Need of Change to Run the Business

Time For Change

ways to implement change
Possible challenges faced by the management that limit the ability to run the business better. Knowing where or what to change is only the first and simple step in the exercise. Just an analysis of the situation would be of no use. There is always a need to move towards making this change.

To quote Karl Marx -

"The philosophers have interpreted the world in several ways; the point though is to change it."

Facts
Before pondering upon several options that can be taken care, it is important to understand a few facts:

1. A majority of those among the management believe that problems are attributable to people in an organisation. The fact though is that over 90 per cent of all problems are due to the processes. Only 10 per cent is attributable to the people.

2. The person owning the process has the authority to change it, usually top management in an organisation.

3. It therefore obviates the necessity to work actively on processes and not people. Changing processes requires one to have a thorough understanding of its impact. It is also necessary to be responsible and accountable for it.

4. Changing a process requires every person responsible to be taken into confidence. This is probably the most difficult part of the process.

5. Keep in mind that about 10 per cent of the problem is attributable to people - it may, however, have a far greater impact on processes to be ignored. The fact therefore is that change management sometimes does require you to "change the management".

6. Making a change in your organisation is not a magic bullet. At no stage can one allow the current systems to stop working without an alternative one being put in place. In a hospital environment, therefore, change needs to be initiated without disrupting the present system. This requires one to follow a method of evolution or making one change at a time, and waiting for it to stabilise before making another. Any attempt at drastic change can only be doomed to failure. It must therefore, be evolutionary in nature.
There are essentially four questions we must ask before bringing about the change contemplated. Why is it necessary to change and what needs to be changed? And if change has to be implemented, what should it be changed to? Finally, how would one go about doing this?

Methodology
Way back in the early 1950s, a physicist and statistician, W Edwards Deming evolved a methodology for business process improvement that came to be known as the the Deming Cycle. His method was one of the continuous improvement process. This is also known as the PDSA cycle - plan, do, study and act. It seems quite simple and obvious until we look at the elements that go into each of these components.

Using the Deming Cycle
The components of the Deming cycle indicate the steps required to be taken in the process of making the change. Though it is not simple math, it is no rocket science either. The following paragraphs outline the steps involved in the PDSA cycle:

Plan - The first stage requires establishing objectives and processes that are required to deliver the desired end result; the focus of the entire plan. All specifications, policies, practices, procedures and other aspects that may need change must be formally listed. An exhaustive list and accuracy of detail should be a part of the plan.

Do - The second stage requires one to carry out changes taking small steps at a time to examine its impact on the results. Every aspect of the process will have to undergo change in line with the overall plan, and not be limited to individual functions, departments or activities. The correlation between each part of the plan and its implementation is extremely crucial to its success.

Study - The third stage requires one to formally study the impact this change would bring. Often, whenever change is put in place, there could be some volatile fluctuations in its results. Such impact of any change that one makes to the system is not abnormal. One of the most dangerous things to do when one observes such fluctuations is either to revert to the older system, or try to take immediate corrective action. But, it should be kept in mind that the results now seen are based on a small sample. Trying to correct a system at such a nascent stage often leads to changes that are even more abnormal than what one started with.
Therefore one should ensure that the process has stabilised before reviewing it or studying its impact. Depending on the magnitude, carry out the study every day, or over a one-year period. For instance, if the change is to impact patients' waiting time in a queue, it is best assessed every day. If, it is to impact the capital structure of the organisation, it is better to review it only after a significant time has elapsed; say six months to a year. It is also important to study the impact not merely as visible numbers of the results, but to try assess the non-measurable, qualitative changes that have resulted from the processes.

Act - In the final stage, one needs to understand with clarity the impact that should be made by using the new standard. It is worth taking a relook at the plan, the method by which it was acted upon, and the end results as seen by stakeholders. One may also need to guage the success and failure involved in the process.

Warning Signs and Mirages

The most important aspect that the management often misinterprets is in involving people in the change process. It is often understood to mean that they communicate with everyone through slogans, posters and notices. This is probably the worst form of communication. They seldom serve any purpose and often have no, or at best negligible impact, on the results in a coprporate setting. It is better to communicate the changes formally through short daily meetings, highlighting the achievements and progress.

The second aspect is not to go by visible figures alone as the basis of evaluating any change. It is often the invisible part of change that is far more important than the visible component.
The third aspect is never to reward or punish people based on short-term results. There have been numerous cases of people working their way around the system rather than working for the system. The biggest reward for individuals in such cases are rarely monetary. These are usually best offered in the nature of being duly recognised as a leader of the group, or appointment to a job suited to the person's aspirations. It could even be a small memento declaring the good work carried out.

And Finally we can conclude...

The journey of change has begun. As the clichéd proverb goes - the only constant is change. While embarking upon this journey, it is often not the destination, but the journey which is important. If you do things even reasonably right, it will lead you to your destination eventually. But, what you might find on this journey is that somewhere the gradient gets too steep or you are running into uncharted territory, and at this stage you may find it difficult to proceed.
I recollect a famous quote often used in rural India, which roughly translates as - "The first time is always a big issue, every subsequent time it is monkey business!" It is therefore necessary to look for help, the first time, but for that expert who has been through this several times before, it is monkey business. Would you be able to make it to the next stage of the journey? There are three facets to it - a Yes, a No and a Maybe. Yes, because failure may not be the only option and help is always available. No, because it is not a question of getting there eventually, but within a timeframe. Time and competition will not wait for you to catch up.
And the Maybe quotient; because you may be already far too deep in the water than you imagined. Getting out of the current mess may be far more difficult than thought. There may be a way out but the "cost" may be far too much to swallow. Henceforth, we should empower ourselves to l address the question of "What to do? When?"

