A Project Report On“PROCESS IMPROVEMENT IN OPD BILLING BY OBSERVING BILLING ERRORS AND THEREBY

INCREASING PATIENT SATISFACTION” Columbia Asia Hospital, Pune

Submitted ByDr. Angela Kaul

12040141081

Under the guidance of

Mr. Naveen Kumar Finance Manager

Columbia Asia Hospital, Pune

Submitted to

Symbiosis Institute of Health Sciences, Pune

(Symbiosis International University) in partial fulfillment of the requirements for the award of the Degree of Master of Business Administration 2013-2015)

STUDENT DECLARATION

I, the undersigned, hereby declare that this project entitled ―“PROCESS IMPROVEMENT IN OPD BILLING BY OBSERVING BILLING ERRORS AND THEREBY INCREASING PATIENT SATISFACTION” is my own work, which was carried out at Columbia Asia Hospital, Pune as a part of my Summer Internship Project. The duration of the project was from 7 th May, 2014 to 7th

August, 2013.

I also declare that all the sources I have used or quoted have been indicated or acknowledged by means of complete references.

_______________________ _______________________

Dr. Angela Kaul DATE

ACKNOWLEDGEMENT

This acknowledgement is a gesture of gratitude toward all those people who were the driving force in the successful completion of the project.

I would like to convey my earnest appreciation to Mr.Naveen Kumar, Finance Manager, Columbia Asia Hospital, Pune, for giving me this opportunity to carry out my project in this esteemed organization.

I take this opportunity to express my profound gratitude and deep regards to Mr.Prashant Mahantgol ,Mr.Vishal Kadam, Mr.Rajesh, Mr.Ravikiran B.A Mr.Naazzir Shaikh and Mr.Sameer Desai for their exemplary guidance, monitoring and for providing me with the necessary information and assistance throughout this project.

Very importantly, I would like to thank Dr.(Col) Vijay Deshpande (HOD-HHCM) of Symbiosis Institute of Health Sciences for providing us this opportunity to undergo a summer internship program. Also, for their good wishes and blessings for this project.

Last but not the least, my heartfelt gratitude to my parents, family and my friends for their constant encouragement, support, help and valuable advice to make this project a success.

Dr.ANGELA KAULMBA-HHCM (2013-2015)Symbiosis Institute of Health SciencesPune, Maharashtra.

PROCESS IMPROVEMENT IN OPD BILLING BY OBSERVING BILLING ERRORS AND THEREBY INCREASING PATIENT SATISFACTION

ABSTRACT

For the improvement of quality and increment of efficiency a study was carried out in the billing department of the Columbia Asia hospital, Pune. A time and motion study was conducted by taking 50 samples to study the time requirement and the delay in the process. Supported by the above mentioned study, observations and access to various data from the hospital authority, the problem areas in the process were found out to be non-value adding steps in the process and error rate in the processing of billing and certain adaptations in the system leading to wastage of resources.This study was done to thereby increase patient satisfaction by studying the same in current scenario.

Good health is the foundation of a happy, productive and rewarded life. More health problems can be managed more effectively if detected early. The modern lifestyle today symbolizes excessive stress and strain, extended working hours, irregular eating habits, late night weekend parties, and inadequate rest. Coupled with high levelled pollution, these factors are bound to cause health related problems, and physical, mental and psychological disorders. With today’s sedentary and unhealthy lifestyle, man is getting prone to number of ailments and diseases. Diseases like diabetes, hypertension, oral and lung cancer and osteoporosis can directly be attributed to the modern way of living. To meet the growing demands of the competitive world, most of us tend to ignore our health until we are compelled to confront a medical complication. To cope up with a rising risk of the medical disorders, health monitors have become mandatory. Not only are the chronic conditions projected to be the leading cause of disability throughout the world by the year 2020; if not successfully prevented and managed, they will become the most expensive problems faced by our health care systems. In this respect, chronic conditions pose a threat to all the countries from a health and economic standpoint. Many diseases can be prevented, yet health care systems do not make the best use of their available resources to support this process.

AIM:

To Increase overall satisfaction rate of patients at the hospital OPD

OBJECTIVE:

Make the patients flow easy Reduce Waiting time during billing at the OPD To improve Quality and safety Create an environment that promotes high quality patient care To understand the billing process of the Hospital To find out the bottlenecks in the process and the problem areas To find out the non-value adding steps in the process To find out non-productive practices in the system Recommend solutions to increase the process efficiency

LITERATURE REVIEW GLOBAL HEALTHCARE INDUSTRY:

The global healthcare services market is forecast to reach $3 trillion by 2015, according to research from Global Industry Analysts. Investment in sectors such as home healthcare, healthcare IT and tele-health are expected to continue fuelling market expansion. Due to the world’s aging population, the demand for home healthcare is likely to continue climbing over the years to come. The healthcare services industry is labour intensive and overburdened in many regions, making tele-health and healthcare IT attractive options. With medical technologies continually developing, these options are proving beneficial to patients and the overall healthcare system. The global healthcare services market is impacted by government legislation and incentives. Spending in the sector continues to climb, partly due to the availability of new drugs, higher health insurance premiums and advanced technology services. Demographic profiles also play an important role in the industry, with demand created by lifestyle-related medical conditions. In addition, an aging population means that age-related health conditions continue to create demand. Spending on home healthcare is forecast to continue rising as elderly and terminally ill patients opt for the ease of receiving healthcare at home rather than in hospitals or clinics. As with many other industry sectors, information technology is also affecting the area of healthcare services, with many healthcare bodies

concentrating their efforts on setting up or enhancing their electronic medical records systems, electronic health records and personal health records.

Key Market Segments

The global telemedicine market is expected to record close to 20% yearly growth between 2010 and 2015, according to research from RNCOS. The sector facilitates interactive healthcare through telecommunication and technology. Market expansion is driven by the need to cut costs within the medical sector, ease of penetration and wider availability of equitable healthcare. Increasingly common conditions, such as diabetes, are also fueling telemedicine market growth. The sector benefits from rising private and state sponsorship. The global healthcare and home monitoring market continues to expand, largely due to patient ease and comfort, cost cutting in the healthcare sector, and technological developments. Berg Insight estimates the number of home monitoring systems with integrated communication capabilities will record 18% yearly growth between 2010 and 2016 to reach almost 5 million connections worldwide. The number of devices with integrated cellular connectivity is forecast to grow at a yearly rate of almost 35% in the five-year period ending 2016 to reach almost 2.5 million. mHealth refers to data services, applications and communications related to mobile health. In addition, mHealthcare and home monitoring are widely used to monitor chronic conditions such as diabetes, cardiac arrhythmia, chronic obstructive pulmonary disease, ischemic diseases and hypertension. According to Berg Insight, over 200 million individuals in the US and the EU suffer from one or more diseases for which home monitoring is a suitable option. Technological developments within the healthcare sector help to keep costs down and elaborate more suitable methods to monitor and treat medical conditions. The potential for wireless technologies remains vast, as it is relatively new to the market. There were more than two million individuals using home monitoring devices with integrated connectivity at the end of 2011. The global regenerative medicine market exceeded $7 billion in 2010, according to RNCOS. This relatively new sector encompasses many disciplines including stem-cell biology, bioengineering, Nano-science and tissue engineering. Factors fuelling market growth include higher incidence of degenerative diseases, aging population and technological innovation.

Market Outlook

The global healthcare system is increasingly overburdened, with rising numbers of people suffering from chronic diseases and lifestyle-related conditions. Expenditure continues to grow due to an expanding, and aging, global population. BCC Research points to the role played by universal healthcare coverage in boosting healthcare system efficiency. As budgets tighten and costs rise, technological development is becoming increasingly important, with health practitioners likely to continue making greater use of communications and information technology to treat their patients.

INDIAN HOSPITAL INDUSTRY:

The Indian healthcare industry has the potential to become a global hub for healthcare services. The liberalization and the entry of global pharmaceutical companies have contributed to the growth of the Indian healthcare industry.

Overview:

The Indian healthcare dates back to the Vedic system of healthcare (Ayurveda) in 5000 BC. Ayurveda proliferated the most during the Vedic period. The Ayurvedic principles of positive health and therapeutic measures relate to physical, mental, social and spiritual welfare of human beings. During the early Vedic period, Ayurveda was perhaps the only system of overall healthcare and medicine. It enjoyed the unquestioned patronage and support of the people and their rulers. Thereafter, the long medieval history was marked by uncertain political conditions and several invasions. This was when Ayurveda faced utter neglect and its growth was stunted. The Unani medicine entered India during this time and gained momentum with the extensive support of Mughal emperors. Later with the British invasion, Allopathic made an entry into India. It was widely accepted because of its swift results. Today, with continuous research and development, allopathic dominates the Indian healthcare market. Healthcare industry in India is divided into two segments: services and manufacturing. The manufacturing segment consists of both medical equipment manufacturing industry and the pharmaceutical production. In manufacturing segment they manufacture medical equipment, where as in pharmaceutical production which manufactures Active pharmaceutical ingredients and formulations. The services segment is basically split into direct services and indirect services. Further direct services are divided into:

1. Hospitals

2. Health insurance services 3. Research and Development 4. Clinical trials

Industry Structure & Segmentation:

Hospital industry structure is complex in nature, as the industry can be looked from different angles. Each hospital is distinct in its characteristics as it differs in structure, functions, performance and the community it serves. Hospitals are normally classified into different types depending upon criteria like, objectives, ownership and system of medicine. The sections below attempt to elaborate the structure of hospitals in little more detail.

Classification of Hospitals: Hospitals are classified into different types depending upon different criteria. Hospitals are divided into: • Classification based on objectives • Classification based on ownership • Classification based on system of medicine

Classification Based on Objectives: Hospitals are classified into three categories based on objectives: • General hospitals • Specialty hospitals • Teaching-cum-research hospitals

General hospitals The main objective of these hospitals is to provide medical care where teaching and research is secondary. General hospitals (GH) are well-known type of hospitals, which deal with all kinds of diseases, injury and also has an emergency ward to deal with immediate threats to health and capable to deliver emergency medical services. GH has major healthcare facilities with large number of beds for intensive care and long term treatment. The hospital is equipped to take care of medical, surgical, maternity, and psychiatric cases, child birth, and plastic surgery and usually has a resident medical staff. Example: government run hospitals, primary healthcare centre, district and taluka hospitals. Example: Osmania General Hospital, and Gandhi General Hospital.

Specialty hospitals

A specialty hospital is dedicated to specific subspecialty care like pediatric centers, oncology centers, psychiatric hospitals and others. Patients will often be referred from smaller hospitals to a specialty hospital for major operations, and consultations with subspecialists. These hospitals have highly trained specialists, high-end technology and have the round the clock services. These hospitals are able to do specialized tests, undertake dialysis for acute renal failure, provide ventilation to patients with respiratory failure and render intensive care to critically ill patients.

Teaching-cum-research hospitals The main objective of these hospitals is teaching based on research and the provision of healthcare is secondary for example, All-India Institute of Medical Sciences, New Delhi, and Post-Graduate Medical Education and Research Institute, Chandigarh.

Classification based on ownership: This classification is mainly based on the ownership of the hospital. It includes hospitals like government, semi-government hospitals, voluntary agencies hospitals and private or charitable hospitals. These hospital provide healthcare services by charging nominal fee from the patient. Many of these hospitals run their services with the help of government and the funds provided by the industrialist.

Government hospitals These hospitals are government-run hospitals; they are either managed by central government or state government. One of the major purpose of these hospitals is to provide free or charged healthcare services at a very nominal cost to poor people. J J Hospital in Mumbai is an example of such a hospital. However, there are other hospitals like railway hospital or defense hospital which are for providing healthcare services to the employees of Railways and Defense of Government of India.

Semi-government hospitals These hospitals are owned by semi-government organizations like Employees State Insurance (ESI) hospital. Some of the hospitals in this category is managed by various municipalities/gram panchayats, etc.

Voluntary agencies hospitals

These hospitals are run with the funds received from various industrialists, national and international charity organizations. Specialists from different countries visit these Hospitals at regular intervals. Some examples include Sri Satya Sai Super Speciality Hospitals in Puttaparthi, Andhra Pradesh and Bangaluru, as well as Amrita Institute of Medical Sciences and Research Centre in Cochin, Kerala..

Charity hospitals In India, charity hospitals have become a popular way of giving back to the society. Many industrialists have sought to serve the society by promoting hospitals. Such Hospitals fall into two categories: not-for-profit hospitals and free hospitals. Example: Christian Medical College and hospital in Tamil Nadu.

Classification Based on System of Medicine: In addition to allopathic, increasing number of patients are relying on Indian systems of medicine such as Ayurveda, Homoeopathy and Unani. The Indian systems of medicine are recognised by the union government. Most states are actively involved in colleges that teach Ayurveda, Homoeopathy and Unani. In addition, many traditional systems prevail in India particularly in rural and agency areas. Typically, the local priest or village head administers medicines made of locally-available herbs. While the Indian systems of medicine certainly have their advantages, a majority of rural population relies on these systems due to lack of allopathic facilities, low purchasing power and illiteracy. The Indian systems of medicine largely rely on herbs from the foot hills of Himalayas, tropical regions of Vindhya Mountains, Western Ghats and the north-eastern part of India. These herbs form the basis for a range of medicines such as decoctions, powders and liquids. In addition to herbs, other sources are also used to prepare medicines in the Indian systems of medicine. The following are the total number of hospitals in system of Medicine 1 Ayurveda 2 Unani3 Homoeopathic

The history of the development of hospitals shows how there is increasing competition between hospitals.“When more than one hospital exists in a local area they compete for market share, since greater market share has a positive effect on economies of scale, utilization rates, learning curves and levels of quality. Competition is not only with other hospitals, but also with doctors who now perform some procedures in their offices,

and with specialized clinics…strategy is to attract physician allegiance since they act as gate- keepers, directing patients to specific hospitals”.

