hospital nabh final project

SUMMER TRAINING REPORT

ON

SGL HOSPITAL GADA ROAD JALLANHAHAR

TO STUDY AND MAKE PROTOCOLS FOR SGL HOSPITAL ONGOING

POLICIES AND PRACTICES IN AN ACCORDANCE TO NABH

ACCREDITATION AND EMPLOYEE SATISFACTION SURVEY IN

SGL HOSPITAL

Submitted in partial fulfilment of the requirements of

MBA IN HEALTHCARE N HOSPITAL

By

DR TARUN SONI

11105135

MBA (Batch 2011-13)

LOVELY PROFFESIONAL UNIVERSITY

Phagwara

Jalandhar Punjab

DECLARATION1

I Dr .tarun soni pursuing Mba [hhm} from lovely professional university phagwara Jalandhar

hereby declare that this project work entitled “To study and make protocol for sgl hospital

ongoing policies and practices in an accordance to NABH accreditation and to conduct a

employee satisfaction survey

is carried out for 42 days.

To the best of my knowledge & belief, it is an original piece of work and is the sheer outcome of

my own efforts under the vigilant guidance of my guides and has not either in full or in part been

submitted to any other institution for the award of any other course.

Dr tarun soni

Mba{ hhm} (10-12)

Date-

2

PREFACE

No professional curriculum is considered complete without work experience. Each individual who under

takes management education has to to pass this phase before he/ she considers him/ her self fully

qualified managers.

Knowledge has two aspects- theoretical and practical and no theoretical concept is complete without

having knowledge of its practical application.

As we all know that practical training plays an important role in building the future of an individual.This

summer training programme proves really beneficial to the future managers as they are confronted with

the problems of actual work environment during their training period.

As per the curriculum requirement, I did 6 weeks training at sgl hospital. Working in such a big

organisation, no matter for a very small period was really a matter of pride. As my specialization area is

major-marketing ,minor-hr, so I concentrated my workings on the project assigned to me i.e. EMPLOYEE

SATISFACTION in sgl hospital . So the learning during the training at sgl hospital. as a report is being

presented in the following pages.

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ACKNOWLEDGEMENT

An exchange of ideas generates a new object to work in a better way. Apart from the ability,

labour and time devotion; guidance and co-operation are two pillars for the success of a project.

Whenever a person is helped or co-operated by others, his heart is bound to pay gratitude to

them.

A satiation and pleasure that accompany the successful completion of task would be incomplete

without the mention of the people who have made it possible and whose consent guidance and

encouragement served as a guiding light for the completion of the study.

I would like to express my gratitude to my project guide Mrs. Palwinder kaur for their

constant encouragement and guidance without the task would not have been completed.

I consider it privilege to express through my report a few words of gratitude to Mr. Mirdula

Mishra my faculty guide who guided and inspired me in completing this study. I would like to

express my deep sense of gratitude to all the staff members for their support and helping me

during my project study.

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TABLE OF CONTENTS

Executive Summary 4

Industry study 6

Company overview 15

Swot Analysis

Research Objective

21

26

Research methodology 33

Limitation

Findings and Recommendations

Data collection

Data analysis

Recommendation for employee satisfaction

35

42

43

45

51

Conclusion 52

Bibliography 53

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EXECUTIVE SUMMARY

As a part of my MBA {HHM}program, I have done my internship trainin at SGL hospital

JALLANDHAR.

At the beigining of our internship we were provided with 10 chapter on NABH accreditation

out of which I was allotted with the three chapters named as (1)Management of medication deals

with hospital pharmacy,(2)Continous quality improvement,(3)Facility management and safety .

Simultaneously I have done my employee satisfaction survey along with the chapters mentioned

above in which Ihave dedicated my two months of summer internship programme.

We actively took part in medical camp and administrativre work like making of ppt.

In NABHaccreditation chapters we were allotted two week time for each chapter for which we

have deeply studied NABH policies and practices illustrating what all standards are to be

maintainted in hospital for getting the NABH standard .I have made protocols for each chapter

through research which include analysing each and every practices of hospital for ex.

Maintenance of attendance register,patient form,case file,working of pharmacy,electricity supply

etc., inclusive of deep study for different department .

After matching NABH standards with ongoing policies and practices of hospital I have

made protocol for each chapter.

It was the research project within an hospital to get NABH accreditation in which employee

satisfaction survey was also amongs the most important part.

So I have conducted survey and got my quessnaire filled by eighty employees and I have made

my analyses according to SPSS and excel.

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INDUSTRY STUDY

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HEALTHCARE INDUSTRY OVERVIEW

Health Care Industry In India

The rate of growth of the health care industry in India is moving ahead neck to

neck with the pharmaceutical industry and the software industry of the country.