Guide to NABH Accrediation

A brief guide for healthcare providers who wish to go for NABH accreditation.
Having gone through the rigorous assessors training for National Accreditation Board for Hospitals & Healthcare Providers (NABH), I understand how demanding the standards are. Moreover, as NABH is very recent, doubts persist over explanation and application of various objectives of the NABH standards. Here I am trying to elaborate few NABH standards.
.2.
Patient and family rights, support individual beliefs, values and involve the patient and family in decision making processes.
Objective Elements
2. A. Patient and family rights include respect for personal dignity and privacy during examination, procedures and treatment.
Explanation: To ensure that inappropriate (revealing/short/broken buttons etc) patient gowns are not in circulation. Right size of gown to be given to the patients. Dignity for the patient to be observed even when the patient is semi/unconscious, while shifting the patient, etc.
2. G. Patient and family rights include information on how to voice a complaint.
Explanation: There should be a mechanism for receiving verbal complaints from the patients/their relatives. Methods could include feedback forms, suggestion boxes etc.
2. H. Patient and family rights include information on the expected cost of the treatment.
Explanation: There should be evidence by way of patients'/admitting relatives' signature that he/she has understood the encumbrances and possible increase in costs depending on further care requirements of patient.
COP.2
Emergency services are guided by policies, procedures, applicable laws and regulations.
Objective Elements
COP.2 B. Policies also address handling of medico-legal cases.
Explanation: Local laws and guidelines also have to be considered while handling medico-legal cases. Medico-legal cases should be intimated to the local police station immediately.
COP.3
Ambulance services are commensurate with the scope of the services provided by the organisation.
Objective Elements
COP.3 A. There is adequate access and space for the ambulance(s).
Explanation: Easy turnaround of vehicle is a must, and ramp must not be steep to cause inconvenience.
COP.3 C. Ambulance(s) is manned by trained personnel.
Explanation: Only well-trained staff (nurses and technicians, etc.) should man the ambulance. And proper training record of the same should be maintained as evidence.
COP.3 G. The ambulance(s) has a proper communication system.
Explanation: A working method of communicating with the base to be made available. Mobile phones accepted as compliance.
COP.7
Policies and procedures guide the care of vulnerable patients (elderly, physically and/or mentally challenged and children).
Objective Elements
COP.7 A. Policies and procedures are documented and are in accordance with the prevailing laws and the national and international guidelines.
Explanation: Lunacy Act 1912 (now replaced by the Mental Health Act 1987) to be referred to for details.
COP.7 C. The organisation provides for a safe and secure environment for this vulnerable group.
Explanation: Hospital to ensure provision of railing, skid free tiles, easy access to wheel chair, nearness to call bell, easy to open doors, prevention for abduction of babies, baby swap, etc.
MOM.2
There is a hospital formulary.
Objective Elements
MOM.2 A list of medication appropriate for the patients and organisation's resources is developed.
Explanation: All medicines for all available and advertised specialities to be available. For instance, narcotics under NDPS Act to be available for pain elevation clinic etc. To ensure availability of all essential drugs, daily and common use drugs, etc.
MOM.2 C. There is a defined process for acquisition of these medications.
Explanation: To include vendor selection method/policy, lead time, cold chain concerns etc.
MOM.2 D. There is a process to obtain medications not listed in the formulary.
Explanation: Short purchase policy, policies for outside purchase, allowing patient to purchase, et., but in consonance to the above point MOM 2-A.
MOM.4 Policies and procedures guide the prescription of medications.
Objective Elements
MOM.4 B. The organisation determines who can write orders.
Explanation: Keeping in mind statuary requirements, the organisation has to outline who shall write orders apart from the treating consultants. This point is of importance in instances when the treating physician may not be available and the orders may be given by him on the phone etc to the nurse/RMO. Also refer point MOM 4 E below.
MOM.4 E. Policy on verbal orders is documented and implemented.
Explanation: The organisation needs to make a policy on accepting verbal orders, especially keeping in mind the potential communication errors which may lead to a wrong medication. A policy may be in place to not to accept verbal orders (preferably) or to get it doubly checked by a senior staff member or a senior resident etc. Apart from that, verbal orders have to be countersigned by the prescribing consultant within 24 hours.
MOM.5 Policies and procedures guide the safe dispensing of medications.
Objective Elements
MOM.5 B. The policies include a procedure for medication recall.
Explanation: Policies have to be in place to recall a particular batch or a lot of medicines/consumables. This is essential in case of identified defective batch or notice from Government regarding the same. The same should also be done when an instance of wrong prescription or wrong administration of medication is identified, to ensure that the same mistake is/was not duplicated for other patients.
MOM.7 Patients and family members are educated about safe medication and food-drug interactions.
Objective Elements
MOM.7 A. Patient and family are educated about safe and effective use of medication.
Explanation: The patient and family members should be explained clearly and in detail about the medication, specially in the OPD and at the time of discharge. This should be done to avoid incidences of over dosage, allergic reaction, etc.
MOM.7 B. Patient and family are educated about food-drug interactions.
Explanation: There is a need to educate the patients and their family members about the adverse reaction of certain food items on some drugs, and the necessity to avoid such food items during the medication period. Example, alcohol contradicted with metranidazole etc.
MOM.11 Policies and procedures govern usage of radioactive or investigational drugs.
Objective Elements
MOM.11 C. The policies and procedures include the safe storage, preparation, handling, distribution and disposal of radioactive and investigational drugs.
Explanation: There was a concern that some junk dealers may sell the nuclear portion/source for making a crude bomb. BARC can be notified to dispose this nuclear source prior to disposal. BARC disposes of the same in safe controlled methods.
HIC.7 There are documented procedures for sterilisation activities in the hospital.
Objective Elements
MOM.7 C. There is an established recall procedure when breakdown in the sterilisation system is identified.
Explanation: Example: Recall of entire CSSD load for a wet item found in the dry pack.
CQI.3
The organisation identifies key indicators to monitor the managerial structures, processes and outcomes.
Objective Elements
CQI.3 D. Monitoring includes utilisation of facilities.
Explanation: Monitoring of bed occupancy, average length of stay (ALOS), ICU utilisation etc. This indicates whether we are optimally utilising our resources and can also pinpoint a deviation in the quality of care if an ALOS varies from estimated for a particular case.
CQI.3 G. Monitoring includes adverse events.
Explanation: There should be a system in place to monitor and also minimise adverse events like bed falls, accidents, drug allergy, wrong drug, etc.
CQI.6 Sentinel events are intensively analysed. Monitoring of these events are essential as occurrence of these will only reflect poor processes and lack of training of staff, both reflecting poor patient care.
Objective Elements
CQI.6 A. The organisation has defined sentinel events. Sentinele even may include neonatal abduction, rape, murder, fall from staircase, electric shock, sparks, birds in AC ducts, bed falls, bed sore after admission, fall from window/balcony, suicide, discharge against medical advice.
ROM.5
Leaders ensure that patient safety aspects and risk management issues are an integral part of patient care and hospital management.
Objective Elements
ROM.5 D. Management provides resources for proactive risk assessment and risk reduction activities.
Explanation: Similar to preventive and corrective action of ISO 9001:2000. Confusion surrounds between the difference of preventive and corrective actions. A preventive action is one where an incidence has yet not occurred, but there is a potential hazard, while a corrective action is one when an incidence has occurred and necessary corrections are put in place for immediate reprieve and further prevention.
Examples of preventive action are naked electrical wires and a check on it to prevent any electric shock and; observing that there is lack of pest control and carrying an immediate pest control activity before infestation of insects and rodents, etc.
While example of corrective action is an electric shock has occurred due to a naked wire and now the naked wires are repaired to prevent such an incident from occurring again.
FMS.1
The organisation is aware of and complies with the relevant rules and regulations, laws and byelaws and requisite facility inspection requirements.
Objective Elements
FMS.1 D. There is a mechanism to regularly update licenses/ registrations/ certifications.
Explanation: SOP may be made with instructions as to how, when and where the licenses will be renewed and from which nodal agency. A list of licenses, consisting of renewal dates (including software package renewals) and trigger date for each, and responsible authority for renewal is a good practice.
HRM.6
The organisation has a well-documented disciplinary procedure.
Objective Elements
HRM.6 B. The disciplinary policy and procedure are based on the principles of natural justice.
Explanation: Both employee and employer shall be given enough opportunity to defend the case. Complainant cannot be the judge.
IMS.5
Policies and procedures are in place for maintaining confidentiality, integrity and security of information.
Explanation: To ensure that there is access only by authorised personnel and that processes exist to safeguard against unauthorised access, physical as well as digital, by way of lock and key, password protection etc. Protocols should be in place to disseminate the right information to the right person/patient and at the right time. Care also has to be taken while sharing data with external agencies where some tests are outsourced as the confidentiality of patients always needs to be maintained.