Hospitals have to compete for patients and to get on insurance companies' lists since there are hospital competition has been found to be socially beneficial because as the competition rises, hospitals provide higher quality care at lower prices, which is advantageous to patients’ health. However, in order to keep increasing the quality of care, hospitals need to find new ways to serve patients and improve patient flows throughout the hospital. This will help to decrease costs and increase patient and employee satisfaction, which are great ways to gain a competitive advantage. In addition, hospitals like Backus are tracking the government’s progress on the reorganization of the healthcare system and want to streamline costs now before new and unexpected costs arise from the changes.Little research has been done in hospital performance, but it is known that they are extremely slow to change and implement improvements, and cannot keep up with the demand for their services. For example,. “Hospital emergency departments in the US are facing increasing challenges due to growth in patient demand for their services, and inability to increase capacity to match demand” Operational Research is relatively new to healthcare. Overcrowded emergency departments and long waiting times are a widespread issue. It is difficult to implement academic recommendations in the real world without continued clinician support (a champion) patient flow in hospitals has been studied extensively. Readers are referred to the many papers in Hall (2006), which are also sources for further references. In the present section, we merely touch on three dimensions, which are the most relevant for our study.

Introduction :

Out Patient Department Services are one of the important aspect of Hospital Administration.OPD is the mirror of the hospital, which reflects the functioning of the hospital being the first point of contact between the patient and the hospital staff. OPD is visited by large section of community, the human relation skill/ Public relation functions are of utmost importance. OPD staff should be polite, cheerful, cooperative & efficient.Patients visit the OPD for various purposes, like consultation, day care treatment; investigation, referral, admission and post discharge follow up not only for treatment but also for preventing and promoting services, the first impression of the hospital is formed from OPD and this is the area frequently visited by a majority of patients.The OPD is located on the ground floor, preferably with the separate entrance. The diagnostic services should be easily approachable from here. Reception, waiting area, Doctors chamber, examination room, minor O.T. and medical examination room are easily accessible. systematic examination of methods of carrying on activities so as to improve the effective use of manpower and equipment and to set up standards of performance for the activities being performed and also the systematic recording and critical examination of the ways of doing things to make improvements one have to establish time standards for carrying out specified jobs and estimates how long a job should take and the manpower and equipment requirements for a given method.It is believed that patient satisfaction can be enhanced and sub-sequent health behavior improved, if providers create an environment that dialogue between the health professional and the patient that enables them to identify the most important and relevant information to transmit to patients and families. It can be hypothesized that understanding and meeting patients need to know through communicating important information desired by the patient can produce more knowledgeable and competent patients who are in a better position to assist their own recovery from illness and manage their own health. While these factors may vary by diagnostic conditions and patient characteristics there is growing evidence that the impact of information may be helpful.The advantages of study in hospital OPD are to improve the methods / procedures of various jobs .Out Patient Department should improve both Clinical and non-clinical facilities such as overall OPD layout that can decrease the overcrowding and de-lay in consultation, In hospitals this can also include reducing the efforts patients need for treatment as well as for their routine hospital checkup.

ABOUT COLUMBIA ASIA HOSPITAL, KHARADI, PUNE.

Pune - Overview

Columbia Asia Hospital – Pune

It is a 100 bedded multi specialty facility situated close to the IT Parks at Kharadi. The hospital has highly qualified medical personnel and technicians to ensure healthcare delivery of the highest quality. It offers a wide range of clinical services such as cardiology, obstetrics & gynecology, minimally invasive surgeries, medical and surgical oncology, pediatrics and neonatology, ophthalmology, urology, gastroenterology, renal transplants, orthopedics, joint replacements, plastic surgery and bariatric surgery.The hospital’s infrastructure along with internationally benchmarked standards of medical, nursing and operating protocols is the key components that will make it a preferred hospital in Pune. A proprietary hospital information system and electronicmedical record management assures error free and convenient patient records management, thereby greatly minimizing patient waiting time.

Year Established - 2013

Business Information

Columbia Asia Hospital in Kharadi, PuneThis is one of the best hospitals not just in India but Asia also. Columbia Asia Hospitals Pvt. Ltd. is one of the foremost healthcare companies to enter Indian

shores through 100% foreign direct investment (FDI) route. This Group is owned by150 plus private equity companies, fund management organizations and individual investors. The very first hospital of this group was started in 2005 in Hebbal - Bangalore. Currently this healthcare group has six multispecialty hospitals, one referral hospital and a clinic. The group has presence in Bangalore, Mysore, Kolkata, Gurgaon, Ghaziabad, Patiala and Pune. In Pune the hospital is located at Kharadi. All the hospitals of the group are clean, affordable and follow strict rules and policy so as to ensure that the patients are always in good care.

Clinical services at Columbia Asia Hospital, KharadiFollowing are the specialties at the hospital: Anesthesiology, Cardiology, Critical Care Medicine, Dermatology, Emergency Medicine, ENT, Gastroenterology, General Surgery, Internal Medicine, Neonatology, Nephrology and Renal Transplant, Neurology, Neurosurgery, Obstetrics &Gynecology, Ophthalmology, Oral & Maxillo-Facial Surgery, Orthopedics, Pediatric Surgery, Pediatrics, Plastic & Reconstructive Surgery, Psychiatry, Rheumatology, Urology and Vascular Surgery.24-Hour services: Emergency room, Laboratory, Pharmacy, Radiology and Ambulance. Specialty Clinics: 8 AM to 8 PM Outpatient clinics, Healthcheck packages: Comprehensive healthcheck - below 30 years. Special Clinics: Travel medicine, Shoulder clinic, Cochlear implant and bone anchored hearing aid clinic, Sports medicine and arthroscopy, Cancer screening, Cardiac screening, Diabetes clinic, Joint replacement clinic, Pain clinic and Weight loss clinic. Blood storage centre: Blood components.

Facilities at Columbia Asia, PuneLaboratory: Histopathology, Clinical pathology, Cytology, Biochemistry and Microbiology. Diagnostic imaging: MRI, Interventional radiology, Picture archival communication system, Teleradiology, Digitized radiography, Ultrasound & color Doppler, Echocardiography, Digitized mammography and16 - Slice CT. Operating theatre: Central sterile services department and Major & minor surgery. Ambulatory &daycare: Daycare surgery, Endoscopy and Dialysis. Cafeteria: Inpatient dining and Outpatient dining. Nursing units: Intensive care, Isolation care, Labor and delivery suite, Neonatal intensive care and Nursery. Patient accommodation: Rooms, Intensive care units and High dependency unit.Other miscellaneous services offered includes Ambulance services, Drinking Water, Housekeeping, Internet Access and Business Facilities, Information desk, Laundry, Lost and Found department, Unclaimed Baggage / Articles, Dietician, Newspaper, 24 hour pharmacy, Telephone, Television in rooms.

Services offered to International patients include assistance with Accommodation, Travel & Foreign Currency, services of a Finance Manager or Insurance Coordinator, Language interpreter service, Made to Order Cuisine etc.

Columbia Asia Group of Hospitals

Columbia Asia is an international healthcare provider with a chain of hospitals across India, Malaysia, Vietnam and Indonesia. The company’s highly skilled medical experts deliver care in modern hospitals specifically designed for the needs of patients and built for maximum comfort and efficiency. Columbia Asia integrates evidence-based, internationally benchmarked medical practices with the latest technology, while providing the highest quality patient care. Our hospitals specialize in Transplants (Kidney, Liver), Interventional Cardiology and Cardiac Surgery, Neurosurgery, Orthopedic Surgery, Surgical Oncology, Cosmetic and Bariatric Surgery and High-risk Pregnancies, among others. Columbia Asia has hospitals in several cities in India and is in the process of setting up facilities in additional locations too.

Leading the Way

Columbia Asia has a clear vision: Provide excellent, affordable care in modern facilities centered on patients' needs. Columbia Asia's highly skilled doctors and nurses deliver care in modern hospitals located close to where people live and work. Columbia Asia hospitals are specifically designed for the needs of patients and built for maximum comfort and efficiency. Patients benefit from advanced medical diagnostics, treatment and the personal care that only comes in facilities where the focus is on each patient.

Columbia Asia provides excellent care at affordable prices. Our transparent rate structure for medical procedures allows patients to know in advance how much their care will cost. There are no hidden or extra charges.Columbia Asia Hospital is like a one man army in the health industry. With a chain of hospitals serving countries like Malaysia, India, Indonesia and Vietnam, the group has made a name and place for itself. The company as a brand came up in the year 1994. It has its headquarters in Kuala Lumpur in Malaysia. The hospitals across the four nations are built with an aim to heal more and more number of people with efficient means and advanced medical techniques. Comparatively smaller in size, the hospitals are just the organization meant for public service. Spending lesser on the size and more on the medical equipments, Columbia Asia focuses more on building a proper healthcare set up. Service oriented hospitals are run under the company; Columbia Asia. The hospital sees a maximum of 8,000 patients every month. The overall monthly revenues earned by the hospital are over one million dollars.Skilled doctors and well trained medical professionals are hired every year to improve the medical services provided by the hospitals in four nations. With over

2600 employees and further plans for expansion, Columbia Asia is growing in size and popularity. The doctors and staffs are recruited from the local area. The company owns about 14 hospitals, which are under construction. 12 other properties are owned by the company. On completion of these projects, the company will have 11 hospitals in the Malaysian nation, 3 in Vietnam, 21 hospitals in India and about 3 in Indonesia.

SWOT ANALYSIS

SWOT analysis is a strategic planning method used to evaluate the Strengths, Weaknesses, Opportunities, and Threats involved in a project or in a business venture. It involves specifying the objective of the business venture or project and identifying the internal andexternal factors that are favorable and unfavorable to achieve that objective. The technique is credited to Albert Humphrey, who led a convention at Stanford University in the 1960s and 1970s using data from Fortune 500 companies.A SWOT analysis must first start with defining a desired end state or objective. A SWOT analysis may be incorporated into the strategic planning model. Strategic Planning has been the subject of much research.Strengths: characteristics of the business or team that give it an advantage over others in theindustry.Weaknesses: are characteristics that place the firm at a disadvantage relative to others.

Opportunities: external chances to make greater sales or profits in the environment.Threats: external elements in the environment that could cause trouble for the business.

Identification of SWOTs is essential because subsequent steps in the process of planning forachievement of the selected objective may be derived from the SWOTs. First, the decisionmakers have to determine whether the objective is attainable, given the SWOTs. If the objective is NOT attainable a different objective must be selected and the process repeated. The SWOT analysis is often used in academia to highlight and identify strengths, weaknesses, opportunities and threats. It is particularly helpful in identifying areas for development. SWOT analysis is a tool for auditing an organization and its environment. It is the first stage of planning and helps marketers to focus on key issues. SWOT stands for strengths, weaknesses, opportunities, and threats. Strengths and weaknesses are internal factors. Opportunities and threats are external factors.

MARKETING AS A VALUE DELIVERING PROCESSThe success of the firm depends upon its ability to deliver better value to the customer than its competitor. Marketing can be seen as the value delivering process. The value creation and delivery sequence can be divided into three phases.The first phase, choosing the value includes segmentation, targeting and positioning i.e. dividing the heterogeneous market into homogeneous segments, identifying target markets and developing offerings value positioning i.e. position the product as delivering central benefits most sought after by target market.The second phase is providing the value. This involves identifying product features, pricing and distribution. The third phase is communicating the value by utilizing the sales force, sales promotion, advertising, and other communication tools to promote the product. Each of these phases adds cost and provides benefits. Value delivery process begins before there is a product and continues while it is being developed and after it becomes available.

MARKETING ENVIRONMENTThe success of any company is based on well it respond to the changes occurring in the environment it operates.The Marketing Environment can be defined as all the internal and external forces that influence marketing activities of the firm.

The internal environment forces include a firm’s production, financial, personnel, R&D, and company image and other related facilities which are more or less controllable by management.The external forces can be further divided into microenvironment and macro environment.The microenvironment consists of the suppliers, customers and marketing intermediaries while the macro environment includes demography, socio-cultural, technological, political, economical and legal environment.

EXTERNAL MICROENVIRONMENT FACTORS:--The external microenvironment includes:1. Market Demand2. The Consumers3. Suppliers

EXTERNAL MACRO ENVIRONMENT FACTORS:--Demographic Environment:-

i) Populationii) Age wise classification

Other demographic variables:--iii) Occupation and literacyiv) Location

Political & Legal environment:-

Marketing activities and marketing decisions are greatly influenced by development in the political and legal environment. This environment includes form of the Government adopted, stability of the government, government policies, laws, rules & regulations, social and religious organizations, government agencies, political ideologies, media and pressure groups that restrict and influence political organizations. Businesses have to operate within the framework of the prevailing legal environment. They have to understand the implications of all the legal provisions relating to their business. Central and State government regulate business legislation covering areas like corporateaffairs, taxation, consumer protection, protection to selected business sectors, protection ofsociety as a whole against unfair business practices, regulations on products, prices &distribution, control on trade practices, protecting domestic firms against the onslaught of foreign firms etc. MNC’s operating in different countries need to understand legal environment prevailing in various countries.