Much has been said and done in the health care sector for bringing about

improvement. Till date, approximately 12% of the scope offered by the health care

industry in India has been tapped. The health care industry in India is reckoned to

be the engine of the economy in the years to come. Health care industry in India is

worth $17 billion and is anticipated to grow by 13% every year. The health care

sector encompasses health care instruments, health care in the retail market,

hospitals enrolled to the hospital networks etc.

Health care industry in India and the GDP or gross domestic product:

Expenses incurred by the Indian Government on health care is the highest amongst

developing countries. India's expenses on health care sector comprises 5.25% of

the GDP. Chances are that the health care market could experience a hike and

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attain a figure ranging between $53 to $73 billion five years from now. This in turn

will reflect an increase in the gross domestic product to 6.2% GDP. The health care

industry in India earns revenues accounting for 5.2% of gross domestic product.

The healthcare industry is one of the largest industry of modern India. The Indian healthcare industry, unlike other industries, stands untouched by recession. There had been a steady growth in this sector, revenues from the healthcare sector accounts for 5.2% of the GDP, making it the third largest growing sector in India, and further the healthcare sector is projected to grow to nearly 1,80,000 crores by year 2012 and a compounded annual growth rate (CAGR) of 15-17 percent for at least the next 7-10 years.

Indian Healthcare Sector structure / Market size

The sector comprises hospital and allied sectors that include:(a) Medical care providers that includes physicians, specialist clinics, nursing homes and hospitals(b) Diagnostic service centers and pathology laboratories(c) Medical equipment manufacturers(d) Contract research organizations and pharmaceutical manufacturers(e) Third party support service providers

In India, 80% of all the healthcare expenditure is borne by the patients. Expenditure borne by the state is 12%. The expenditure covered by insurance claims is 3%. As a result the price sensitivity is quite high. The high level healthcare facilities are out of reach for the patients.

Among the top five therapeutic segments, gastro-intestinal and cardiac are experiencing both high volume and value growth. Opthologicals, cardiovascular, anti-diabetic and neurological drugs continue to top the growth list. The anti-infective, neurology, cardiovascular and anti-diabetic segments have witnessed a high number of new product launches in recent years.

Current Healthcare Landscape

Amount spent on healthcare - 103,000 crores / annum

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86,000 crores is the Healthcare delivery market

17,000 crores is the Retail pharma market

Key findings of current private spending

Private spending on healthcare delivery 69,000 crores

61 % of this is spent on OPD services, 44,000 crores Indicates low levels of affordability and a disease pattern dominated by infections

39 % on IPD services = 25,000 crores

85 % of IPD spend is in 5 areas : cardio, cancer, accidents, infections and maternity

Roads Ahead – 2012

Private spending on healthcare delivery 156,000 crores because of an increase in population will lead to increase treatments

Change in socio-economic mix will lead to 8 % increase in treatment rate and 30 % increase in avg. price paid

Change in prices – 26 % increase in price per treatment

Change in mix of diseases – 50 % increase in prevalence of lifestyle diseases will lead to 12% increase in treatment rate & 7 % in price and this would lead to a change in GDP from 5.2%to 6.2%

Richest 15% will account for 50% of all private healthcare spending & 60% of inpatient spend

Private spending would increase by another 39,000 crores if the insurance is likely to impact on middle-income households approx. 350 million in 2012, leading to achieving GDP spending to 7.5% and private spending on healthcare delivery to 195,000 cr.

Healthcare Fact File

Parameters Current By 2012

No. Of Beds 1.2 beds per 1000 9,14,543 In addition

No. Of Doctors 50,00,000 doctors 6,25,130 In addition

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No. Of Nurses 0.8 per 1000 8,36,000 In addition

Infant Mortality Rate 34:1000 10:1000

Maternal Mortality Rate 4:1000 1 :1000

% of population Insured 12.00% 50.00%

Total Private Spending 69,000 Crores 156,000 Crores

OPD Spending 44,000 Crores 82,000 Crores

Hospitals 30,000 hospitals approx 17300 In addition

Primary Health Centres / Community Health Centres

1,50,000 approx 1,64,000 In addition

Retails chemist outlets 3,50,000 24,000 In addition

Medical Colleges 229 179 New

Estd Current mrkt size 103,000 Crores 1,80,000 Crores

Average life Expectancy 63.3 years 74 years

Investments plan in Healthcare

The sector has been attracting huge investments from domestic players as well as financial investors and private equity (PE) firms. Funds such as ICICI Ventures, IFC, Ashmore and Apax Partners invested about US$ 450 million in the first six months of 2008-09 compared with US$ 125 million in the same period a year ago, according to an analysis carried out by Feedback Ventures. Feedback Ventures expects PE funds to invest at least US$ 1 billion in the healthcare sector in the next five years.

According to a Venture Intelligence study, 12 per cent of the US$ 77 million venture capital investments in the July-September 2009 quarter were in the healthcare sector. As part of its ‘Healthymagination’ initiative, GE will spend US$ 3 billion over the next six years on research and development, provide US $2 billion of financing over the next six years to drive healthcare

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information technology and health in rural and under served areas, and invest US$ 1 billion in partnerships, content and services.