Effective Management of Medical Records is in our own interest

Effective Management of Medical Records is in our own interest In-patient as well as out-patient medical records generated in the hospital, in its own interest as well as for the patient are required to be stored for stipulated time depending on the relevance of the record. There is a lot of significance of good practices required in managing medical records.
Are medical records so important?
Medical records constitute a range of medical care documents, which include patient’s history, diagnostic investigations, consent documents, operative notes, nurses’ daily notes, intake / output sheet, treatment sheets, etc. Managing these records systematically is really important, as these records are the only way for the doctor to prove that the treatment was carried out properly. These records become the sole and critical evidence for the treating doctors to defend themselves from any claim of negligence and also for further treatment of patient whenever needed.
How Are Medical Records Stored?
Today in most hospitals, medical records are paper based and are stored manually in designated areas in the hospitals – some have a dedicated medical records room and officers looking after them. However, with increasing volumes of patients over the years, the physical records occupy more space and its more time consuming and difficult to retrieve the patient record. The paper based records are also prone to damage by weather, rodents, dust, etc. along with occupying hell lot of space and also the retrival becomes difficult and lengthy process.
Classification of Medical Records
There are two ways in which medical records can be relevantly classified: the extent to which they can be shared and the contents of the records.
The Extent to Which Records can be Shared
Must be given to the patient- certain records, viz. discharge summary, referral notes, etc., have to be shared with all patients including those who are discharged against medical advice irrespective if the bill payment has been made.
Can be given to the patient after formal application- records such as, indoor papers, operative notes, investigations, etc., requires a formal application from the patient. The copies of these records given to the patient are generally attested as true copies by the hospital.
Given only with direction of the court - some OPD and IPD records, especially those of medico-legal cases cannot be given to the patient without the direction of the Court.
On the other hand, medical records can be distinguished as per the constituent documents and each of them have its own significance, for example – discharge notes, are considered as a critical proof with respect to the in-hospital treatment provided to the patient, irrespective of the fact that the patient has been discharged with / against the advice of the doctor.
Preservation Period, Legal Aspect
There has been ambiguity with respect to clear regulations on how long a medical record must be preserved. Most hospitals follow their own set of policies in retaining records as per the relevance. The limitation period for filing a case paper is up to three years under the Limitation Act 1963 (two years under the Consumer Protection Act 1986). Nonetheless, the limitation period starts only after the patient becomes aware of the effect of the alleged negligence by the doctor.
The Maharashtra Government has issued a resolution (ref GR No. JJH-29 66/ 49733) which says that OPD paper should be kept for three years, indoor case papers for a period of five years and in case of a medico-legal case, 30 years. Usually medical records are summoned in a court of law in:
• Medico legal cases: where often the medical records are referred to establish medical history / treatment given, especially important in road traffic accidents, medical negligence, etc.
• Insurance cases: where the insurance company wants to review the medical records verify the claim
• Workmen’s compensation cases: In cases where an injury occurs to a workman out of and in the course of employment.
• Criminal cases – to prove the nature, timing and gravity of injuries.
MCI Guidelines
The Medical Council of India, has issued the (Professional Conduct, Etiquette and Ethics) Regulations, 2002, which mentions the following on Maintenance of Medical Records (Section 1.3)
• Every physician shall maintain the medical records pertaining to his / her indoor patients for a period of three years from the date of commencement of the treatment in a standard proforma laid down by the Medical Council of India (Section 1.3.1 and Appendix 3).
• If any request is made for medical records either by the patients / authorised attendant or legal authorities involved, the same may be duly acknowledged and documents shall be issued within the period of 72 hours (Section 1.3.2)
• A registered medical practitioner shall maintain a Register of Medical Certificates giving full details of certificates issued. When issuing a medical certificate he / she shall always enter the identification marks of the patient and keep a copy of the certificate. He / She shall not omit to record the signature and/or thumb mark, address and at least one identification mark of the patient on the medical certificates or report. The medical certificate shall be prepared as in Appendix 2. (Section 1.3.3 and Appendix 2).
• Efforts shall be made to computerise medical records for quick retrieval. (Section 1.3.4)
Role of Virtual Record Room (VRR) in Maintaining Medical Records
In my last article in June 2011 of Express Healthcare, I had introduced the concept of VRR. This time, I have outlined a practical case study of VRR implementation.