Economic Environment: -

Economic environment consists of economic policies, economic systems, and economic conditions prevailing in the country. Economic policies consists of export-import policies, industrial policies etc. Economic system includes free market economy, mixed economy etc. Economic conditions include interest rates, inflation rate etc. Marketer need to pay attention to different economic variables as gross domestic product, disposable income and purchase power of different population segments, rate of growth of economy and different sectors, credit availability and interest rate, behavior of capital market, exchange rates, capital rates etc. Marketer need to know the different stages of business cycle and the stage of cycle economy is currently operating into. The business cycle consists of four stages: -Recovery, Boom Recession and Depression.

Socio-cultural Environment: --

Socio-cultural environmental factors include culture, traditions, attitudes, norms, values and lifestyles of people. Social factors affect how people live and behave thus deciding customer buying behavior which eventually influences firm’s marketing plans and programs.

Culture: -

Culture is the combined result of factors like religion, language, education and upbringing. Some cultural values are deep rooted and do not change easily called core-cultural values e.g. faith in marriage. There are also values and practices which may change over the period of time called secondary values. The cultural shifts carry with them marketing opportunities as well as threats. e.g. Influences of western countries have considerably affected food and clothing habits of Indian customers.

Social class: -

Any society is composed of different social classes. A social class is determined by income, occupation, location of residents etc. Each class has its own standards with respect to lifestyle, behavior etc. known as class values or class norms. E.g. people belonging to middle class are more prices conscious. Certain changes can be observed in Indian social environment like increasing number of nuclear families, growing awareness about consumer rights, growth in number of working women, concern for environment, and change in attitude towards health and recreation.

Increase in number of working women has caused growth in demand for domestic appliances, ready-to-cook food items, beauty products etc. Increased interest of people in better health and fitness has brought more business for sports goods, fitness centers, and private sports clubs. It has also brought changes in the eating and dieting habits of people. Demand for health foods, health drinks, low calorie diets have gone up. Growing influence of social cultural forces has compelled marketer to embrace societal marketing concept.

Technological Environment: -

Technology has a very wide impact on all marketing activities. It also has tremendous impact on our life style, consumption pattern and our economic well being. New machines can reduce production costs; the increasing computing and processing capabilities of computers is increasing effectiveness and efficiency of the business. Companies can make better product at lower costs and plan truly global supply chains where manufacturing and warehousing are disbursed throughout the world depending upon cost-effectiveness. The technology has helped marketer in environment analysis and decision making (MIS, Decision support system).

Competitive Environment:

The Competitive Environment has a major influence on marketing programs of companies. Companies need to constantly assess the competition, anticipate competitive actions and formulate marketing strategies to deal with them. Competitors considerably influence the company’s choice of marketing strategies particularly in relation to selection of target market, suppliers, marketing channels as well as product mix, promotion mix and price mix. Company may face competition at different levels. A company competes with companies offering similar products and services. e.g. Surf and Ariel, Colgate and Pepsodent etc.

Natural Environment: -

The ecological balance has been disturbed by the rapid industrialization, higher consumption of fossil fuels, increasing consumerism and rapid urbanization. This has resulted in Ozone layer depletion, global warming and various other problems.

SEGMENTATION, TARGETING AND POSITIONING

BASES FOR SEGMENTATION OF CONSUMER MARKET

1) Geographic Segmentation2) Demographic Segmentationa. Age and Life Cycle stageb. Genderc. Incomed. Generatione. Social Class3) Psychographic Segmentationa. Life Style:-b. Personality: -c. Values:-4) Behavioral Segmentationa. Occasionsb. Benefitsc. Usage Rated. Loyalty Statuse. Buyer Readiness Stagef. Attitude

SERVICE In economics, a service is an intangible commodity. More specifically, services are an intangible equivalent of economic goods.Service provision is often an economic activity where the buyer does not generally, except by exclusive contract, obtain exclusive ownership of the thing purchased. The benefits of such a service, if priced, are held to be self-evident in the buyer's willingness to pay for it. Public services are those society (nation state, fiscal union, regional) as a whole pays for through taxes and other means.By composing and orchestrating the appropriate level of resources, skill, ingenuity, and experience for effecting specific benefits for service consumers, service providers participate in an economy without the restrictions of carrying inventory (stock) or the need to concern themselves with bulky raw materials. On the other hand, their investment in expertise does require consistent service marketing and upgrading in the face of competition == Service characteristics == Services can be paraphrased in terms of their generic key characteristics.

1. IntangibilityServices are intangible and insubstantial: they cannot be touched, gripped, handled, looked at, smelled or tasted. Thus, there is neither potential nor need for transport, storage or stocking of services. Furthermore, a service can be (re)sold or owned by somebody, but it cannot be turned over from the service provider to the service consumer. Solely, the service delivery can be commissioned to a service provider who must generate and render the service at the distinct request of an authorized service consumer.

2. PerishabilityServices are perishable in two regards

The service relevant resources, processes and systems are assigned for service delivery during a definite period in time. If the designated or scheduled service consumer does not request, an empty seat on a plane never can be utilized and charged after departure. When the service has been completely rendered to the requesting service consumer, this particular service irreversibly vanishes as it has been consumed by the service consumer. Example: the passenger has been transported to the destination and cannot be transported again to this location at this point in time.

3. InseparabilityThe service provider is indispensable for service delivery as he must promptly generate and render the service to the requesting service consumer. In many cases the service delivery is executed automatically but the service provider must preparatory assign resources and systems and actively keeps up appropriate service delivery readiness and capabilities. Additionally, the service consumer is inseparable from service delivery because he is involved in it from requesting it up to consuming the rendered benefits. Examples: The service consumer must sit in the hair dresser's shop & chair or in the plane & seat; correspondingly, the hair dresser or the pilot must be in the same shop or plane, respectively, for delivering the service.

4. SimultaneityServices are rendered and consumed during the same period of time. As soon as the service consumer has requested the service (delivery), the particular service must be generated from scratch without any delay and friction and the service consumer instantaneously consumes the rendered benefits for executing his upcoming activity or task.

5. VariabilityEach service is unique. It is one-time generated, rendered and consumed and can never be exactly repeated as the point in time, location, circumstances, conditions, current configurations and/or assigned resources are different for the next delivery, even if the same service consumer requests the same service. Many services are regarded as heterogeneous or lacking homogeneity and are typically modified for each service consumer or each new situation (consumerised). Example: The taxi service which transports the service consumer from his home to the opera is different from the taxi service which transports the same service consumer from the opera to his home – another point in time, the other direction, maybe another route, probably another taxi driver and cab.

Each of these characteristics is retractable per se and their inevitable coincidence complicates the consistent. Each of these characteristics is retractable per se and their inevitable coincidence complicates the consistent service conception and makes service delivery a challenge in each and every case. Proper service marketing requires creative visualization to effectively evoke a concrete image in the service consumer's mind. From the service consumer's point of view, these characteristics make it difficult, or even impossible, to evaluate or compare services prior to experiencing the service delivery.

Service delivery

The delivery of a service typically involves six factors: The accountable service provider and his service suppliers (e.g. the people) Equipment used to provide the service (e.g. vehicles, cash registers,

technical systems, computer systems) The physical facilities (e.g. buildings, parking, waiting rooms) The requesting service consumer Other customers at the service delivery location Customer contact

The service encounter is defined as all activities involved in the service delivery process. Some service managers use the term "moment of truth" to indicate that defining point in a specific service encounter where interactions are most intense.Many business theorists view service provision as a performance or act (sometimes humorously referred to as dramaturgy, perhaps in reference to dramaturgy). The location of the service delivery is referred to as the stage and the objects that facilitate the service process are called props. A script is a sequence of behaviors followed by all those involved, including the client(s). Some service dramas are tightly scripted, others are more ad lib. Role congruence occurs when each actor follows a script that harmonizes with the roles played by the other actors.In some service industries, especially health care, dispute resolution, and social services, a popular concept is the idea of the caseload, which refers to the total number of patients, clients, litigants, or claimants that a given employee is presently resp responsible for. On a daily basis, in all those fields, employees must balance the needs of any individual case against the needs of all other current cases as well as their own personal needs.

PATIENT SATISFACTION

Why Should You Evaluate Patient Satisfaction?

Improving the quality of patient care in hospitals is a vital and necessaryactivity. Patients report they receive less individual attention than ever before. They complain that doctors and nurses are too busy tending to the technical aspects of care to provide the much needed attention to patient’s personal needs. While the business community has been involved in assessing customer satisfaction for at least a decade, the medical community has lagged considerably in assessing patient satisfaction. More recent developments in the medical environment have prompted the health care profession to recognize patients as valuable customers. Medical groups have been more involved in this process due primarily to major incentives from a payer driven to a patient-driven mode and the increase competition among physicians arising from the diminished differences in price.The National Committee for Quality Assurance(NCQA) efforts in the collection of Health Plan Employer Data and Information Set survey results has also affected the collection of patient satisfaction data in physicianpractices.There are many reasons why critical access hospitals should evaluate patientsatisfaction. We are often the poorest objective judge of one’s own appearance. It is also unusual for those around us to give unsolicited criticism about the need forimprovement (Emily Post advises against it as impolite). Most people when receivingpoor service or bad food at a restaurant doesn’t complain, they just warn their friend’s and refuse to return. You can be blissfully unaware of any problem and patients remainunsatisfied.Patient satisfaction is as important as other clinical health measures and is a primary means of measuring the effectiveness of health care delivery. The current competitiveenvironment has forced health care organizations to focus on patient satisfaction as away to gain and maintain market share. If you don’t know what your strengths and weaknesses are, you can’t compete effectively. The data gathered through measuring patient satisfaction reflects care delivered by staffand physicians and can serve as a tool in decision-making. Patient satisfaction surveys can be tools for learning; they can give proportion to problem areas and a referencepoint for making management decisions. They can also serve as a means of holdingphysicians accountable – physicians can be compelled to show they have acceptable levels of patient satisfaction. Patient satisfaction data can also be used to document health care quality to accrediting organizations and consumer groups and can provide leverage in negotiating contracts. Probably the most important reason to conduct patient satisfaction surveys is that theyprovide the ability to identify and resolve potential problems before they becomeserious. They can also be used to assess and measure specific initiatives or changesin service delivery. They can identify those operations and procedures that require better explanation to patients. And most importantly, they

can increase patient loyalty by demonstrating you care about their perceptions and are looking for ways to improve.There are a number of challenges small facilities, in particular, may face with conducting patient satisfaction surveys. These include: tight budgets, lack of funding, lack ofcommitment from administration or staff, lack of in-house expertise to plan and managetask, lack of in-house resources for existing staff, with small sample size, designing a statistically valid sampling process, obtaining acceptable response rates and reliabledata, properly analyzing and reporting survey data, translating findings into informationthat can be used for program planning and quality improvement efforts, no institutionalincentives for performance improvement, and selecting a survey instrument that will produce valid and reliable results. Although there are numerous challenges for small rural hospitals, we are hoping this publication will make the process easier to understand and manage.

What is Satisfaction?

Before attempting to evaluate patient satisfaction, we need to know what it is. How we define patient satisfaction will help us structure an evaluation processes that provide adequate measurements of the variables that contribute to a patients’ level of satisfaction. Although most patients are generally satisfied with their service experience, they may not be uniformly satisfied with all aspects of the care they receive. Therein lays the challenge to management – how much service is enough to elicit high satisfaction and keep them coming back?A patient’s experience within a hospital environment is based on numerous encounters with a wide variety of individuals and locations. The first encounter is with the facility’s parking lot, followed by physically accessing the facility, the admissions process, encounters with physicians, nurses, lab personnel, and other service providers and their respective physical locations, including patient rooms and the care they receive while in their room, the discharge process, and finally the billing/payment process. There arena number of factors that could impact on the patient’s perception of the care provided throughout an inpatient stay. Factors may include the cleanliness of the environment, the appearance of the facility, the ease of access to specific locations, the concern expressed from various staff and providers for the patient’s well-being, the amount of time they had to wait before getting care, the quality of the interaction with providers, the clarity of the communication fromproviders, the outcome from the care provided, the cost of the visit, the providers, the outcome from the care provided, the cost of the visit, the quality of the food, the perceived efficiency in which care was delivered, and on and on.

Over the years there have been various definitions of patient satisfaction. Susie Linder-Pelz (1982b, p. 578), in her review of the patient satisfaction literature, offers the following definition: patient satisfaction is “…positive evaluations of distinct dimensions of the health care. (The care being evaluated might be a single clinic visit, treatment throughout an illness episode, a particular health care setting or plan, or the health care system in general.)”The suggestion by Linder-Pelz is that satisfaction must be understood within the context in which a variety of elements may be more or less satisfying to the patient. She identified 10 elements that can be used to determine satisfaction:

1. Accessibility/convenience2. Availability of resources3. Continuity of care4. Efficacy/outcomes of care5. Finances6. Humaneness7. Information gathering8. Information giving9. Pleasantness of surroundings10.Quality/competence

A well-designed patient satisfaction survey will incorporate these elements as it relates to the total patient experience.

Survey MethodsThere are two broad categories of surveys: the questionnaire and the interview. Questionnaires are typically paper-and-pencil instruments that the patient completes but also can include computerized versions that are accessed at thesite through a kiosk or through the Internet. Interviews are completed by theinterviewer and are based on what the patient says. The following section discusses the various types of surveys and the advantages or capabilities and the disadvantages or limitations of each type.