The government, along with participation from the private sector, is planning to invest US$ 1 billion to US $2 billion in an effort to make India one of the top five global pharmaceutical innovation hubs by 2020.

The Ajay Piramal Group-owned private equity (PE) firm, India Venture Advisers, will launch its second US$ 150 million healthcare fund next year.

Leading international clinic chain Asklepios International is gearing up for a foray into the Indian healthcare market. As part of the 2.3 billion euro group’s strategy to enter the sub-continent, Asklepios is mulling the launch of a US$ 100 to US$ 200 million fund.

Gulf-based healthcare group Dr. Moopen is investing over US$ 200 million for setting up hospitals and eye-care centers across India.

Healthcare major, Fortis Hospitals plans to invest US$ 55 million, to expand its facilities pan-India.

Employment Opportunities

India faces a huge need gap in terms of availability of number of hospital beds per 1000 population. With a world average of 3.96 hospital beds per 1000 population India stands just a little over 1.2 hospital beds per 1000 population. Moreover, India faces a shortage of doctors, nurses and paramedics that are needed to propel the growing healthcare industry. India is now looking at establishing academic medical centers (AMCs) for the delivery of higher quality care with leading examples of The Manipal Group & All India Institute of Medical Sciences (AIIMS) already in place.

A recent survey conducted by HarNeedi.com, gives an out look on the roles that are in great demand, Specialist doctors such as, Cardiologists, Cardiothoracic surgeons, Interventional Cardiologists, Orthopedics, Emergency Medicine Specialists, Oncologists, Radiologists, Ophthalmologists, Neurologists, Neuro-surgeons, Gynaecologists, Urologists, Duty doctors etc… are in great demand.

Some of the other profiles that are in great demand are that of experienced nurses and technicians who can handle various specialties such as ICU’s, Cath labs, Operation Theaters, Emergency Departments etc. Technicians, like Radiographers, CT Technician, Radiotherapy technicians, emergency medical technicians etc. are also in great demand.

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Considering all the above facts and the massive growth in the healthcare industry, huge investments would offer several opportunities for Indian companies to create 'win-win' situations and there would be emerging opportunities for professionals as well in the near future.

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ORGANISATION OVERVIEW

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SGL HOSPITAL

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Type TRUST

Founded 1994

Location JALLANDHAR

Key people BABA KASHMIR SINGH JI (President)

Industry Healthcare Industry

Employees 145+

Website http://www.sglhealthcare.org/

http://www.sglhealthcare.org/

SGL HOSPITAL is an amalgamation of expertise, resources, opportunities and

medical engineering excellence. With leadership position in line with healthcare

services, the hospital believes in its crucial role of a responsible corporate citizen

and sincerely practice empowerment of the underprivileged and sustainance of the

human life. Guided by the six ‘E's - Enrichment of mind, Enrichment of body,

Education, Empathy, Empowerment of citizens and Environmental sustainance,

each and every hospital contributes towards the betterment of the community at

large.

DEPARTMENTS:

ORTHOPAEDIC DEPTT. MEDICINE DEPTT. PAEDIATRIC DEPTT. OPHTHALMOLOGY DEPTT. ONCOLOGY DEPTT. PLASTIC AND BURN SURGERY DEPTT. GENERAL SURGERY DEPTT. GYNAECOLOGY DEPTT. UROLOGY DEPTT. ENT DEPTT. RADIOLOGY DEPTT. PATHOLOGY DEPTT. PRE-MATURE BABY UNIT (P.B.U) INTENSIVE CARE UNIT(I.C.U)

SGL HOSPITALS is a multi-super specialty hospital that redefines the standards of excellence in healthcare services and brings together the best of infrastructure, technology & medical intelligence Our quality standard along with technology and medical intelligence enables us to provide healthcare services.

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• Led & Managed by Highly Qualified Doctors. • Patient Care - -At SGL Hospitals we are committed to provide personalized

medical services to patients with care and compassion.• State of the Art Infrastructure --At SGL Hospitals we have 5 operating

theaters, 100 beds and over 10 critical care beds catering to 14 different specialties. We aim to establish a healthcare powerhouse with a vision to

offer the best in clinical care, education and research.• Our Technology --At SGL Hospitals we have the most advanced technology

and state-of-the-art treatment facilities with the motto to deliver quality healthcare services at an affordable cost.

• Strategic Location :

SGL Hospitals is located across a sprawling in JALANDHAR gada road, parallel to GT road.

• The Rich Come Here For The Best Care In Town. The Poor Come Here For The Kindest Care, For No One Here Is Turned Away For Lack Of Funds.