Quick recap; a VRR is like an online vault of patient records just like the MRD room – a secure online library containing Electronic Medical Records (EMR) of the patients – available for view / access to the authorised personnel as per their preferences. It’s a centralised repository of all patient records at one place, which can be securely accessed 24x7 from anywhere.
A VRR is not something that is important only for tax authorities or municipal corporations as we think of in India, but it is extremely important, critical and legally required in the context of medical care provided to patients. Following is the case study of BSES MG Hospital, Mumbai.
Example BSES MG Hospital, Mumbai
Since the time BSES MG Hospital has implemented the virtual record room; it has been empowered with 24x7 secure retrieval, enabling the admin to process queries regarding medical records substantially faster. Apart from the most evident improvement in time efficiencies, the EMR solution has made BSES MG Hospital’s medical record keeping more systematic. Each physical file has been scanned and fed in the software application. All scanned images can be easily identified intuitively. Ready reference information on the patient demographics (identification, emergency contact, doctor details, etc.) is instantly available from the patient profiles created.
BSES MG Hospital receives end-to-end service (from scanning till patient profiling) to achieve this in addition to the EMR application. The hospital staff doesn’t have to worry of records getting damaged or being misplaced. By using secure login, the authorised personnel can know at all times how many / which records belong to which patient; especially useful in medico-legal cases such as accidents, domestic violence, etc. The software also facilitates them with audit trails, telling them when and by whom the application was accessed.
Implementation of the EMR solution was a fairly simple affair for BSES MG Hospital. They outsourced the entire piece – including software, hardware and manpower. All they had to do is provide a small space for the scanning to happen and an internet connection for data transfer. In fact, they were also able to export all the patient registration details from their existing Hospital Information System (HIS) to the new application – rendering a high degree of accuracy of data entry of patient details. This made the EHR solution complimentary to the existing HIS.

Suggested Topics For Doing Summer Training/Writing Thesis

1.waiting time and consultation time of old and new patient in a particular opd and find out the contributing factors and it's effect on patient's satisfaction

2.Manpower Utilization(Medicos & Para Medicos) , Space Utilization & Patient's Flow and Positioning of various service points.

3.Equipment utilization of each big equipment in OPD (specially in ENT, Dental, Chest and Urology they have many equipments)

4.Time motion study for patients and staff.

5.Diagnostic Referral trends with comparison to previous months.

6.Inter departmental referral trends.

7.Individual potential analysis (for any clarification email us at ranjanranjan@gmail.com)

8.Feasibility study to start organ transplant or any other facility not available (like CT Scan, MRI , Photo Therapy etc)

9.Waiting time and consultation time of Old & New Patients in a particular OPD & find out the contributing factors and its effect on patients satisfaction.

10.We can also do study about the patients retention measures taken by the hospital.

11. A study of credit collection unit with a view to access the feasibility of outsourcing the collection function.

12. Criticality Analysis of Pharmacy Inventory.

Health Care Business Model

Corporate Hospital which came after Apollo Hosptial like Max, Fortis, Wockhardt In less than ten years of time , Wockhardt, Fortis and Max have added close to 5,000 beds, something that took Apollo 20 years. (It is of course another matter that projections show that India needs an additional 80,000 hospital beds each year.) Their revenues have also grown briskly — about 30 per cent annualised for the past five years for each.
While their respective strategies are responsible for their success, it is also true that they timed their entry well. India has a long history of privately run and owned hospitals. By the 1960s, once it became clear that there weren’t enough government hospitals to meet the country’s needs or that they weren’t just good enough, the middle classes swiftly changed allegiance to privately run hospitals. These were of two types. A majority were trusts, set up by big business houses (Escorts in Delhi, Birla Hospital in Kolkata, etc.), while a sprinkling were for profit institutions though these were usually nursing homes and not full blown hospitals, often built by doctors.
So, the notion of a ‘for-profit’ hospital is new. And while many did crop up in the 1980s (a few even tapped the capital markets), Apollo’s is considered to be the first national success story. Till f Max, Fortis and Wockhardt jumped into the ring..
The Strategies
There aren’t any precise estimates of how big the hospital industry is. Apollo’s hospitals group has a turnover of Rs 719 crore over 8,000 beds. That translates into revenues of Rs 2,460 per bed per day. According to some approximations, there are around 875,000 hospital beds in India. So that translates into an industry worth Rs 78,630 crore. However, that would perhaps be on the higher side as majority of the beds wouldn’t fetch Apollo rates. According to a CII McKinsey report, the entire healthcare industry is worth $18.7 billion, with the private sector controlling 65 per cent of it. But this figure includes the pharma industry as well as other healthcare related businesses like pharmaceuticals, diagnostics, etc.
Indeed, hospital industry executives believe it is futile looking for over arching figures. What is more relevant is whether the drivers of the business are in place. And they are.