Interviews

Interviews are a more personal form of surveys than questionnaires. Interviews can occur on an individual basis or within groups and either over the telephone or in person. Properly conducted interviews can provide managers and decision makers

with a deeper understanding of patient perceptions about their hospitalenvironment.Unlike structured survey methods which require strict adherence to a set procedure to ensure the scientific accuracy of the results, interviewing techniques are less rigid and concentrate more on revealing issues and underlying face-to-face nature of group meetings enable you to not only ask patients “what “are their issues, opinions, and needs, but also to probe “why” they feel such issues, opinions and needs exist.The interpersonal nature of interviews allows for much give and take of information. Often during the course of an interview, issues raised will need clarification from either the facility or patients. Interviews provide an outstanding opportunity to answer questions and clarify issues .Conducting these interviews can serve a public relations role for your organization. By providing patients with a formal opportunity to express their views, your facility is making a strong statement of its interest in the attitudes of patients. Still, the manners in which you respond to the issues raised will ultimately demonstrate your respect for, and commitment to patient involvement in the health care system. For the sake of brevity, detailed information on the process of conductingindividual and/or group interviews is not repeated here. Please refer to the publication “Conducting Key Informant and Focus Group Interviews” for more specific information on the process of interviewing. These same techniques can be applied to individual patients and groups.The advantage of interviews is their personal form. Unlike questionnaires, the interviewer has the opportunity to probe or ask follow-up questions. Interviews are generally easier for the respondent, especially if what is sought is opinions or impressions. However, they can be very time-consuming and they are resource intensive. The interviewer is considered a part of the measurement instrument and interviewers have to be well trained in how to respond to any contingency. In addition, if the interviewer is on the staff of the facility, there may be some reticence by patients to share their perceptions openly and honestly. Even an outside interviewer might encounter problems because the patient’s identity is known. Interviews conducted by people external to the organization are preferable.

Q uestionnaires

When most people think of questionnaires, they think of written surveys. Written surveys consist of the same exact instrument sent (usually mailed) to a wide number of people. In this instance, a patient satisfaction survey could be distributed directly to patients either at the completion of their inpatient stay or by mailing them to their homes.

There are also digital ways to gather patient satisfaction data. Some facilities may provide access to a kiosk that will allow patients to answer questions regarding their stay. Others have websites that allow patients to provide feedback via the Internet. The most obvious advantage to this approach is that data-entry is completed by the patient, eliminating the need for manual data entry.This also minimizes human error. However, this approach will not be appropriate for all patients, especially those who are not computer literate or who do not have access to the Internet. This might be a good option in combination with another method of obtaining patient satisfaction data.A second type of questionnaire is the group-administered questionnaire. Thedifference between a group administered questionnaire and a group interview is that each respondent is handed an identical survey to complete while in the roomfor a group administered questionnaire and for a group interview, respondentsdon’t complete a survey individually but listen and answer questions as part of agroup.There are many advantages to a written survey. They are relatively inexpensive to administer and you can send the exact same survey to a wide number of people. They allow the respondent to fill it out at their own convenience. They can be completely anonymous and confidential, removing the fear of responding honestly. However, the disadvantages are that response rates from written surveys are often very low and they are not the best vehicles for asking for detailed written responses. In addition, poorly designed questions can be misinterpreted by respondents and incorrectly designed surveys may produce invalid and misleading results.Group administered questionnaires are also inexpensive to administer and could increase the response rate. However, there may be reluctance on the part of the patients to respond honestly for fear of being identified. Measures would be necessary to insure confidentiality. The remaining sections of this publication, discuss the specific steps to design, distribute, and analyze a patient satisfaction survey using a written survey model.

Research Methodology

The Research approach adopted in this study is Questionnaire and Descriptive Method. This includes collection of data using observational checklist from patients visiting Out Patient department.

Collection Of Data

Primary Data: Observation Method, Interview Method with patients and staff orally Secondary Data: Internet, Articles, Other SourcesSample Size: Sample size of 50 Patients is included in study.Statistical Analysis: Graphical analysis interpretation.To get actual quantified data and understand perception of patients: Questionnaire was designed.

Questionnaire:

Used to collect data.Data was collected from the Out- Patient Department during day (9.30 am – 4.30 pm). Data was mainly collected from the Patients who visited the Hospital OPD.

Waiting Time:

1) Demographics

Name of Patient:Age: Gender: M/FRegistration No:Occupation: To eliminate any bias – randomized sampling was done and hence –Gender: Male - 25 & Female - 25

Male Female0

5

10

15

20

25

30

Axis Title

Equal numbers of Male and Female patients were interviewed and options of both were taken into consideration.

2) How did you come to know about our Hospital?

a) Doctors Referral b) Recommended buy other patients ,or relatives or friends c) Websited) News paper advertisement or TV Advertisementse) Other (Please Specify)

6%

74%

6%

10%

4%

First Information Doctors Referral Patients ,or relatives or friends WebsiteNews paper advertisement Other

From this we understand that maximum patients come by referral either from patients who are already having treatment or have received treatment in past. Or from those who know about the hospital.Second important reason is news paper advertisements. So more attention should be given to print media. Writing columns in reputed news paper also will help to increase awareness about the hospital.

3. How was first appointment taken?a) Personally visited for inquiry b) Relatives came to inquiryc) Telephonic inquiryd) Directly came without appointment

7%

26%

63%

5%

First appointment taken by -Personally visited for inquiry Realtives came to inquiryTelephonic inquiry Directly came without appointment

This helped me to understand that maximum patients, more than 60% - first interact on telephone, and do enquiry before coming. So, more attention on improving that should be given. Patients all queries should be answered & all information should be given with full clarity.

4. First visit detailsFrom your place of residence –How did u come to hospital?This question was included- as patient flow not only starts from the entrance gate of hospital, but it starts – right from patient’s house.

Bus Own Car Two wheeler Auto

9

24

12

5

Mode Of Transport

This data reveals that maximum patients come by four wheeler. Many patients come from very far location so they have to either they have to come by own car or hire a bus or auto .Also many patients – don’t have physical capacity to travel by auto or on 2 wheeler. So, in spite of extra burden of cost,many patients have to bare cost for four wheeler.

From feedback- it was clear, that things have to be done. They are – Make more covered parking space available to all 4 wheeler. As people find it difficult as there is very little space for four wheeler.Quantitative Data –Regarding Time.I used interval scale for assessing time factor.

5. Time taken for registration Process?a) Less than 5 minutes b) 5-10 minutesc) 10-20 minutes and the last one is – d) More than 20 minute

Less than 5 Minutes

5-10 Minutes

10-20 Minutes

> 20 Minutes

6

23

17

4

Registration Time

6. Waiting time to see doctors? Time to see consultant:a) Less than 15 minutesb) 15 minutes to 1 hourc) 1 hour to 3 hoursd) > 3 hours

Waiting Time to see consultant Feedback

Less than 15 minutes 4

15 minutes to 1 hour 25

1 hour to 3 hours 20

>3 hours 1

Less than 15 minutes

15 minutes to 1 hour

1 hour to 3 hours

>3 hours

4

25

20

1

Waiting time for consultant

This reveals that maximun patients have to wait for atleast 1 to 2 hours to see consultant. Also many patients said that time varies a lot.This is the main portion of total waiting time. So ,once this is managed ,then we can achieve to reduce total waiting time ,and also increase patient satisfaction .

7. In this I was interested to know the waiting area comfortable for patients and their relatives ? Whichfacilities are currently available ? And is there anything that needs to be improved or added ?

1) Do you find the waiting area comfortable ? Yes/ NO ( please give your comments if any )

Almost all patients agreed that waiting area is comfortable – But observed that many patients relatives occupy the waiting area as there is no separate wating area for relatives whos family member is admitted. So this hsould be informed . And there are no beds in waiting area,Separate room should be provided for that.

2) What facilities are available ?- Comfortable chairs or beds ?- Water , tea or coffee machine ?- Fans, lights & ventilation ?

All patients said that – Lighting ,Ventilation was satisfactory.Pure filtered water is kept near waiting area .Patients are satisfied with canteen facilities.

8) What you normally do while waiting ?This was again an open ended question and many people said – that they just wait and do nothing , other than thinking about – how much more time ?So , to avoid this,and increase patient satisfaction , we may select options- from next question and make utilization of current available waiting time .

9) What would you prefer to do during the waiting time ?a) Read books or magazines b) Watch informative CD, or Presentationsc) Watch cartoons or light programsd) Relax or sleep e) Other than this (Please Specify)

29 32

10 103

Preference

This question was asked , and multiple answering was allowed.As many patients opted for more than one options – so we understand that – what is more preferred over what.

Data reveals that –32 people have opted to watch informative CD, or presentations. They said that –it will be surely helpful to know them do’s and don’ts.Also – that will keep them engaged which will reduce anxiety ,and also be helpful for their relatives to take good care at home , and avoid common mistakes .Also 29 out of 50 were interested to read books or magazines. Maximum being from urban area , are literate . And so – they said that – informative books and magazines will be useful. Also some other books for light reading may be useful to divert mind from pain and stress.These things can be implemented, to make patient relax , and help to reduce anxiety

10. Were you informed about your waiting number or current status or doctor’s arrival timw , or expected waiting time ?a) Always b) Most of the times c) Only when asked d) Never

Information given FeedbackAlways 2

Most of the times 8Only when asked 24

Never 16

Always Most of the times Only when asked Never

2

8

24

16

Information given

This data tells that – almost half the patients have to ask by themselves – about waiting number or current status or doctor’s arrival time, or expected waiting time. That sometimes makes them unstable, anxious and hence may affect patient satisfaction level.So, hospital should adopt – Token System

Common problems to be encountered in OPD system are as follows: Long patients wait time will occur at the front desk of the hospital. Patients might be conveyed to wrong services. Large number of patients waiting to be served at the OPD will result in uncomfortable conditions such as congestion, noise, and poor ventilation. Long work-shifts will cause cleaning crew to wait idle and related cost will increase Patients could prefer another health clinic due to improper management.Solution :The delay can be avoided if the patients at the time of registration may be advised about the probable time of his turn. This can help the patient in chalking out his schedule. Besides, the patients from the village may be given preference so that they can go back to their village after examination and consultation and thus may not unnecessarily crowd the hospital premises.

Recommendations: By word of mouth publicity from relatives and close friends only one doctor is more recognised and famous as compared to other doctors More availability of the doctor in the hospital Easy going and adjusts with the cost of surgery which is affordable by all class of people . Word of Mouth plays an important role in increasing the revenue at the hospital OPD The Marketing Department should do market study for more recognised doctors for the each department on panel who can generate more revenue. According to my observation the hospital is at risk by keeping a hope on just one doctor(of respective department) hoping that hospital will get enough revenue Even Doctors now a days are more aware of the market availability and there demand in market with such good experience as it is observed already the patients are being diverted from the hospital to there private OPD as well as for surgery either to the other hospital to the doctor is attached or there own small hospital setup . So the administrative staff should take into notice about it and take a quick action to appoint more experienced doctor who are available in the market

On Market study and it’s been notices that many other hospitals in Pune and Mumbai where the doctors has been given the per day target of patients as well as surgeries If they don’t get the revenue that is expected by the hospital the doctor is asked to leave from the panel the same thing has to be followed by the hospital if the revenue generation is the current concern. The Marketing Department should take initiative and do more marketing for the doctor’s who have less patients as compared to other Being in Pune its been observed that public in market is more turning to safer drugs available in the market that is Ayurvedic and Homoeopathy mode of treatment which are safer drugs .If compared to other hospitals like DMH they have many doctors who work with them for Ayurvedic and homoeopathic panel.

Here same the marketing and R&D Dept should hire some Specialized doctors who are ready to join for opd from 8pm to 10 pm, as if many IT companies office get over at around 7pm or 8 pm even the office people can easily get a appointment and visit a doctor. Many times it’s been observed that some investigation are not available at the hospital so the patient is recommended to get the test done from other hospital. So the administrative staff should take it into notice as many patients are getting diverted in this way to Increase the no of bed in the hospital as many patients are getting diverted to other hospital because of non availability of the bed at the right time. Signages: They play an important role in the hospital which is like a maze. They have to keep on asking at least 2-3 persons who come on their way for the direction . Signages should be user-friendly ,so that even a non educated person should easly read it. Best solution is to put up a board just next to OPD reception with proper signages If revenue generation is the issue the main initiative the hospital should do is the more marketing about the doctor who don’t have many patients or either make them set a target for revenue generation. There is no use in just wasting the time slot that has been given to the doctors who just don’t get more than 2-3 patients .instead hire new doctors who can get more patients and profit the hospital. Observed that doctors who have just 1-2 patients they don’t just come to the opd time schedule ,before coming they ring up at OPD reception counter and confirm about their patients if they find there is just one patient they just don’t turn up at the OPD .

Toilets are not clean The passage area should be kept clean and dry as far as possible. The housekeeping Department should be more alert and quick to guide the visiting patients to flush the toilet Include more seating arrangements to the patients as there is more rush from 9.30 am to 11.30 am It is inconvenient for the patients to wait for long time in standing position due to less seating arrangements and even the doctor’s delay in starting opd results in more fatigue.

Since the outpatients are considered as the best marketing agent for the hospital. Apart from the quality of staff, equipments the main feelings and image carried by patients about hospital mainly depends on human aspect and the concern, sympathy and understanding shown by hospital staff.