• Special Corporate Services We offer personalized services to corporate patients that include Appointment Scheduling, Special Treatment Packages, Discount Faculties on OPD & IPD, Ambulance facility, Health Awareness Lectures/Workshops, Health Check Camps that are specially designed to suit employee needs.They aspire to be a leading player of repute by delighting their customers in India and across the world with premium home furnishing solutions at reasonable prices.

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SERVICE AT A GLANCE:-

SUPER SPECIALTIES

Anaesthesiology &

Critical Care Medicine

Trauma & Spine Surgery

Internal & Respiratory Medicine Neuro Surgery

Gastro Enterology Paediatric Surgery

Nephrology Urology

Neurology Medical & Surgical Oncology

In-Vitro Fertilization (IVF) Plastic Surgery, Aesthetic &

Reconstructive Surgery

Minimally Invasive (Laproscpic)

Surgery

Dermatology

GENERAL SPECIALTIES

Medicine Ophthalmology

Surgery ENT

Paediatrics Chest & Allergy

Obstetrics & Gynecology Diagnostic Radiology & Imaging

Orthopedics & Joint Replacement

SUPPORT SERVICES

Physiotherapy & Rehabilitation Dietician

Health Check up Schemes (Preventive Check up)

24 HOUR SERVICES

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Accident & Emergency X-Ray

Pharmacy Ambulance Facility

Pathology & Lab Services

Excellence in Health Care Since 1994

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SWOT ANALYSIS

SWOT AnalysisStrengths

• Multi & Super-specialty treatment • Clinicians of International repute • Ethical Practice• Centralized location

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Affordable Rates Healthcare facilitiesAreas for improvement

Pharmacy (for cashless patients) Ambience (for icu patients) Medical records (room required) Discharge timeStaff TurnoverOPD ServicesMonetary & non monetary Incentives methods to regulate staff

OpportunitiesLiaisons with corporate sector Enhanced Trauma & Emergency centreIvf patientsWomen & child floorEnhance doctor panelSet up of committees to know the working & to upgrade it.Capture rural areasBenefits of Non profit organisations.

ThreatsLack of proper management.Surrounded by other hospitals. Like pimsRetention of technicians, Nurses & staff.Credit payments & debts

MISION

“A Dream of Making Quality Healthcare Accessible At Affordable Rates to the Masses”

To make the dream a reality we commit ourselves to:

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Developing a healthcare powerhouse for complex medical & surgical problems to be replicated in rural &

urban areas.

Vision Changing over to (IT)Technology Upgardations like

New Website development , Telemedicine setup, etc. Establishing patient friendly atmosphere by

minimizing the complaints & getting a patient co-ordinator to guide them.

Streamlining of Capital Equipments Procurement (Budget Involvement is a Must)

NABH – Accreditation is a MustStreamlining Hospital area practice shar (Doctor Revenue Sharing Models) , Senior – Highest & then

accordingly.

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CSR activities

SGL Hospitals being a super specialty hospital, out reach programs play an important role in fostering community care network & intends to reach out to the unreachable & unaffordable. SGL hospitals have been a tremendous support in organizing and implementing several development activities and programmes based on regional requirements and needs. SGL Hospitals considers a variety of programs under its outreach umbrella:

.Out Reach Camps

.Support sgl-volunteer program

RESEARCH OBJECTIVE

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IN ORDER TO BRIDGE THE GAP BETWEEN SGL HOSPITAL POLICIES AND PRACTICES WITH THE NABH STANDARDS I HAVE MADE DETAILED PROTOCOLS FOR MY 3 CHAPTER IN SOFT COPY AND GIVEN MY SUGGESTION FOR THE HOSPITAL .

The main point of concern for the healthcare organisation was to trace out the the gap between their standards and NABH standards so that they could improve on such parameter and implement the same and compete with other healthcare organisations which are:

COMPETITORS:

PIIMS HOSPITALS LAJVANTI NURSING HOME MISSION HOSPITALS OTHER HOSPITALS

During the study there were four research objective which were more of standards of NABH which hospitals must practice if they have to make themselves eligible for the accreditation process and to show the evidences of the policies and

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procedures to prove the same when the NABH inspection team comes to analyse their prevailing healthcare services, so the research objective was to analyse the policies and procedures of the chapters listed below and provide feedback and suggestion accordingly so that they could improve on such parameters for which protocol had to be prepared which were

MANAGEMENT OF MEDICATION CONTONOUS QUALITY IMPROVEMENT FACILITY MANAGEMENT AND SYSTEM HOSPITAL INFECTION CONTROL

INTRODUCTION TO NABH NATIONAL ACCREDITATION BOARD FOR HOSPITALS & HEALTHCARE

PROVIDERS (NABH)

NATIONAL ACCREDITATION BOARD FOR HOSPITALS & HEALTHCARE PROVIDERS (NABH)

Hospital Accreditation

ZIn India, Heath System currently operates within an environment of rapid social,economical and technical changes. Such changes raise the concern for the quality of health care. Hospital is an integral part of health care system.Accreditation would be the single most important approach for improving thequality of hospitals. Accreditation is an incentive to improve capacity of national hospitals to provide quality of care. National accreditation system for hospitals ensure that hospitals/ Health Care Organisation (HCO), whether public or private,

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national or expatriate, play there expected roles in national heath system. Confidence in accreditation is obtained by a transparent system of control over the accredited hospital and an assurance given by the accreditation body that the accredited hospital constantly fulfills the accreditation criteria.