Firstly, the healthcare market in India is under priced, not only compared to the developed world, but also compared to other Asian countries. If a heart surgery costs $14,250 in Thailand, $20,000 in Singapore and $30,000 in the US, it costs $5,000-7,000 in India. This, despite the fact that Indian doctors (and nurses) are considered to be one of the best in the world.
Secondly , rising income levels and greater awareness has ensured that people are more conscious of the service level of hospitals and don’t mind paying slightly more if what they get in return is substantially higher.
Three, India’s cheaper healthcare has stoked the flames of healthcare tourism — patients come here from all over the world to be treated. along with the intrinsically lower costs, has ensured that hospitals are uniformly full and don’t have lean patches .Also, traditionally healthcare is a recession-proof industry.
This means hospitals can flourish pretty much, as long as they get two things right — managing doctors and understanding the psyche of Indian patients. A quick insight: unlike in the west, where people go to GPs for everyday illnesses, Indians tend to go to specialists. Max Healthcare tried changing this, but failed. Indeed, Max bore the brunt of public scrutiny far more than any other given that it came up in Delhi, and was the first private player of any significance after Apollo.
The original Max plan was simple. Have local primary care centres, which would feed into secondary care centres, which would converge at a tertiary care centre. This model is established abroad, but was being tried for the first time here. It did not worked here in India.
Doctors and patients differed. The former felt that the primary clinics were mpeting with their private practice and, therefore, were reluctant to join up. The absence of a full fledged hospital within Max was another disincentive for doctors who were usually attached to big hospitals for tertiary care treatment which is the big ticket spend. Primary care is like a filter. The absence of a tertiary care hospital also meant that Max’s clinics were used as referral centres to other hospitals.



Also, Max had started its centres at upmarket Delhi localities, assuming correctly that the resident had more spending power and would be willing to afford better medical care. But this turned out to be a bit of a liability, since those patients were used to visiting marquee doctors, whom Max did not have. Though Max had consultants trained internationally, they were unknown names in Delhi.
Analjit Singh describes those days as “his struggle to understand the Indian healthcare market”. Worse was to follow. By 2003, Max’s CEO and the chief medical officer quit. Also, a tie-up with Harvard Medical International (HMI) was terminated in 2004. (Wockhardt would sign up with them later.) Many blamed Singh for his unwillingness to delegate. He took the criticism in his stride and continued to be closely involved. What he learnt has shaped the Max Healthcare of today.
It has adapted the original primary-secondary-tertiary model to a roughly secondary-tertiary model. The secondary care clinics have been upgraded to smaller hospitals (a 20-bed outfit is now a 60-100 bed outfit); simultaneously, the practice of the primary centres has moved to the secondary and main hospital and all primary centres have been closed down.
Max today has four secondary care centres — two at Panchsheel in south Delhi and one each at Noida and Pitampura (north-west Delhi). Plus, it has a general hospital (half- way between a secondary and tertiary care) in Patparganj in east Delhi. It also has as a massive tertiary care unit at Saket (south Delhi), which comprises a general hospital (Institute of Allied Medical Sciences), plus five superspecialty institutes. “Our strategy to meet the demand has been to create five institutes — cardiac, orthopedics and joint replacement, neurosciences, pediatrics and one for obstetric and gynaecology,” says Max executive director and CEO Mukesh Shivdasani. Work is on for another superspecialty hospital in Gurgaon, which will focus on transplant surgery and another one in Patparganj with oncology as the superspecialty. Analjit Singh feels he now has the critical mass to expand.But his advice to all who want to get into hospitals:

“The business is capital-intensive, it has long gestation, and the viability comes when you have played that out.”

Nephew Shivinder’s experience was different. Fortis decided to set up its first hospital at Mohali, Chandigarh, a market that didn’t have any other large, tertiary care private hospital. The idea was to attract patients from Himachal Pradesh, Haryana and Punjab. Simultaneously, it planned secondary care centres in other locations, which would be linked to the big Mohali hospital. It was a classic hub and spoke model.

Health Care Abbreviations in Govt.of India Schemes

ANM : Auxiliary Nurse Midwife
AYUSH: Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy
BEE : Block Extension Educator
BMS : Basic Minimum Services
CBR : Crude Birth Rate
CHC : Community Health Centre
FWTRC : Family Welfare Training and Research Centre
GDMO: General Duty Medical Officer
HA (F)/LHV : Health Assistant (Female)/Lady Health Visitor
HA (M) : Health Assistant (Male)
HFWTC : Health And Family Welfare Training Centre
HW (F) : Health Worker (Female)
HW (M) : Health Worker (Male)
ICDS : Integrated Child Development Schemes
IMR : Infant Mortality Rate
IPHS: Indian Public Health Standards
ISM & H : Indian System of Medicine and Homeopathy
IUD : Intrauterine Device
MMR: Maternal Mortality Ratio
MCH : Maternal and Child Health
MNP : Minimum Needs Programme
MO : Medical Officer
MOHFW : Ministry of Health & Family Welfare (GOI)
MTP : Medical Termination of Pregnancy
NHP : National Health Policy
PHC : Primary Health Centre
PRI : Panchayati Raj Institution
QPR : Quarterly Progress Report
RCH : Reproductive and Child Health

Health Care Market In INDIA

The healthcare market in India

India's secondary and tertiary care, especially in terms of the private sector, is primarily concentrated in urban areas. While no accurate up-to-date statistics are available, as of 2005 the nation had over 15,900 hospitals containing 875,000 beds. More than 70% of secondary care facilities derive from private hospitals, which contain 40% of the country's hospital beds. Half of all the nation's hospital admissions are the responsibility of private hospitals.