Token System to reduce waiting time : This is as a protocol, when patients arrives first at reception desk, they should first be informed about –has consultant- that is has the doctor arrived or not. Then patient should be given token, so that –they will get idea- where they stand, and how much time approximately will be there. This gives a secured feel to patients, and will also help us manage patients flow , without affecting their satisfaction. Then patient should be sent to get follow up done by senior or junior research fellows. Then once follow up is done, patient should be transferred to waiting area, where- comfortable chairs, and minimum 2 beds should be kept. As – few patients are not able to sit for long time, so for them beds should be there, with a curtain – as separation. Token System: As patient will be having a token number in his/her hand , and current number will be displayed on the machine – so patient will be assured about what is actually happening. Also – this assurance will make the patient relax, and sit in one room, which will be easy to manage. Also – patient can rest, read books , watch CD, or presentations – in that room . Then for example –X patient has token no 21, and currently number is 16 on board, that patient will know that there is still time, if needed he may go to washroom, and then wait again .No need to hold natural urge. Or even- when patient has number 18, and currently 16 number is gone, then

he/she can start getting ready to go inside , and when 17 number goes inside-we can ask -18th patient to come and sit on the chair next to Doctors cabin. This will avoid time wastage – in patient shifting ,and also wil avoid overcrowding of all patients in front of cabin Also – patient wont trouble doctors and receptionist – by continuously asking about – how many still to go ? This will create an image – of transparency in patients mind. And hence patient satisfaction level will Increase. And for VIP patients, or extra critical patients, who need to be addressed urgently,- they should not be given token number. As – if they are given token number- and if other patients see them bypassing, then they will feel bad. As- every patient who is coming, is suffering from some other ailments- which itself makes every patient anxious. Then, if these –emergency patients come, they should be directed to cabin separately. And here – on machine, the last number should not be changed. Patients waiting – won’t know that someone else has gone. They will think that last patient- for example 26 has gone in, and still that patients hasn’t come out .And number 27 is ready to wait till his/her number is not displayed. This system should be implemented, which will surely make whole system function smoothly.

Conclusion :This Study – gave a clear idea of current scenario , and what all bottlenecks are. Which are the things – which are appreciated by patients, and what are area for improvement. I believe that few suggestions can certainly show improvement in operational management and also perception of patients. And this study emphasises on imprortanceof TIME factor in patient’s satisfaction level .Patient flow can be streamlined, to give best results.

BILLING: WHAT, WHEN AND HOW

Brief History of Medical Billing and Collections

Many decades ago, the business aspects of hospitals worked much like the business aspects of any other service industry. Physicians charged a fee for their services, and the patients received and usually paid the bills. Prices were reasonable, and the physician had flexibility to do charity work when he or she felt it necessary or appropriate. Most doctors made a healthy living, and had no problem providing a reasonable amount of charity care. Then insurance companies got into the picture. They offered to pay for health care, if you, the patient, gave them money upfront.

They would then take that money, and invest it. They invested in the stock market, and probably other areas. As needed, they’d liquidate some of those assets to actually pay for medical services provided to their members. They would make money when their investments did well, or if their patients did not need as much in services as they paid in premiums. If their investments did poorly, they’d raise their premiums. To this day, health insurance premiums reflect the stock market more than they reflect medical advances or increases in health care billing. Then the government got involved. Initially, the government paid for services at a reasonable rate, and with few regulations. Over the years though, the regulations have increased, and the reimbursements have dropped. The government though is subject to the influence of lobbyists. Hospitals argued for more money, pharmaceutical companies argued for more money. In many areas, not only the hospitals, the reimbursements have not kept pace with costs. Hospitals, for example, are required by law to treat anybody who shows up in their emergency room, without regard to their ability to pay. As the stock market goes down, and insurance premiums go up, the number of uninsured increases. To offset the expense associated with treating the uninsured, hospitals increase the bills charged to all of the paying patients. This means that the insurance companies need to pay more to the hospitals. When they get to keep less of the money that they bring in, what do they do? They raise premiums of course, then more people drop their insurance, the hospitals charge more, and the cycle continues without a visible end. The story is not over however. Insurance companies have found more ways to keep more of the money that you send them. They designate some of their doctors as “premium” doctors. This term implies higher quality. It really means less expensive. Those doctors willing to work for less or who cost them less get the designation as “premium” physicians. These are then marketed to large companies. The large companies get a tax break for providing health insurance to their workers. The employees get a small portion of that break on the cost of the insurance. Of course, they get no choice of insurance companies. That decision has been made, often on a financial basis, rather than quality basis, by the owners of the company. The small business and the individual cannot negotiate with the insurance company for lower rates, nor do they get a break on their taxes for obtaining health care insurance. They get hit from both sides. Only two more steps here. Now that the government is involved (in USA), they set prices. Most insurance companies have now abandoned the “usual and customary” in favor of a fixed percentage of Medicare rates. There is no other industry or service in this country where the government sets the amount that is to be paid for the product or service. As the government decides to spend less on health care, the insurance companies get to keep even more of your premiums.

In most arenas, you get that for which you pay. If you want a good product, you expect to pay a little more for it. In medicine, on the other hand, the government sets the prices. (They often end up spending more for the care of a lesser quality physician.) Still, the full responsibility for the care of the patient belongs to the physician. In many areas, not only the hospitals, the reimbursements have not kept pace with costs. Hospitals, for example, are required by law to treat anybody who shows up in their emergency room, without regard to their ability to pay. As the stock market goes down, and insurance premiums go up, the number of uninsured increases. To offset the expense associated with treating the uninsured, hospitals increase the bills charged to all of the paying patients. This means that the insurance companies need to pay more to the hospitals. When they get to keep less of the money that they bring in, what do they do? They raise premiums of course, then more people drop their insurance, the hospitals charge more, and the cycle continues without a visible end.

BILLING PROCESS

The hospital billing process is: (a) Preregister or register patients, including scheduling appointments and establishing the patient's account; (b) Establish financial responsibility for visits by explaining the facility's payment policy to patients and verifying their insurance coverage and any precertification requirements; (c) Check patients in by copying their insurance cards and other identification cards, collecting co-pays and/or deductibles, and obtaining the required consents forms, such as a HIPAA Privacy Disclosure and the hospital's Notice of Information Practices; (d) Check patients out, providing them with post discharge care instructions if required; (e) Review coding compliance by checking the accuracy of the diagnosis and procedure codes recorded in the patient's medical record and verifying that they are logically connected; (f) Check billing compliance by collecting the patient's charges accumulated during the hospital stay and verifying them against the charge description master, the patient's medical record, and knowledge of the payer's requirements; (g) Prepare and transmit claims using the facility's patient accounting system, including the use of a scrubber to test claims before transmitting them; (h) Monitor payer adjudication to ensure that bills are paid on time and in full, including claim follow-up and payment processing.

(i) Generate patient statements for remaining balances when health plan payments do not pay the bills in full and for self-pay patients; (j) Follow up on patient payments and handle collections, including writing off uncollectible accounts. The first four steps deal with the patient's visit, the next three steps with the patient's claim, and the final three steps with post-claim activities. During preregistration or registration, the following information is gathered and entered into the patient accounting system to establish the patient's account: personal data, basic billing data, medical information, an account number, and a medical record number.

A routine charge is the total of the costs of all supplies that are customarily used to provide the service. An ancillary charge is made for each specific service that is used to treat the patient in addition to routine charges, such as for anesthesia and blood administration. The charge description master (CDM) is a computerized list of charge codes and associated data for all services the facility offers. Each entry identifies the hospital department and subcategory, the charge code for the service, the description, a medical code (when required), a standard claim form revenue code (RC), and the price. When the codes for services from the various charge slips are entered into the patient accounting system, the code automatically posts the correct charge to the patient's bill.

Billing errors include:

(a) Billing for services or supplies that are not documented in the patient's medical record; (b) Billing for services that are insufficiently documented in the patient's medical record; (c) Billing twice for the same service (double billing); (d) Billing for medically unnecessary services; (e) Billing for services that are included in other charges; (f) Billing inaccurate information about providers or the wrong providers.(i) Generate patient statements for remaining balances when health plan payments do not pay the bills in full and for self-pay patients; (j) Follow up on patient payments and handle collections, including writing off uncollectible accounts. The first four steps deal with the patient's visit, the next three steps with the patient's claim, and the final three steps with post-claim activities.

During preregistration or registration, the following information is gathered and entered into the patient accounting system to establish the patient's account: personal data, basic billing data, medical information, an account number, and a medical record number.

A routine charge is the total of the costs of all supplies that are customarily used to provide the service. An ancillary charge is made for each specific service that is used to treat the patient in addition to routine charges, such as for anaesthesia and blood administration.

The charge description master (CDM) is a computerized list of charge codes and associated data for all services the facility offers. Each entry identifies the hospital department and subcategory, the charge code for the service, the description, a medical code (when required), a standard claim form revenue code (RC), and the price. When the codes for services from the various charge slips are entered into the patient accounting system, the code automatically posts the correct charge to the patient's bill. The advantages of using information technology in the hospital billing process, such as electronic health record (EHR) systems and electronic input devices during the admissions process, are (a) Immediate access to health information; (b) Computerized management of physician orders; (c) Access to research for decision making processes; (d) Automated alerts and reminders; (e) Electronic communications and connectivity; (f) Patient support tools such as patient education on health topics; (f) Administrative reporting tools; (g) Error reduction. The biggest disadvantages are (a) The cost of implementing the system (b) The large learning curve for staff in becoming proficient with the new technology; (c) The potential risk to the confidentiality and security of patient data.

Hospital billing is the process of submitting and following up on claims with the payer (patient, corporate or health insurance companies) in order to receive payment for services rendered by a healthcare provider. To be precise

Step 1 The patient receives services at one of the hospitals.

Step 2 The patient receives an initial statement in the mail that includes visit specific information (see below). - Charges for treatment and/or testing (itemized statement available upon request) - Insurance information, if applicable.Step 3 Hospitals’ Patient Accounting Department begins the billing and collection processes based on insurance information provided at the time of registration. Step 4 If the account balance is not resolved in a timely manner by any insurance company (third party payer), the patient may be billed.Step 5 Patients may receive collection notices or statements from Hospitals’ internal and external collection sources. If a patient requires financial assistance, there are Financial Assistance Programs available for those who meet eligibility requirements.

The Importance of Hospital Billing The medical industry is comprised of many divisions and sections which all work together to offer patients a positive experience. This is true whether services are provided through an emergency care centre, doctor's office or any of the many types of medical help offices available. While many will focus on procedures performed at various hospitals and treatment centers, medical service administrative functions are equally as important, including hospital billing. Hospital billing brings together charges based upon patient stays or procedures performed at a hospital. By coordinating with doctors' offices throughout the community, this financial department can ensure a smooth relationship between doctors and patients. Because the medical billing process can be complicated, it is important for all entities involved to check information and avoid any discrepancies the patient might find.

While many hospitals employ their own accounting departments, the practice of outsourcing accounting services has risen over the years. This practice can save money while offering a more streamlined process to keep errors to a minimum. Outside sources work hard to provide state-of-the-art technology that can keep transaction costs down while eliminating problems such as fraud. Finding a service that can balance the complexity of a medical network can be a cost saving option that is valuable in economic down times.

In order to maintain a smooth accounting process, doctors should be willing to coordinate their own billing practices with the medical community. If they choose not to participate, errors might occur due to inconsistencies between accounting sources. Doctors should consider being on the same system as community hospitals in order to experience the best value for money invested.

Many healthcare practice management companies exist to provide integrated accounts receivable services for medical communities. Offering professional services with highly experienced staff and management, they often provide a group package at considerable savings that can encompass the entire community's needs for consistent accounting and collections. Through proven success with the companies they represent, healthcare billing services enable doctors and medical services to focus on their patients' needs and provide excellent health care.

Medical accounts receivable services will cover all aspects of hospital billing. This includes insurance transactions and follow-up as well as self-pay with follow-up and third-party payments. All aspects of the process will be scrutinized and followed through so that patients can enjoy a more relaxed experience at potentially trying times. Allowing for a more personal patient/doctor relationship, the right hospital billing service can work with the medical community to put an end to financial headaches while making doctors' practices and hospitals' procedures more profitable.

Keeping Finances in Order with Medical Billing Medical billing is extremely beneficial to the business. They can increase profits and productivity, reduce collection times and successfully process claims all while complying with regulations and standard government procedures. Most medical billing caters to a wide range of services. These services typically include statement mailing, workers compensation billing, collection and pre-collection services, payment plan setup and monitoring and credit bureau reporting. A company may also provide patient records services such as transcribing, coding and record storage.

Medical billing should focus on staying up to date with coding, regulations and new technologies that decrease the time spent per account. The staff are courteous, competent and highly successful in the field. They will deal with the headaches caused by insurance company requirements, saving your office from spending the time necessary to handle common errors in an ever-changing system that seems nearly impossible to keep up with. Luckily, since the specialists deal with these scenarios every single day, the amount of errors within the claim are dramatically decreased. Special software will also do a pre analysis guaranteeing that accurate coding will allow the claim to process with no hassles. Code updates are done regularly to maintain accuracy. The paperwork of claims processing is reduced due to electronic recording and storage.

Medical Billing Revenue - Reducing No-Shows When patients miss appointments, they interrupt the flow of patient care and impede clinic productivity. A missed appointment amounts to reduced billing and missed revenue. The rate of no-shows runs at high for the average medical clinic. Worse, if the clinicians are part-time or full-time staff rather than contracted, they sit idle on the company clock. In this case, a missed appointment is not just a missed opportunity for revenue, it's lost money with each passing minute. An effective office manager uses three strategies to protect clinic revenue:

Charge for missed appointment: This strategy works well in terms of no-show reduction for ongoing cases but it is ineffective for missed intakes. Billing full service fees for misses is not possible for procedures covered by medical insurance. In addition, billing insurance companies for services not rendered is a major offence that carries severe disciplinary action including financial penalties.