Benefits of Accreditation

Benefits for PatientsPatients are the biggest beneficiary among all the stakeholders. Accreditation results in high quality of care and patient safety. The patients are serviced by credential medical staff. Rights of patients are respected and protected. Patients satisfaction is regularly evaluated.

Benefits for HCOAccreditation to a HCO stimulates continuous improvement. It enables hospital in demonstrating commitment to quality care. It raises community confidence in the services provided by the hospital. It also provides opportunity to healthcare unitto benchmark with the best.

Benefits for Hospital StaffThe staff in an accredited HCO is satisfied lot as it provides for continuous learning, good working environment, leadership and above all ownership of clinical processes. It improves overall professional development of Clinicians and Para Medical Staff and provides leadership for quality improvement with medicine and nursing.

Benefits to paying and regulatory bodiesFinally, 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.

NATIONAL ACCREDITATION BOARD FOR HOSPITALS& HEALTHCARE PROVIDERS (NABH)

Definition of SHCO

Small Health Care Organisations (SHCO)Those healthcare organizations having bed strength between 20 to 50 beds andare in possession of supportive and utility facilities that are appropriate andrelevant to the services being provided by organization.Exclusions- Polyclinics- Diagnostic Centres- Superspeciality* centres (single/ multiple)

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ExceptionsSpeciality** Day Care centres (minimum bed strength not mandatory)* Super Speciality centres are the centres which reflect requirement of DM/MCh or equivalent qualified personnel.** Speciality centres are the centres which reflect requirement of MD/ MS orequivalent qualified personnel.


Organizational Structure

Accreditation CommitteeThe main functions of Accreditation Committee are as follows:- Recommending to board about grant of accreditation or otherwise based onevaluation of assessment reports & other relevant information.- Approval of the major changes in the Scope of Accreditation includingenhancement and reduction, in respect of accredited hospitals.- Recommending to the board on launching of new initiatives

Technical CommitteeThe main functions of Technical Committee are as follows:- Drafting of accreditation standards and guidance documents- Periodic review of standards

Appeals CommitteeThe Appeal Committee addresses appeals made by the hospitals against anyadverse decision regarding accreditation taken by the NABH. The adversedecisions may relate to the following:- refusal to accept an application,- refusal to proceed with an assessment,- corrective action requests,- changes in accreditation scope,- decisions to deny, suspend or withdraw accreditation, and- any other action that impedes the attainment of accreditation.

NABH SecretariatThe Secretariat coordinates the entire activities related to NABH Accreditation tohospitals and healthcare organizations.

NATIONAL ACCREDITATION BOARD FOR HOSPITALS& HEALTHCARE PROVIDERS (NABH)

NABH SHCO Standards

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NABH Small Health Care Organisation (SHCO) Standards has been prepared bytechnical committee contains complete set of standards for evaluation of HCO forgrant of accreditation. The standards provide framework for quality of care forpatients and quality improvement for hospitals. The standards help to build aquality culture at all level and across all the function of HCO.Outline of NABH Standards

Patient Centered Standards• Access, Assessment and Continuity of Care (AAC)• Care of Patient (COP)• Management of Medication (MOM)• Patient Right and Education (PRE)• Hospital Infection Control (HIC)

Organisation Centered Standards• Continuous Quality Improvement (CQI)• Responsibility of Management (ROM)• Facility Management and Safety (FMS)• Human Resource Management (HRM)• Information Management System(IMS)

.NATIONAL ACCREDITATION BOARD FOR HOSPITALS & HEALTHCARE PROVIDERS (NABH)

Preparing for NABH Accreditation

HCO management shall first decide about getting accreditation for its HCO from NABH. It is important for a hospital to make a definite plan of action for obtaining accreditation and nominate a responsible person to co-ordinate all activities related to seeking accreditation. An official nominated should be familiar with existing hospital quality assurance system. Hospital shall procure a copy of standards from the NABH Secretariat against payment. Further clarification regarding standards can be got form NABH Secretariat in person, by post, by e-mail or on telephone.The HCO looking for accreditation shall understand the NABH assessment procedure. The HCO shall ensure that the standards are implemented in the organization.The HCO can download the application form for NABH Accreditation from the web-site. The applicant hospital must have conducted self-assessment against NABH standards atleast 3 months before submission of application and must ensure that it complies with NABH Standards.


NABH Accreditation Procedure

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Scrutiny of assessment reportNABH shall examine the assessment report. The report is taken to the accreditation committee. Depending on the score and compliance to standard would decided the award of accreditation or otherwise as per details given below.