Between 2000 and 2006, public hospitals rose by more than two thirds from less than 4,600 to over 7,660. During that period, bed capacity in government-run facilities rose by a modest 14%, reaching just over 430,000 in 2006. According to IMS, the disparity between the two figures can be attributed to efforts to broaden the country's hospital sector, particular through establishing more small community and district inpatient facilities.

Similar to the situation in Brazil and China, India's primary care sector suffers from shortages of staff, equipment and supplies. Overcrowding and poor facilities means many middle income patients seek an initial diagnosis in public hospitals before opting for treatment in private facilities in spite of the obvious financial implications. Efforts are, however, being made to address some of these issues and in particular quality standards were introduced to help drive improvements. IMS has identified that mechanisms which penalise poor performers and reward those providing good quality are badly needed.

Public private partnerships (PPP) are being targeted as a means of improving India's public hospital management. According to IMS, government hospitals are increasingly contracting private operators to manage their facilities, and this is a trend which looks set to continue. Critics, however, claim patients face more substantial payments in PPP-managed facilities while the involvement of private players is also likely to have an impact on hospital procurement strategies, which will begin to affect manufacturers supplying the public hospital sector.

"Similar to the situation in Brazil and China, India's primary care sector suffers from shortages of staff, equipment and supplies."A scheme supported by the World Health Organization aims to bridge the gap between primary health centres and large city-based public hospitals in India by developing a network of 100-bed facilities in smaller towns. Yet again, recruiting and retaining qualified staff has proved a major problem to the progress of the scheme and IMS expects a shortage of fully trained health professionals will continue to prevent improvements to healthcare outside major cities.

Aware of the public hospital sector's shortcomings, successive Indian governments have actively promoted the expansion of the private hospital sector, which has also been strongly driven by the nation's growing middle class. IMS predicts this growth will continue in the long term.

A range of tax exemptions from central and state governments has allowed private providers to purchase land at preferential rates in return for commitments to meet quotas for free treatment of poor outpatients and inpatients. Private hospitals also provide treatment to central state government employees and their families, which is substantially reimbursed under government-backed health insurance programmes for public sector workers.

Leading hospital chains have already invested heavily in expansion programmes in India, particularly by establishing speciality and tertiary care facilities in major metros and tier I cities and constructing new facilities in tier II cities. Some of the most prominent private hospital chains operating in India include Apollo, Fortis, the Global Hospitals Group and Manipal Health Systems. While such leading hospital chains operate to world-class standards, the standards of practice in private facilities elsewhere in India vary widely.

According to IMS, tighter regulations on private providers could trigger a restructuring of the private hospital market and force the closure of smaller poor quality facilities. At state levels, initiatives are currently being pursued that are designed to regulate private providers but draft legislation aimed at imposing minimum standards at national level is still on its way through parliament

Government is pushig hard for medical health insurance to the population. Differnet type of healthcare cards are now initiatted to provide health insurance to poor economic sections

Hospital Information System (HIS)

DEFINATION AND IMPORTANCE :
Hospital Information System (HIS) is vital to decision making and plays a crucial role in the success of the organization. Computerization of the medical records and documentation has resulted in efficient data management and information dissemination for the users. Managers, Clinicians and other healthcare workers can now access the information without delay or errors. Studies has revealed, the existing system in our hospitals defenately requires up gradation to meet the requirements of the managers and the clinicians. Health care team feels HIS assists in decision making, and medical audit. HIS helps in education and research.

INTRODUCTION
Over the last few decades, medical sciences have made great strides leading to radical improvements in the modes of investigations, therapeutic activities and surgical procedures. This has enhanced the imperative need to have authentic and accurate medical records.

Every department and subsystems in an institution can be viewed basically as an information-processing agency. The Medical Records Department (MRD) is no exception. It is not a place where patient charts, complete or incomplete, are dumped and forgotten thereafter. The administration can actively use this department for monitoring and controlling the quality of patient care; in assessing of the performance of the medical staff; in keeping check on how some of the hospital’s resources are being put to use; and in gathering data for short term and long term decisions.

Most of the present Medical Records Departments have been changed into departments of hospital information management in order to take up responsibilities to function more effectively and efficiently in this regard. This new drift will support the need for an improved Hospital Information System making the Medical Records Department the main source of health information. It is no doubt that a carefully planned Hospital Information System and intelligently used information will be a great asset to any health care industry. The Hospital Information managers must have the necessary skills to facilitate and manage this transition and bridge the gap in the changing patterns switch over to 21st century.

Statement of the Problem:
A study of Medical Records Department of a tertiary care ABC hospital with special reference to the Hospital Information System.

Objectives:
1.To study the existing Hospital Information System in the medical records department.
2.To identify the shortcomings, if any, in the existing Hospital Information System in the Medical Records Department.
3.To suggest the necessary steps to improve the existing Hospital Information System in the Medical Records Department.
Methodology:
The study was conducted in 554 bedded multispecilaity tertiary care hospital. The Medical Records Department of the hospital was studied for assessing the Hospital Information System. Descriptive research approach as adopted for this study. Descriptive statistics have been used to find out the deficiencies, if any, in the existing Hospital Information System. The target population consisted of managers, doctors and patients in the hospital. The data were collected from a sample of 60, consisting of 05 managerial heads, 10 doctors and 40 patients selected by the disproportionate stratified sampling technique. The inclusive criteria for selecting the sample, were the managers who involved in decision making process, doctors with experience of more than one year, and the computer literate patients, willing to participate in the study.