Minimize no-shows: Recognize that any activity that reduces the frequency of no-shows is a revenue-generating activity. Use down time to:

Make reminder calls for upcoming appointments: It works best when reminders reach the consumers one to three days ahead of their appointments. Note that any degree of success is improved billing and money in your pocket.

Follow up on recent no-shows: Call patients who failed to appear this week, survey them as to the reason for their missed appointment, and reschedule next appointment.

Analyze no-show statistics: Feed missed appointment survey information back into patient scheduling system, alarming about the types of appointments that are most likely to be missed. Use this knowledge to target reminder efforts, or to change scheduling. For instance, waiting time for appointment is related to the likelihood of missing it. Specifically, both very short turnaround times (one to three days) and longer waits (10 to 14 days) are associated with poorer attendance. Waiting periods of four to seven days positively correlate with best attendance.

Overbook: Overbooking is an effective strategy in terms of billing revenue protection. It requires good understanding of your no-show statistics and it rests on the premise of the interchangeability of clinicians. Identify the most vulnerable appointment type in terms of missed revenue and cluster them during periods of the day ("target periods") when you can have a pool of clinicians on site. You can

implement this strategy by scheduling appointments on the quarter-hour rather than the half-hour increments during the target period.

Medical Billing Service - the Services You Can Expect Medical billing services are a blessing to medical practitioners that are hard-pressed for time and resources. They take over the burden of billing and related administrative tasks from the healthcare provider and increase their revenue. Medical billing services are quickly becoming the industry standard because of the many advantages they offer. Medical billing services offer both claim submissions and comprehensive practice management solutions. Generally, small organizations that are either home-based or small scale offer only simple billing services. Larger practice management companies offer comprehensive packages that promise long-term benefits for the practice. These services can offer anything from advertising to scheduling assistance, and much more. Depending on your organizational needs you can hire a provider who offers suitable services. The services are broadly categorized into standard services, extended services and practice management services.

Standard billing services These are the minimum any medical billing provider offers. These include:

Claim submissions: Billing providers use medical billing software to submit claims. The patient demographics, encounter data, and insurance details are entered into the application that is programmed to validate the claim for accuracy. Accurate claims reduce the chances of claim rejection by the insurance company. The validated claim is submitted to the insurance company electronically within 24 hours.

Regular follow-up of claims: This is where medical billing providers prove their mettle. They follow up on the claim aggressively and tenaciously. The medical practice reaps the rewards of this strategy by receiving more payments on time.

Analytical reporting: Billing services capture and project key statistics in monthly reports. The reports can help business heads of the medical practice take steps to improve the growth, productivity and cost-savings in the establishment.

Patient billing and enquiries: Billing services take care of the logistics of the billing function, and assist in patient enquiries.

Extended billing services

These take on responsibilities that are not directly related to the billing process. They include:

Diagnosis and procedure coding: Billing providers do the medical coding for the patient record before it is entered into the medical billing software application. Medical transcription: Medical transcription is done before the medical coding stage. Many billing providers offer transcription as an administrative service. Practice management services These offer holistic services that overhaul the medical practice's administration. Services include: Financial services: Financial services start with claims collections and move on to accounting, tax planning, budgeting, accounts payable and more. Negotiation of contracts: Billing providers have the necessary expertise to effectively negotiate with hospitals and managed care representatives. Medical providers can leave this task to the billing providers with confidence. Human resource services: Medical practices can outsource human resource functions such as payroll, staffing, incentive programs, and employee contracts to medical billing providers. Medical billing services enable medical practitioners to focus and improve on patient care, without worrying about outstanding receivables. Billing services take away the burdensome administrative tasks related to insurance claims and revenue management and promise an increase in revenue.

Simple Medical Billing Process for the Patients Hospital is the place that many people hope to find some cures for their illness. As we know, each day, there are thousands of people that a hospital must handle. As an institutions that involved many systems including some costing systems, the hospital also need some excellent billing services. It's not only about the systems, but it needs the excellent operators too. The billing system in a house is a very complicated system. There are so many kinds of systems that involved and being fused into the billing systems. The medical billing process is something complicated. There are many sectors' billing statements that must be handled by the medical billing systems. The medical billing process is also about many kinds of costing process that involved each departments of the hospital. All those departments billing systems will be integrated to the whole hospital medical systems in a very complex billing process that must be perfectly handled by the hospital's accounting departments. But contrary with the complex medical costing process, the process from the patients must be simplified. It means, the complex process should only happen inside the management and the patients must not have to deal with those complicated systems.

The hospital must make sure that the medical billing process that the patients must deal with is the simple process that will not push them with some complicated systems. The hospital billing process might be the integration of some complex billing systems of many departments in the hospital, but the patients will not necessary to know or feel about it. The patient must only deal with the simple medical billing process that they must pay for the whole medical treatments that they have got from the hospital. That is the way a hospital must run. It will give some comforts to the patients.

Billing Cycle A billing cycle is an interval between bills for products and services. Typically, this interval lasts for one month, and consumers may be able to adjust the timing of their billing cycles to meet their economic needs, depending on the company. Billing cycles are used to calculate things like interest and account standing, and they are an important part of the financial world.

Each bill will include a note specifying which billing cycle is covered by the bill, so that consumers can understand when and why various charges might have been incurred. Products may be billed in a similar way; a consumer may be given 30 days to pay for something, for example, and many retailers rely on a credit system with the wholesalers who send them products. Many people are also familiar with the concept of the billing cycle in terms of financial accounts like credit cards. In the case of a credit card, consumers are charged interest on outstanding transactions from past billing cycles, and they may be charged for failing to pay on an account in a timely fashion, or paying less than the minimum.

In some cases, a company will adjust its billing cycle to meet the needs of clients. If, for example, someone gets paid on the first of the month, he or she may request a billing cycle which runs from the 15th through the 15th, to ensure that bills can be paid on time. The period between billings may also be adjusted to meet the needs of bookkeepers and other company staff who specialize in financial matters for large companies, to ensure that financial staff is not swamped with bills at any particular period of the month. If you are trying to pay down debt and keep your bills organized, you should consider synchronizing your billing cycles to a day which is convenient for you. This can ensure that you never miss a bill, because you can pay your bills all at once. It may also help you keep your finances organized, because you can keep track of the lump sum required to pay all your bills, rather than paying them sporadically throughout the month as they arrive.

Medical Billing in a Nutshell Medical billing is the process by which doctors and hospitals receive payment from health insurance companies. It also involves resolving any disputes and following up on claims that have been delayed or rejected. Medical billing is a complex series of procedures that require a great deal of time by skilled professionals. In fact, large hospitals often have an entire department dedicated to billing. The medical billing process is vital to any health care organisation; hospitals and medical practices cannot operate without payments from insurance companies.

When you visit a doctor's office or a hospital, a detailed record is kept of any tests, procedures, or examinations that are performed in the treatment of your condition. Any diagnoses made by the medical staff are also noted. This is your medical record, and it provides information necessary to the billing process. After you provide your insurance information to the doctor's office or hospital, the medical billing cycle begins.

Before a bill is submitted to an insurance company for payment, it must be coded. During coding, each service or procedure must be given an alphanumeric code based on a standardized system. Some electronic medical billing programs can assign these codes automatically, by pulling information directly from the medical record; however, the bill is often checked manually by a staff person to ensure accuracy. After the coding process is finalized, the bill is transmitted to the insurance company. This is normally done electronically, but in some cases a bill may be sent via fax or standard mail.

When the insurance company receives the claim from the doctor, the information is reviewed to determine whether the patient was covered at the time of service, and whether the treatment is appropriate for the diagnosis submitted. If the procedure or treatment falls within standard and customary treatment for that condition, it is considered medically necessary and the bill is approved for payment. The payment amount will depend on the allowed amount, which varies depending on your particular policy and whether or not your doctor is on a list of network providers. Next, the insurance company will either send the appropriate payment electronically to the health care provider, or send a notice of denial if the claim has not met the standards for payment. In either case, the patient will also be notified of the result of the claim. If the insurance company denies payment, the health care provider will review the claim to determine if it has errors or missing information, make corrections, and resubmit the claim for payment. Medical coding is a very

complex process and data entry errors are fairly common; a claim may be resubmitted to the insurance company several times before it is finally paid. Once the insurance company has paid, the health care provider will then send a bill to the patient for any remaining balance, such as a deductible or unpaid co-pay. Each provider has their own policies about collecting payments from patients. The medical billing department may attempt to collect money from the patient for several years, although many larger hospitals turn old debts over to a collection agency, which frees the billing clerks to concentrate on current billing.

5 Things to Consider for the Right Medical Billing Service A number of factors are important to consider:

Experience: experience makes the man perfect. Hence a well experienced billing system is the efficient one.

Data Protection: Bills submitted should have full audit trial without a delete option. This will protect data in the submitted bill and reduce the possibility of fraud or mismanagement.

Performance and Service: shorter lead times and minimized error rate service should be the motto. An institutionalized process model should be followed. Manage the billing process from A to Z. The process includes, Data entry and submission (the importance of a fast and accurate process management cannot be overestimated; a good service provider will submit the bills within 48 hours of receiving claims), Payment Posting, Patient Billing, and Denial Follow-up.

Location: If the service is outsourced then in today's global economy the possibility of providing billing services on a cross boarder basis is now a reality. While many overseas companies are more than adequate to perform the task, keep in mind that your patient population will frequently interact with your medical billing company.

Reporting: Provide frequent reports to higher management to help track both practice and the billing department’s performance. Based on these 'must haves' the billing department in a hospital must run.

To compare the concordance of family physicians' billing for evaluation and management services with medical record documentation. A Multi-method, cross-sectional observation study was conducted, Evaluation and management services. A comparison of medical record documentation with actual billing in community

family practice. Eighty-four family practices in northeast Ohio were included.

Four thousand fifty-four outpatients visiting 138 family physicians were the participants.

The outcome measure here was the degree of concordance between evaluation and management Current Procedural Terminology codes billed by physicians, with those codes assigned by trained research nurses using American Medical Association criteria to code medical records for the same visits.

The results were found to be discrepancies between the multifactorial nature of family practice outpatient visits and the Current Procedural Terminology coding criteria, which dictate over coding for depth rather than breadth, made coding difficult (multiple-rater kappa statistic between research nurses = 0.36). Among 4137 outpatient visits with complete billing information, 57% of the Current Procedural Terminology codes generated by medical record review were concordant with the actual billing code assigned by physicians. Under coding and over coding occurred at a similar frequency (21% and 19%, respectively) and differed by more than 1 code in fewer than 4% of visits. Visits by new patients were more likely to be inaccurately coded than visits by established patients.

Record documentation by community family physicians largely reflects the level of services billed using evaluation and management codes. Under coding is as common as over coding. Efforts from regulatory agencies should be redirected from penalizing physicians for over coding to focusing on the development of coding criteria that reflect the multifactorial nature of outpatient primary care practice. Moving ahead with another study, Bundled babies and bundled billing: how to properly use the new pediatric critical care codes, which talked about the changing environment and the required change in adapting to the same.CMS introduced new pediatric critical care codes and renumbered neonatal and pediatric critical care Current Procedural Terminology (CPT) codes in January 2009. Unlike the time-based critical care codes used for adult care, services for many children use bundled codes for all critical care services by a single physician during a calendar day. New codes have been added for 24- to 60-month old children. CPT codes for critical care of neonates and children 28 days to 24 months were renumbered. This article discusses the changes and the impact on physicians providing critical care services.

The complexities associated with the coding, billing, and reimbursement process seem to increase daily.

Keeping abreast of the changes in this environment is, to say the least, a challenge. Coding and billing for gastrointestinal endoscopy, explains to succeed in today's billing environment the gastroenterologist should surround his or her practice with staff, resources, and education.

Experienced skilled staff, preferably a certified professional coder should be employed. Certified coders bring advanced coding skills to one’s practice, which allows increased proficiency with the coding and billing process. Provide the necessary resources for staff. Current coding material is crucial to the financial success of the practice. CPT-4, ICD-9, and Correct Coding Guide are the bare basics of the resource material available to staff. Maintaining a library of resource material (i.e., Medicare bulletins, managed care newsletters, and so forth) aids the staff with the necessary tools to carry out their duties. In addition, specific gastroenterology coding subscriptions are available to assist in staying ahead of the ever-changing billing and coding environment.

Continuing education in the billing and coding process for both the physician and staff is essential. Numerous workshops are offered periodically. It is imperative that staff attends all Medicare-sponsored workshops in addition to gastroenterology-specific coding seminars. More and more physicians are now aware of their responsibility in the billing process and have begun to participate in the coding education along with their staff. This is a significant indicator of a physicians' intent to have a compliant and financially successful practice.

Insurance has proved itself to be a boon for many patients but how does it serve the clinical care providers?Here is a study showing how much time and cost is incurred by the clinical care providers while being the interface between the patient and the policies, What Does It Cost Physician Practices to Interact with Health Insurance Plans? , explains Physicians have long expressed dissatisfaction with the time they and their staffs spend interacting with health plans. However, little information exists about the extent of these interactions. We conducted a national survey on this subject of physicians and practice administrators. Physicians reported spending three hours weekly interacting with plans; nursing and clerical staff spent much larger amounts of time. When time is converted to dollars, we estimate that the national time cost to practices of interactions with plans is at least $23 billion to $31 billion each year. Varied diagnosis, varied treatment, varied patients so is varied process and procedures. A standard streamlined process will help managing the cost incurred.

An article named, Addressing medical coding and billing part II: a strategy for achieving compliance. A risk management approach for reducing coding and billing errors, explains Many physicians rely on office staff and billing companies to process their medical bills without ever reviewing the bills before they are submitted for payment.