1. Pre-accreditation entry level: Conditions for qualifying to this award are asbelow:• All the regulatory legal requirements should be fully met.• No individual standard should have more than two zeros.• The average score for individual standard must not be less than 5.• The average score for individual chapter must be more than 5.• The overall average score for all standards must exceed 5.The validity period for pre-accreditation entry level stage is from a minimum 6months to a maximum of 18 months. It means that a hospital placed underthis award cannot apply for assessment before 6 months.

2. Pre-accreditation progressive level: Conditions for qualifying to this awardare as below:• All the regulatory legal requirements should be fully met.• No individual standard should have more than two zeros.• The average score for individual standard must not be less than 5.• The average score for individual chapter must be more than 6.• The overall average score for all standards must exceed 6.The validity period for pre-accreditation progressive level stage is from aminimum 3 months to a maximum of 12 months. It means that a hospitalplaced under this award cannot apply for assessment before 3 months.


NABH Accreditation Procedure

3. Accredited: Conditions for qualifying for accreditation are as below:• All the regulatory legal requirements should be fully met.• No individual standard should have more than one zero to qualify.• The average score for individual standards must not be less than 5.• The average score for individual chapter must not be less than 7.• The overall average score for all standards must exceed 7.The validity period for accreditation is 3 years subject to terms and conditions.

Issue of Accreditation CertificateNABH shall issue an accreditation certificate to the HCO with a validity of threeyears. The certificate has a unique number and date of validity. The certificate isaccompanied by scope of accreditation.The applicant hospital must make all payment due to NABH, before the issue ofcertificate.

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All decision taken by NABH regarding grant of accreditation shall be open toappeal by the hospitals, to chairman NABH.

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RESEARCH METHODOLOGY

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PROJECT REPORT

INTRODUCTION

This Project report includes overview of prevailing healthcare services. To list out the scope and purpose of the NABH standards Current strategies are compared and advised by providing feedback and

suggestions Employee satisfaction survey was done and analyses is done

RESEARCH AT HOSPITAL INCLUDES THE FOLLOWING ACTIVITIES:

Study of NABH standards(chapters). Understanding the policies and procedure ,practices of hospital with the help

doctors and administration department. Observing policies and procedures of various department Creating protocols to illustrate all and provide feedback and suggestions Studied HR practices in hospital Conducted employee satisfaction survey by interviewing employee of

different departments my sample size is 100

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LIMITATIONS

Every project has some limitations. Even the researcher came across some limitations while working on the project which made the analysis a little inappropriate at times. Some of the basic limitations faced during the research are listed below:

Sample chosen may not be representing the characteristics of the entire population

Secondary data was considered while undertaking studies, so all the shortcomings of secondary data are inherent

there was a time constraint, due to which a small number of EMPLOYEEs

were surveyed.

The research is based in the hospital only. At the time of research, few of the patients and the staff did not sincerely

respond to me.

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RECOMMENDATIONS FOR SGL HOSPITAL

General cleanliness and maintenance of all the buildings and surrounding structures needs to be scheduled and carried outvAll clinical areas along with supportative services shall be interconnected through covered corridors.All isolated blocks used by patients need to be connected with min hospital building through all weather proof covered links.

Dietary and Laundry services if so desired need to be replanned with requisite functional elements and flow. Proper covered food trolleys need be procured for transporting cooked meals to patient dining areas

Toilet facility for inpatients, outpatients, staff and visitors / attendents need to be replanned and provided at appropriate locations and their upkeep and maintenance shall be accorded priority.

The Surgical suites, Delivery suites needs to be replanned with due consideration of four well defined zones of varying degree of cleanliness. They are sterile,clean,protective and disposal zones.

Surgical suites shall be grouped between 2-3 OTs in one location for easy control and operational efficiency. Some of the OTs may be planned with individual AHU, HEPA filter and Laminar flow. The requirement of OT planning and internal facility to be provided in each OT was explained to the surgeon, nursing staff and PIU staff.

.

In the Imaging suites- Radiology department, there is a need to create change rooms for male and female patients going in for plain X-ray. This will curtail the service time for X-ray as more than double number of patients can be imaged. It is advisable to locate the dark room / automatic processor for easy access from all X- rayrooms. The PIU shall work in consonance with hospital administration and facilities incharge / users..

The Flooring, skirting and dado shall be provided as per the facility need. They

shall be easily maintainable. The skirting and dado shall be kept flush with wall surface to avoid dust collection.

At present the ambulances are parked near the entrance canopy near emergency. All ambulances need to be provided a covered parkig bay with the emergency and ambulance control room. It shall have communication facility with the emergency and ambulance control room.

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Medical store needs to be replanned with adequate space & ample shelving forThe Flooring, skirting and dado shall be provided as per the facility need. They shall be easily maintainable. The skirting and dado shall be kept flush with wall surface to avoid dust collection..