The tool used to collect the data was a structured, closed ended questionnaire. The questionnaire was constructed with emphasis on the content, clarity and simple language. The scoring for the managers and the doctors has been done on a four-point scale and the scoring for the patients is on a three-point scale. The scoring has been given according to the nature of the questions.

A pilot study was conducted for the patients, to check the validity and feasibility of the study. The tool was administered to subjects, for ascertaining the reliability. The reliability calculated by using split method r = 0.73, 0.86 and 0.76, for managers, doctors an the patients respectively, which was high and satisfactory.

Observation & Discussion:
It was observed that decentralizaed filing system is being followed in the Medical Records Department of the teritary care hospital i.e. the department is divided into two units – Out Patient (OP) and In-Patient (IP) MRD.

The other information available to the hospital management include

1.OP and IP Statistics
2.Death cases
3.Left against Medical Advise (LAMA) cases
4.Long standing cases
5.Cash and Collection reporting
Structured questionnaires were used to find out the deficiencies in the existing system. The various studies conducted earlier, shows the importance of Management Information System (MIS) in an organization. It lays emphasis on the nature of the modern organization, the current legal and social environment; advancing technology and the expanding role of management that have created information needs which cannot be satisfied by traditional means. A closer examination of these four areas will reveal the demand for more sophisticated management information1.

Table – 1 Opinion about the existing Hospital Information System
Category
(n=60) Response
Good Moderate Poor Total
Managers — 7(70%) 3(30%) 10
Doctors — 16(80%) 4(20%) 20
Patients — 25(87%) 5(13%) 30
Totalresponse(%) — 48(80%) 12(20%) 60

This hospital does not have a separate admission department and all the registration and admission procedures are through the Medical Records Department. The Medical Records Department is partially computerized. In addition, an in-hour Hospital Information System exists in this hospital.

The study reveals that the department is providing information to the health authorities regularly. The overall opinion of the managers, doctors and patients about the existing Hospital Information System in the hospital is satisfactory (80%) and 20% feel that the system is poor. (Table-1)

Table – 2 Opinion about the existing Hospital Information System
Role of HIS in Manager’s responses regarding the existing system
Strongly
Agree Agree Disagree Strongly
disagree
Decision making — 5 (50%) 4 (40%) 1 (10%)
Utilization of resources — 4 (40%) 6 (60%) —
Enhances communication — 2 (20%) 4 (40%) 4 (40%)
Strategic planning — 4 (40%) 3 (30%) 3 (30%)
Quality assurance — 2 (20%) 8 (80%) —
Reduces waiting time — 4 (40%) 6 (60%) —
Utilization process 1 (10%) 4 (40%) 3 (30%) 2 (20%)
Medical audit 2 (20%) 5 (50%) 3 (30%) —
Role of HIS Doctor’s responses regarding the existing system
Strongly
Agree Agree Disagree Strongly
disagree
Reduces the cost 2 (10%) 5 (25%) 13 (65%) —
Shorten the stay — 3 (15%) 13 (65%) 4 (20%)
Continuity of patient care — 2 (10%) 3 (15%) 15 (75%)
Effective referral system 1 (5%) 6 (30%) 12 (69%) 1 (5%)

The purpose of the Hospital Information System is to raise “managing” from the level of piecemeal spotty information, intuitive guesswork and isolated problem solving to the level of systems insight, systems information and systems problem solving. It is, thus, a powerful method for aiding administrators in solving and making decisions2.

However, it was found that the majority of the managers (70%), disagree with the statement that the HIS of the hospital helps in discharging effectively their managerial responsibilities as well as in enhancing the inter and intra hospital communication (80%) Half of the managerial heads (50%) agree that the statistical information from the Medical Records Department helps in decisionmaking. With an increase in the number of third party payer’s utilization requirements, the admitting and utilization management are in frequent communication3.

The majority of the managers (80%) agree that the existing Hospital Information System does not help in the Quality Assurance Programme (QAP) as well as in enhancing the functions of the supportive services. Half of the managerial heads agree that the Hospital Information System does not help as a tool in the various utilization processes.

The various studies conducted earlier regarding information system reveals the benefits for doctors and nurses and includes, qualitatively better data, more available data on patients, direct consultations of colleagues and experts, use of decision based systems, reduced work load, the gain of time, and the availability of administrative support4.

Majority of the doctors do not believe that the existing Hospital Information System can help to reduce the cost of patient care (65%) or shorten the stay of the patient in the hospital (65%)5. (Table-2).

Table 3 – Disadvantages of the existing Hospital Information System – HIS
Disadvantages of existing
Hospital Information System Doctor’s responses regarding the existing system
Strongly
Agree Agree Disagree Strongly
disagree
Non-Existence of ward
Computers is affecting
patient care — 17 (85%) 3 (15%) —
OPD consultations take
longer time — 16 (80%) 1 (5%) 3 (15%)
Delay in getting
longer time 1 (5%) 14 (70%) 5 (25%) —

The majority of the doctors (85%) feel that the nonexistence of ward computers is a hinderance in providing the expected patient care. They also feel that the existing Hospital Information System does not help either in making the OPD consultations quicker or in generating quick laboratory reports6. (Table-3)

Table – 4. Opinion about current HIS with respect to Internal and Personnel Performance
Internal Performance of the Hospital Doctor’s responses regarding the existing system
Strongly
Agree Agree Disagree Strongly
disagree
Infection Control — 7 (35%) 12 (60%) 1 (5%)
Defining Community needs — 2 (10%) 14 (70%) 4 (20%)

Majority of the doctors disagree that the Hospital Information System helps in infection control (65%) and in defining the community needs (90%). Majority of them agree that the Hospital Information System helps in education and research (60%)7.