Some physicians may not be receiving the payment they deserve when they do not sufficiently oversee the medical practice's coding and billing patterns. This article emphasizes the importance of monitoring and auditing medical record documentation and coding application as a strategy for achieving compliance and reducing billing errors. When medical bills are submitted with missing and incorrect information, they may result in unpaid claims and loss of revenue to physicians. Addressing Medical Audits, Part I--A Strategy for Achieving Compliance--CMS, JCAHO, NCQA, published January 2002 in the Journal of the National Medical Association, stressed the importance of preparing the medical practice for audits.

The article highlighted steps the medical practice can take to prepare for audits and presented examples of guidelines used by regulatory agencies to conduct both medical and financial audits. The Medicare Integrity Program was cited as an example of guidelines used by regulators to identify coding errors during an audit and deny payment to providers when improper billing occurs. For each denied claim, payments owed to the medical practice are are also denied. Health care is, no doubt, a costly endeavor for health care providers, consumers and insurers. The potential risk to physicians for improper billing may include loss of revenue, fraud investigations, financial sanction, disciplinary action and exclusion from participation in government programs. Part II of this article recommends an approach for assessing potential risk, preventing improper billing, and improving financial management of the medical practice.

CPT (current procedure terminology) coding and patient accounting: controlling the process andimproving billing efficiency, explains as outpatient volumes increase in hospitals across the country, more and more coding responsibilities are being placed with the patient accounts department. Both registration and outpatient billers are involved in assigning current procedural terminology (CPT) codes for surgery and emergency room procedures, as well as maintaining the hospital's charge master. Often these responsibilities are assigned without regard for the level of coding expertise and degree of clinical knowledge of the personnel involved, which can lead to significant loss of reimbursement and untimely billing delays.

This article addresses common problems and offers suggestions for improving coding, minimizing problems, and increasing billing efficiency.

In 21stcentury it is all about the image you carry among your customers which finally leads to the brand value and hospitals are on the run for the same. Traditionally this run included the uplifting of the major aspects of the hospital but today even billing has become a part of it.

Averting Expected Challenges through Anticipatory Impression Management: A Study of Hospital Billing, talks on the same lines.

Existing theory and research on organizational impression management focuses on how spokespersons use remedial tactics, following image-threatening events, to put their organization in the best possible light.

By contrast, little theory or research has considered how organizations use impression management tactics to avert undesirable responses to upcoming events. This paper uses a qualitative and inductive study of billing procedures at three large hospitals to develop theory about how organization members use impression management tactics to fend off specific, expected challenges to organizational practices that are ambiguously negative. We found that hospitals use anticipatory impression management tactics to: (1) Distract, diminish, or overwhelm patients' attention to hospital charges; and (2) to induce emotions that lead patients to simplify their information processing of those charges. Hospitals appear to use such anticipatory obfuscations both to fend off patients' initial challenges and to prevent their existing challenges from escalating. We discuss these findings in terms of their contributions to theories of symbolic management, social influence, and routine service encounters.

BILLING AND QUALITY

Tomorrow's hospital will be the lean hospital, quality of care, better service and more control overbudget will be the standard not the exception. Reducing the percentage of non-value-added work by simply aligning their technology needs, hospitals quality levels can improve and significant cost savings realized. Increasing efficiency may be one approach to achieving this goal, but ultimately you need a system that can expedite care.

Key Principles for Hospitals from Toyota's Lean Production System throws light

on the same aspect. Which can be taken up for the healthcare industry as well?

The Toyota Production System, which was developed from the late 1940s through the mid-1970s by top Toyota executives to improve the company's manufacturing processes, is now used by numerous companies across various industries to reduce inefficiencies and improve the overall value of their end product to customers. Although originally developed for the manufacturing industries, the key goals of lean production — eliminating waste, valuing employees and continually improving — can be applied to service providers, such as hospitals.

"One thing that hospitals need to keep in mind regarding lean processes is that it is an approach to management, a philosophy for improving and leading organizations," says Mark Graban, senior fellow at the Lean Enterprise Institute and author of Lean Hospitals. "[Hospital leaders and clinicians] will have concerns about how this transfers to healthcare, but the key management practices are very transferable."

Six sigma process

Six Sigma is a set of strategies, techniques, and tools for process improvement. It was developedby Motorola in 1986. Six Sigma became famous when Jack Welch made it central to his successful business strategy at General Electric in 1995. Today, it is used in many industrial sectors.

Six Sigma seeks to improve the quality of process outputs by identifying and removing the causes of defects (errors) and minimizing variability in manufacturing and business processes. It uses a set of quality management methods, including statistical methods, and creates a special infrastructure of people within the organization ("Champions", "Black Belts", "Green Belts", "Yellow Belts", etc.) who are experts in the methods.[5] Each Six Sigma project carried out within an organization follows a defined sequence of steps and has quantified value targets, for example: reduce process cycle time, reduce pollution, reduce costs, increase customer satisfaction, and increase profits.

The term Six Sigma originated from terminology associated with manufacturing, specifically terms associated with statistical modeling of manufacturing processes. The maturity of a manufacturing process can be described by a sigma rating indicating its yield or the percentage of defect-free products it creates. A six sigma process is one in which 99.9999998% of the products manufactured are statistically expected to be free of defects (0.002 defective parts/million), although,

as discussed below, this defect level corresponds to only a 4.5 sigma level. Motorola set a goal of "six sigma" for all of its manufacturing operations, and this goal became a by-word for the management and engineering practices used to achieve it.

Doctrine

Six Sigma doctrine asserts that:

Continuous efforts to achieve stable and predictable process results (i.e., reduce process variation) are of vital importance to business success.

Manufacturing and business processes have characteristics that can be measured, analyzed, controlled and improved.

Achieving sustained quality improvement requires commitment from the entire organization, particularly from top-level management.

Features that set Six Sigma apart from previous quality improvement initiatives include:

A clear focus on achieving measurable and quantifiable financial returns from any Six Sigma project.

An increased emphasis on strong and passionate management leadership and support.

A special infrastructure of "Champions", "Master Black Belts", "Black Belts", "Green Belts", etc. to lead and implement the Six Sigma approach.

A clear commitment to making decisions on the basis of verifiable data and statistical methods, rather than assumptions and guesswork.

The term "Six Sigma" comes from a field of statistics known as process capability studies. Originally, it referred to the ability of manufacturing processes to produce a very high proportion of output within specification. Processes that operate with "six sigma quality" over the short term are assumed to produce long-term defect levels below 3.4 defects per million opportunities (DPMO). Six Sigma's implicit goal is to improve all processes, but not to the 3.4 DPMO level necessarily. Organizations need to determine an appropriate sigma level for each of their most

important processes and strive to achieve these. As a result of this goal, it is incumbent on management of the organisation to prioritize areas of improvement.

Six Sigma is a registered service mark and trademark of Motorola Inc. As of 2006 Motorola reported over US$17 billion in savings from Six Sigma. Other early adopters of Six Sigma who achieved well-publicized success include Honeywell (previously known as AlliedSignal)

and General Electric, where Jack Welch introduced the method. By the late 1990s, about two-thirds of the Fortune 500 organizations had begun Six Sigma initiatives with the aim of reducing costs and improving quality.

In recent years, some practitioners have combined Six Sigma ideas with lean manufacturing to create a methodology named Lean Six Sigma. The Lean Six Sigma methodology views lean manufacturing, which addresses process flow and waste issues, and Six Sigma, with its focus on variation and design, as complementary disciplines aimed at promoting "business and operational excellence". Companies such as GE, Verizon, GENPACT, IBM and Sandia National Laboratories use Lean Six Sigma to focus transformation efforts not just on efficiency but also on growth. It serves as a foundation for innovation throughout the organization, from manufacturing and software development to sales and service delivery functions.

The International Organisation for Standards (ISO) has published ISO 13053:2011 defining the six sigma process.

Methodologies

According to Vinay T Belagala, a famous Marketing Analyst, Six Sigma projects follow two project methodologies inspired by Deming's Plan-Do-Check-Act Cycle. These methodologies, composed of five phases each, bear the acronyms DMAIC

DMAIC is used for projects aimed at improving an existing business process.

DMAIC

The DMAIC project methodology has five phases:

Define the system, the voice of the customer and their requirements, and the

project goals,specifically.

Measure key aspects of the current process and collect relevant data.

Analyze the data to investigate and verify cause-and-effect relationships. Determine what therelationships are, and attempt to ensure that all factors have been considered. Seek out root cause of the defect under investigation.

Improve or optimize the current process based upon data analysis using techniques such as design of experiments,poka yoke or mistake proofing, and standard work to create a new, future state process. Set up pilot runs to establish process capability.

Control the future state process to ensure that any deviations from target are corrected beforethey result in defects. Implement control systems such as statistical process control, production boards, visual workplaces, and continuously monitor the process.

Is Health Care Ready for Six Sigma Quality, Is quite a question now.

A particular study explains it as follows.

Serious, widespread problems exist in the quality of health care: too many patients are exposed to the risks of unnecessary services; opportunities to use effective care are missed; and preventable errors lead to injuries. Advanced practitioners of industrial quality management, like Motorola and General Electric, have committed themselves to reducing the frequency of defects in their business processes to fewer than 3.4 per million, a strategy known as Six Sigma Quality. In health care, quality problems frequently occur at rates of 20 to 50 percent, or 200,000 to 500,000 per million. In order to approach Six Sigma levels of quality, the health care sector must address the underlying causes of error and make important changes: adopting new educational models; devising strategies to increase consumer awareness; and encouraging public and private investment in quality improvement. Now moving on to the learning from examples let us see“5 Tips for Applying Six Sigma from Three Top Hospitals by Elaine Schmidt “.Six Sigma leaders from three of America’s premier healthcare institutions (The Johns Hopkins Hospital, Mayo Clinic and New York-Presbyterian Hospital) recently shared their experiences with iSixSigma Magazine method in order to improve operations and, ultimately, patient care. They also offered the following

advice for hospitals considering deployments of their own.

1. Diagnose Your Environment

Laura Winner, a deployment leader at Johns Hopkins, advised that anyone contemplating a Six Sigma deployment in a healthcare environment “really think about the culture you live in. There’s not one approach that’s going to work for everybody. If you are in a community hospital, for instance, you might be able to do a top-down deployment,” she said.

“If you’re in an academic hospital that’s big and decentralized, you may need to figure out where you’re going to get resistance and what would work best for you.”

Deployment at Johns Hopkins, through a blend of Lean Six Sigma and Six Sigma called Lean Sigma, has not been top down. Training is available to the front-line staff, including nurses, physicians and administrators, all of whom apply the improvement method while remaining in their regular positions.

2. Consult the Process Owners

Master Black Belt Mary Cramer said that part of New York-Presbyterian’s success, including a project that significantly reduced variance on length of stay at the hospital, has come from involving the experts of any given area in the project. “Six Sigma is data driven and evidence based,” she said.

“Clinicians are scientists. When we demonstrate that the data are valid and that we have gone through rigorous methods to collect and analyse the data, then we’ve got them.”

Cramer, however, says that process owners also know when to put the brakes on certain projects:

“What we are suggesting may not actually be an issue. We get the VOC [voice of the customer] from those close to the processes.”

3. Don’t Beat the Money Drum

“Don’t get into it just to save money,” Johns Hopkins’ Richard Hill said. Healthcare professionals are motivated more by issues of patient safety and providing quality care.

Johns Hopkins, for instance, adopted Six Sigma in 2001 after the death of a pediatric patient due to medical error. According to Deployment Leader Winner, the hospital aligns project priorities with the Institute of Medicine’s aims of safety and efficiency.

4. Operate with the Right Tools

“You can use a stethoscope for a tourniquet,” Todd Billie, a planning analyst at Mayo Clinic, said. “But it’s probably better for listening to the heart. You have to have a certain amount of flexibility to use the right [improvement] tool at the right time.”

Mayo Clinic combined elements from Six Sigma, Lean Six Sigma and other methodologies to create its own program, called the Mayo Quality Academy. Using their training from this program, the staff was able to decrease the average time between a patient’s initial contact with the Clinic’s transplant centre and setting an appointment from 45 days to 3 days.

5. Practice Your Bedside Manner

Winner said it’s important to make clear to hospital staff members that freeing up some of their time through the improvements created by a Lean Sigma project is not going to mean a head reduction. “You need to reassure employees that you will find value-added activities to fill the time you’re freeing up.”

The application of six sigma in healthcare services is relatively new topic and very little researches been performed in this area. The paper, an overview of six sigma applications in healthcare industry, is extremely valuable to researchers and practitioners who are currently engaged in six sigma research.

Delays, measurement and medical errors and variability often undermine the delivery of safe, effective patient care. However, it is possible to minimize them by applying six-sigma. This methodology aims to focus on the root causes of healthcare problems, analyses them by flowcharts and fishbone diagrams and produces near-perfect healthcare services.

Five case studies in healthcare were designed to show the performance improvement accomplished by six sigma. The DMAIC (Define-Measure- Analyze-Improve-Control), i.e. a road-map for problem solving and service/process

improvement, is implemented.

The findings in this paper show that the healthcare organization has a greater ability to address challenges across the system. Resource utilization has been maximized. Fewer redundancies, waste and rework have been observed. Bottle-necks related to scheduling have diminished. Working conditions have improved for healthcare personnel. Increased patient and physician satisfaction as well as cost savings have been achieved. These will enable the healthcare organization to increase its market share in the long run.

L ean Six Sigma methodology has been used to improve care processes, eliminate waste, reduce costs, and increase patient satisfaction.