Medical store needs to be replanned with adequate space & ample shelving for storage of drugs & care needs to be taken to prevent dampness by proper maintenance. Locked areas for storage of high risk medicines with proper compliance need to be provided in

Training programme could be immplemented for employees during non working hours so that they may be able to attend sessions without any distruption of therir work .Training session can be carried down in slots .

Bias free environment can be immplemented by daily report submission of employees by PCC which could include certain performance parameter before the name of employee for ex .no of patient attended,work done ,time devoted for work etc

Review committee can sit once in a month for for proper updation and documentation of quality assurance programme

Feedback of working staff could be taken for the upgradation of new practices and employees can be given some incentive for their involvement.

Remuneration can be introduce to increase motivation for work amongs employees.

Person responsible for audit should be bais free Cooperation and involvement of medical staff. A good medical records could be made imperative to patient illness and all

events connected with it while he or she is in the hospital are lucidly and faithfully recorded.

.

Person responsible for giving training can go through studies in order to sharp his or her knowkedge .

Requirement can be made available before training programme It may occur at time when all employees cannot be present because of their

working hour ,so time table can be made when employees in different slots can undergo their training programme.

One small traing room can be made available with necessary requirement. Two copies of sensitive case can be made so that during inspection also

proper treatment can take place and information in both the file can be matched and updated.

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Each patient can be given patient satisfaction quessionaire written in easy language which can help to determine certain factor where improvement can be done for ex.cleanliness in the rooms.

EMPLOYEE SATISFACTION SURVEY

SAMPLING TECHNIQUE:-CONVINEANCE SAMPLING has been used for the purpose of selecting the sample .

DATA COLLECTIONThe data collected for the research is undertaken through the primary as well as secondary data

method. This can be illustrated in the following way:-

PRIMARY DATA-

The primary data has been collected from various mediums like:

Questionnaire. Observation.

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SECONDARY DATA-

The secondary data has been collected from various mediums like:

Information acquiring through Intranet

HR manual,past records,roster.

SGL Hospital Employee Satisfaction Survey

1. What is your age?

Under 21..............................................................

21 to 34................................................................

35 to 44................................................................

45 to 54................................................................

55 or older...........................................................

2. What is your sex?

Male.....................................................................

Female.................................................................

3. What is your marital status?

Married................................................................

Unmarried...........................................................

4. How long have you worked for SGL Hosopital?

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

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www.sglhealthcare.org

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

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

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

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

5. Your role at SGL Hospital

Disagree Agree

Strongly strongly

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

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

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

6. Overall, how satisfied are you with SGL Hospital as an employer? (Please circle one number)

Very Very

Dissatisfied Satisfied

1 2 3 4 5 6 7

7. SGL Hospital training program

DisagreeAgree

StronglyStrongly

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

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

Disagree agree

Strongly strongly

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

9.Your relations with your immediate supervisor

Disagree Agree

Strongly strongly

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

Conclusion and analyses

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9%

21%

25%

31%

14%

work experienceless than one year one year to less than two yeartwo year less thanfive year five year to less than ten yearmore than ten years

From the above graph it could be concluded that more no of employees have good work experience as 31% of employees have work experience between five to ten years and 14% of employees are have work experience of more than 10 years.

male46%female

54%

Employees sex

In the hospital organization more no of female employees are preferred so in SGL

hospital female employees are 54% which is more than male employees.

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I am given enough authority to make decision I need to make

disagree strongly4%

disagree20%

average29%

agree30%

agree strongly18%

decision making authority

Overall more number of employees are satisfied with the authority given to them so in the graph it is indicated that 17% of them are strongly satisfied to carry out their work ,30%of them agree to it with 29 % of employees have neutral answer.

I like the type of work I do

disagree strongly1%

disagree29%

average16%

satisfied36%

agree strongly18%

I like the type of work i do

Until and unless employees are not satisfied of work they do they are not able to carry out their work effectively as the graph indicate only 1% of employees are not satisfied of work they do so it is the good indication for hospital that employees are giving their best.

36% of employees are satisfied along witht18% of people who agree strongly.

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I believe my job is secure

most of the employees have very less faith on their job security in the hospital as most of the employees are kept according to their work performance as any mistake can be harmfull to the patient,so only 6% of people agree strongly on fact that their job is secure.

overall,how satisfied are you with SGL hospital as an employer?

very dissatisfied5%

dissatisfied18%

average22%

satisfied45%

very satisfied9%

employee satisfaction

Employees rate their overall satisfaction level in the SGL b

Among which 45% are satisfied and 18% are not satisfied

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disagree strongly13%

disagree24%

average34%

agree24%

agree strongly6%

Job security

SGL hospital provided as much initial training as I need


disagree6%

average36%

satisfied26%

agree strongly21%

Training

Training is the next step after recruitment and selection. Training is also necessary to keep the employees update with the changing technology. With each promotion employees are send to the training programmes. It is not only restricted to promotion but at many stages during job

1)the above figures indicate that SGL hospital have good practices regarding the training programme as 21% of respondents agree strongly with 26% of people agreeying to the the good training programme provided to them.

