge and experience of the respondents

sometime may subject to bias

There may be some kind of biases which may occur. For example acquiescence biaswhere the respondent tries to stick to the positive responses. Sometimes a respondent canalso choose to be neutral in all his responses. A biased response is also a limitation to thestudy

The study could not be able to cover all the sections of the employees which may resultin some errors.

Researcher bias A researcher may also have some biases for example a particular expectation about the response he should get, so his study may also bend towards his ownexpectation.


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Chapter 8

F indings of the study

FindingsThe findings of the project are based on the guidelines laid down by theNABH for all the hospitals seeking the accreditation.

1. Induction Program:

As per NABH every new joinee needs to attend 3 day inductionprogram which is mandatory and the ratio should be cent percent.


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front office recruitment in max hospital

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