At the end it all boils down to the money. Non retrieval of money on hospital business is one of the big problems.

Applying six sigma to the same and improving the process is the aim here in this article, Six sigma for revenue retrieval, Deficiencies in revenue retrieval due to failures in obtaining charges have contributed to a negative bottom line for numerous hospitals.

Improving documentation practices through a Six Sigma process improvement initiative can minimize opportunities for errors through reviews and instill structure for compliance and consistency. Commitment to the Six Sigma principles with continuous monitoring of outcomes and constant communication of results to departments, management, and payers is a strong approach to reducing the financial impact of denials on an organization's revenues and expenses.

Using Six Sigma tools can help improve the organization's financial performance not only for today, but also for health care's uncertain future. Satisfying your customer and earning good money is the basic motto of any business.

Operational research is a vast and grand tool to solve many of the aspects of operations. Queuing theory is one of them. There are many instances where queuing can be used to help understand the problem like waiting time, idle time, service time etc. here is one article explaining the scope of queuing in healthcare scenario. And hence the same can be implemented in billing department as well. A survey of queuing theory applications in healthcare is one such study.

This paper surveys the contributions and applications of queuing theory in the field

of healthcare. The paper summarizes a range of queuing theory results in the following areas: waiting time and utilization analysis, system design, and appointment systems. The paper also considers results for systems at different scales, including individual departments (or units), healthcare facilities, and regional healthcare systems. The goal is to provide sufficient information to analysts who are interested in using queuing theory to model a healthcare process and want to locate the details of relevant models.

METHODOLOGY / PROCEDURE OF THE STUDY:

a)AREA OF THE STUDY: Hospital industry, operations, billing department

b)PLACE OF STUDY: Columbia Asia Hospital and research centre, Mumbai.

c) POPULATION:

50 bills were considered for the time and motion study.

For the establishing the error pattern for the arrival of bills and such retrospective scenarios, around 50 bills were considered.

Further parts of the study are not population oriented rather system oriented.

d) UNIT OF STUDY: The outpatient bills generated by the hospital.

e) PERIOD OF STUDY: 10thmay 2014- 10thJuly, 2014.

f) RELIABILITY OF DATA: Authenticated bills generated by the hospital and personalobservation.

g)RESEARCH QUESTION:

Is the current process functioning efficiently and deprived of any non-value adding steps.

Is the man power available utilized properly.

Is the sigma rate of performance satisfactory?

Is the process having any expenditure leak which can be mended?

h) METHODOLOGY OF THE RESEARCH:

The study conducted was a retrospective study

The process of billing was understood and a flow chart was prepared.

The delay and non-value adding steps in the processes were marked. Certain problem areas were found during the observation of the process.

A time and motion study of the process was carried out by taking a sample of 50 patients bill processing at the OPD.

The above image depicts the flow process chart of the billing process and order entries at the out-patient department of Columbia Asia Hospital,Pune.

The data and the scenario were analyzed and the recommendations were given

After studying the whole process of the billing I could arrive at the following conclusion regardingthe problem areas.

THE PROBLEMS ARE STATED WITH THEIR ERRORS IN THE TABULAR FORMAT ATTACHED BELOW.

SR. NO. PATIENT NAME

TIME TAKEN FOR OPD BILLING (IN MINUTES)

REASONS FOR DELAYTYPE OF ERROR (I.T/PROCESS)

1 VISHNU RAO PARIT 2 NA NA

2 PRADEEP M DHUMAL 3.5SYSTEM ERROR AS VISIT WAS NOT ACTIVATED FROM REGISTRATION COUNTER

IT

3 PRAVEEN R. 1 NA NA

4 MEENAKSHI N. 3.5

INTERRUPTION FROM ANOTHER COLLEAGE REGARDING SOME INFO. FROM ANOTHER OPD STATION

PROCESS

5 UMA MALAYA 2 NA NA

6 ANJALI CHINURKAR 3.5 CTRL + P NOT WORKING FOR PRINT OPTIONS IT

7 ARYAMAN SHARMA 2 NA NA8 NAMIT KUMAR 2 NA NA9 SAGAR RUKE 2 NA NA10 ANDREA DAS 2 NA NA

11 VAIDYANATH SAWANT 2 NA NA

12 ROGER MENEZES 2 NA NA13 RANTIDEV SINGH 2 NA NA14 ANSUYA DORAJEE 2 NA NA15 VIDYA KHATARKAR 2.5 NA NA16 VIMLA DUBEY 2.5 NA NA

17 KANTILAL RD 4.5

DELAY IN BILLING SINCE THE PATIENT IS 63 YRS. OLD HENCE WAS NOT INFORMED ABOUT SENIOR CITIZEN DISCOUNTS BY FRONT DESK

PROCESS

18 ARYAN SHARAN 10 + DELAY DUE TO SOME CONFUSION AS SOME REFUND TO BE ADJUSTED AS INFORMED BY CUSTOMER CARE EXECUTIVE

IT

BUT THE SYSTEM SHOWED NO SUCH OUTSTANDING

19 SATISH KUMAR 4.5+SINCE TAKING THE FINAL BIL L OF IN PATIENT ADMISSION CHARGES N DISCHARGE SUMARY

PROCESS

20 PALLAVI MALLARI 2 NA NA21 JAYANT PRASSANA 2 NA NA22 SURABHI NAG 2 NA NA

23 NIHARIKA 3.5 DELAY DUE TO UNAVAILABILITY OF CHANGE (Rs.32) PROCESS

24 COL.A.K SHARMA 2 NA NA25 PALLAVI KOKIL 2 NA NA26 SUKANITA DAS 2 NA NA27 AMIT KANSAL 3 NA NA28 MUKUL SRIVASTAVA 2 NA NA

29 HYORIM LEE 5+ DELAY SINCE PATIENT IS A FOREIGNER-LANGUAGE BARRIER PROCESS

30 SAKI PARK 3 DELAY COZ PT.DID NOT KNOW MRN NO. PROCESS

31 SWATI WADHWA 2 NA NA32 NIRANJAN NAMJOSHI 1 NA NA33 NITIN PARAJALE 1 NA NA34 AMRIT GUPTA 2 NA NA

35 KARTHIK THANGAMELU 2 NA NA

36 VIKAS KHARE 2 NA NA37 MADHUMATA 2 NA NA38 RANJANA LAAD 2 NA NA39 KIRAN KUMAR 2 NA NA40 SUPARNA MANNA 2 NA NA41 RATI KURSE 2 NA NA

42 KINSHUK SHARMA 4.5

DELAY COZ CHEQUE HAD TO BE GIVEN BACK AND THAT TOOK TIME COZ OF SIGN FOR APPROVAL

PROCESS

43 RANBIR ZUTSHI 5+DELAY COZ CHILD RAN AWAY WITH THE MEDICINES TO BE BILLED FOR.

PROCESS

44 RAJASHREE M.GAIKWAD 7+

DELAY DUE TO WRONG SURNAME UNDERSTOOD (V INSTEAD OF M)SO THE CASHIER HAS TO CALL REGISTERATION COUNTER WHETHER VISIT ACTIVATED AND WHETHER PHARMACY GAVEPRESCRIPTION TO CORRECT PATIENT

PROCESS

45 SANJUKTA BHATTACHARYA 4+

DELAY DUE TO CALL FROM OTHER NURSING STATION FOR THE ADJACENT CASHIER

PROCESS

46 GIRISH DESALE 2 NA NA47 KOMAL JOHARLE 2 NA NA

48 MEENA VOHRA 10+

DELAY DUE TO COLLECTION OF SOME PREVIOUSLY PAID BILLS YET HAD TO WAIT FOR ALMOST AN HOUR DUE TO RUSH AT THE COUNTER

PROCESS

49 KESHIA GOVILA 5+DELAY AS PRINTER CARTRIDGE GOT OVER SO HAD TO BE REPLACED

IT

50 TURNA MITRA 4.5DELAY DUE TO PT. HAVING SOME CONFUSION SO DISCUSSING IT WITH SPOUSE

PROCESS

IT PROCESS NA0

5

10

15

20

25

30

35

40

TYPES OF ERROR FOR 50 PATIENTS

TYPE OF ERROR FOR 50 PATIENTS

From this, we can interpret that for 34 people the type of error is not applicable since the billing at OPD takes place well within 2-2.5 min(from observation) while for 7people it is IT related and 9 people it is process related.

TYPE OF ERROR FOR 50 PATIENTS

ITPROCESSNA

From this, it can be interpreted that for 68% of the patients type of error was not applicable while for 18% it was process related and for 14% it was I.T related.

0 to 1 mins 1 to 2 mins 2 to 3mins 3 to 4 mins 4+ mins0

2

4

6

8

10

12

14

16

18

20

TIME TAKEN FOR OPD BILLING OF 50 PATIENTS

TIME TAKEN FOR OPD BILLING OF 50 PATIENTS

From this,it can be interpreted that the maximum no. of patients i.e. 19 took 1to 2 minutes for OPD billing and the minimum no. of patients i.e 3 took less

than 1minute for OPD billing.

TIME TAKEN FOR OPD BILLING OF 50 PATIENTS

0 to 1 mins1 to 2 mins2 to 3mins3 to 4 mins4+ mins

From this, it can be interpreted that 38% of the patients took 1-2 min, 24% of the patients took 2-3min, 12% took 3-4min, 20% took more than 4min and 6% 0f the patients took less than 1min.for OPD billing.

SAMPLING TECHNIQUE: Simple random sampling method was followed for the data collection. In probability sampling, the sample is selected in such a way that each unit within the population has a known and equal probability of being selected.

SCHEDULE:

17 th May- 22 nd May - understanding the workflow, process mapping and observation.

23 rd May- 30 th May - problem statement finding

31 st May- 15 th June - data collection

15 th June- 30 th June - data analysis, data collection (if required)

1 st July- 10 th July - report writing, compilation and submission of report.

Above stated schedule included an extensive interaction with the guide at every step and his approval regarding the same.

FINDINGS AND DISCUSSION:

a) In terms of the Process improvement

Introduction: According to the guidelines the billing process has to be completed in 2-2.5minutes. Study was conducted to find out the time taken for the completion of the process and hence to the non-value added steps and unwanted delay in the process were marked.

Study:

A time and motion study has been conducted by taking a sample of 50 bills to find out the total time taken in the process.

Although the process is taking less than 3 minutes we can still think of eliminating the delay as there is a scope of improvement and certain man-power which can be replaced by technology.

Solutions:Billing clerks

There is definitely wastage of man-power but we cannot ignore the fact that due to the pattern of job availability that is the arrival of bills is concentrated at one point of time and the job demands an immediate action where there is no question of delay we cannot think about the reduction of man power.

So the only feasible solution is making the billing clerks multitasking and giving them other clerical tasks that do not ask for a time restriction and can be done in the time when there is no bills to be processed.

Now such work in the billing department are o Credit and TPA letter covering (OP) o Credit and TPA letter covering (IP) o IP credit and TPA letter and cheque verification

Leave management Though there are 9 billing clerks but due to the leave availed by them at one point of time the availability is reduced, hence the leave management is seen to be an issue which can be looked upon by the billing manager.

Change in shifts The current shift allocation adds up man-power at 12pm whereas the workload starts reducing then onwards hence a change in the shifting pattern can be considered. Where the duration of the shift can be reduced to 4 hours instead of 8 hours with a lower pay amount and the shift of 12pm-8pm can be changed into 4pm-8pm .

SUGGESTED ALLOCATION

SHIFTS NUMBER OF CLERKS8am-4pm 29am-5pm 310am-6pm 34pm-8pm 1

CONCLUSION:

To conclude, I would say that the above study has been done over a period of two months utilizing certain operational research tools resulting to the estimation of non-value adding steps in the process, man-power utilization and allocation, error rate in the processing of billing and certain adaptations in the system.

LIMITATIONS OF THE STUDY:

Human error Sampling error Consideration of ideal case scenario and maximum utilization of resources .

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Annexure : Questionnaire

1. Demographics

Name of Patient :Age : Gender : M/FRegistration No :Occupation :

2. How did you come to know about our Hospital ?

a) Doctors Referral b) Recommended by other patients or relatives or friends c) Websited) News paper advertisement or TV Advertisementse) Other (Please Specify)

3. How was first appointment taken ?a) Personally visited for inquiry b) Realtives came to inquiryc) Telephonic inquiryd) Directly came without appointment

4. First visit detailsFrom your place of residence –How did u come to hospital ?

5. Time taken for registration Process ?a) Less than 5 minutes b) 5-10 minutesc) 10-20 minutesd) More than 20 minutes

6. Waiting time to see doctors ?Time to see consultant:

a) Less than 15 minutesb) 15 minutes to 1 hourc) 1 hour to 3 hoursd) > 3 hours

7. In thi I was interested to know was the waiting area comfortable for patients and their relatives ? Whichfacilities are currently available ? And is there anything that needs to be improved or added ?

a) Do you find the waiting area comfortable ?b) Yes/ NO ( please give your comments if any )c) What facilities are available ?

1) Comfortable chairs or beds ?2) Water , tea or coffee machine ?3) Fans, lights & ventilation ?

8. What you normally do while waiting ?This was again a open ended question and many people said – that they just wait and do nothing , other than thinking about – how much more time ?

9. What would you prefer to do during the waiting time ?a) Read books or magazines b) Watch informative CD, or Presentationsc) Watch cartoons or light programsd) Relax or sleep e) Other than this (Please Specify)

10.Were you informed about your waiting number or current status or doctor’s arrival timw , or expected waiting time ?

a) Always b) Most of the times c) Only when asked d) Never