2)only 7% of people disagree strongly.

my salary is fair to my responsibility


disagree38%average

33%

agree9%

agree strongly11%

salary

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Salary Remuneration is what an employee receives in exchange for their contribution to the organization.Generally wage and salary helps an organization obtain, retain and maintain a productive workforce. From the analysis of the pie chart the following inferences can be drawn:

1)most of the employees are very dissatisfied with the amount of salary given to them only 9% agreeing to the fact that their salary is fair to their responsibility which is very low in number and can be harmfull to the organisation because thir may be instances due to less salary they may quit job.

2)Total 47% of the people are some how satisfied with neutral answer

My supervisor treats me fairly

disagree strongly1%

disagree24%

average30%

agree26%

agree strongly19%

My supervisor treats me fairly

The satisfaction of the employees are much concerned with the behaviour and co-ordination with the immediate supervisor

1)overall response is neutral as in hospital industry employees are not handled by only one supervisor they are under the authority of doctors,visiting doctors etc so any minor mistake can give them punishment due to which reason for behaviour of their supervisor.

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CROSS TABULATION1)how long have you worked for SGL hospital? * I believe my job is secure Croshjstabulation

Count

I believe my job is secure Totaldisagree strongly disagree average Agree agree strongly

disagree strongly

how long have you worked for SGL hospital?

less than one year 2 5 0 0 0 7one year to less than two year 3 4 7 3 0 17

two years to less tthan five years 2 7 7 4 0 20

five years to less than ten years 3 1 11 8 2 25

ten years or more 0 2 2 4 3 11Total 10 19 27 19 5 80

Interpretation :

There are people who have work experience of more than 5 years in SGL hospital then also they are not sure about their job security.

2) how long have you worked for SGL hospital? * my salary is fair to my responsibility Crosstabulation

Count

my salary is fair to my responsibility Totaldisagree strongly disagree average agree agree strongly

disagree strongly



two years to less than five years 2 8 6 2 2 20



INTERPRETATION

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Employees who have work experience between five years to ten years disagree on their salary ,as they say that their salary is less in an accordance to the responsibility given to them in the hospital organisation.

3) how long have you worked for SGL hospital? * I am givin enough authority to make decision I need to make Crosstabulation

Count

I am givin enough authority to make decision i need to make Totaldisagree strongly disagree average agree agree strongly

disagree strongly



two years to less than five years 1 5 6 6 2 20



INTERPRETATION

Employees who have work experience of more than five years agree to the authority given to them to take decisions for the smooth functioning of hospital the above interpretation indicate that employees who have more experience are provided with more of authority which is a good indicator for such patient care centre.

how long have you worked for SGL hospital? * my supervisor treats me fairly Crosstabulation

Count

my supervisor treats me fairly Totaldisagree strongly disagree average agree agree strongly

disagree strongly



two years to less tthan five years 0 7 7 2 4 20



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INTERPRETATION:

Employees who have work experience of more than 5 years agree to the fact that their supervisor do not treat them properly.so it can be concluded that work experience do not matter for supervisor to talk to their employees as in hospital organisation any one can be punished if any mistake is commited.

CONCLUSION

By interpretation it is clear that employee satisfaction depend on the salary and other benefits provided by them .

By looking through Pie chart we can conclude that majority of the employees are not satisfied with salary .

Training programme is effectively carried out. most of the employees have very less faith on their job security in the hospital as

most of the employees THERE IS A RELATION BETWEEN SALARY , other benefits and employee

satisfaction but we cant say that aitration rate is more due to employee dissatisfaction.

As overall 55 % (more than half) of employees are overall satisfied. More than half of employees have more than 5 years of work experience

within an hospital

RECOMMENDATIONS

Give better work profiles according to the capabilities,background of a person.

There should be Direct supervision of the facilities available in organization.

Promotion and transfer policies should be revised to improve growth path.

SGL should carry out equal pay packages among employees of same grade.

Proper supervision could be given.

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Clarify the rules and regulation to employees time to time.

Employee should be rewarded even at non- monetary level.

Feedback of employees could be taken

Result of the survey conducted should be shared with in the organization and should be communicated to respective authorities so that a complete action plan can be chalked out for

betterment of employees and organization.

Job security assurance could be set up by maintaining performance appraisal system.

Leave system should be made easy without reduction in salary.

Some compensation can be given to employees like free monthly check up.

BIBLIOGRAPHY

www.NABH accredita tion.com (Home Page, Profile)

www.hospital industry.com ( Home Page, corporate vision)

www.hindustanpetroleum.com (Home Page, Profile)

www.google.com

NABH accreditation books and hospital guides

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http://www.google.com/

hospital nabh final project

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