The different benefits of information system to the community are, to prepare a programme of health education for the area (with priorities for the health activities), information on the indicators of health which can help to focus attention on target group for specific health services, and, help to prevent epidemics8,9.

CONCLUSION
The present scenario in India is that most of the Medical Records Department are partially computerized10. This system exists in some Health Care facilities, where entries are made by different Health care providers, such as Physicians, Nurses and therapists, into the computer in different nodes in a local area network. The survey conducted in the hospital reveals the importance of information networking between the departments. Majority of the beneficiaries of Hospital Information System, are aware about the advantages of computerisation in the HIS in providing better health care. All of them agree that only in an efficient system the information can be readily available. The exciting possibility of a modern and computerised information system is not too far. In the coming years we can visualize the patient record existing in electronic medium, where a patient can have a single record from birth to death that can be assessed from any where in the world11.

BioMediCal Waste Disposal

HERE IS THE NOTIFICATION FROM MINISTRY OF ENVIRONMENT & FORESTS



New Delhi, 20th July, 1998
S.O. 630 (E).-Whereas a notification in exercise of the powers conferred by Sections 6, 8 and 25 of the Environment (Protection) Act, 1986 (29 of 1986) was published in the Gazette vide S.O. 746 (E) dated 16 October, 1997 inviting objections from the public within 60 days from the date of the publication of the said notification on the Bio-Medical Waste (Management and Handling) Rules, 1998 and whereas all objections received were duly considered..

Now, therefore, in exercise of the powers conferred by section 6, 8 and 25 of the Environment (Protection) Act, 1986 the Central Government hereby notifies the rules for the management and handling of bio-medical waste.

1. SHORT TITLE AND COMMENCEMENT:

(1) These rules may be called the Bio-Medical Waste (Management and Handling) Rules, 1998.

(2) They shall come into force on the date of their publication in the official Gazette.

APPLICATION:

These rules apply to all persons who generate, collect, receive, store, transport, treat, dispose, or handle bio medical waste in any form.

3. DEFINITIONS: In these rules unless the context otherwise requires

(1) "Act" means the Environment (Protection) Act, 1986 (29 of 1986);

(2) "Animal House" means a place where animals are reared/kept for experiments or testing purposes;

(3) "Authorisation" means permission granted by the prescribed authority for the generation, collection, reception, storage, transportation, treatment, disposal and/or any other form of handling of bio-medical waste in accordance with these rules and any guidelines issued by the Central Government.

(4) "Authorised person" means an occupier or operator authorised by the prescribed authority to generate, collect, receive, store, transport, treat, dispose and/or handle bio-medical waste in accordance with these rules and any guidelines issued by the Central Government;

(5) "Bio-medical waste" means any waste, which is generated during the diagnosis, treatment or immunisation of human beings or animals or in research activities pertaining thereto or in the production or testing of biologicals, and including categories mentioned in Schedule I;

(6) "Biologicals" means any preparation made from organisms or micro-organisms or product of metabolism and biochemical reactions intended for use in the diagnosis, immunisation or the treatment of human beings or animals or in research activities pertaining thereto;

(7) "Bio-medical waste treatment facility" means any facility wherein treatment. disposal of bio-medical waste or processes incidental to such treatment or disposal is carried out;

(8) "Occupier" in relation to any institution generating bio-medical waste, which includes a hospital, nursing home, clinic dispensary, veterinary institution, animal house, pathological laboratory, blood bank by whatever name called, means a person who has control over that institution and/or its premises;

(9) "Operator of a bio-medical waste facility" means a person who owns or controls or operates a facility for the collection, reception, storage, transport, treatment, disposal or any other form of handling of bio-medical waste;

(10) "Schedule" means schedule appended to these rules;

4. DUTY OF OCCUPIER:

It shall be the duty of every occupier of an institution generating bio-medical waste which includes a hospital, nursing home, clinic, dispensary, veterinary institution, animal house, pathological laboratory, blood bank by whatever name called to take all steps to ensure that such waste is handled without any adverse effect to human health and the environment.

5. TREATMENT AND DISPOSAL

(1) Bio-medical waste shall be treated and disposed of in accordance with Schedule I, and in compliance with the standards prescribed in Schedule V.

(2) Every occupier, where required, shall set up in accordance with the time-schedule in Schedule VI, requisite bio-medical waste treatment facilities like incinerator, autoclave, microwave system for the treatment of waste, or, ensure requisite treatment of waste at a common waste treatment facility or any other waste treatment facility.

6. SEGREGATION, PACKAGING, TRANSPORTATION AND STORAGE

(1) Bio-medical waste shall not be mixed with other wastes.

(2) Bio-medical waste shall be segregated into containers/bags at the point of generation in accordance with Schedule II prior to its storage, transportation, treatment and disposal. The containers shall be labeled according to Schedule III.

(3) If a container is transported from the premises where bio-medical waste is generated to any waste treatment facility outside the premises, the container shall, apart from the label prescribed in Schedule III, also carry information prescribed in Schedule IV.

(4) Notwithstanding anything contained in the Motor Vehicles Act, 1988, or rules thereunder, untreated biomedical waste shall be transported only in such vehicle as may be authorised for the purpose by the competent authority as specified by the government.

(5) No untreated bio-medical waste shall be kept stored beyond a period of 48 hours

Provided that if for any reason it becomes necessary to store the waste beyond such period, the authorised person must take permission of the prescribed authority and take measures to ensure that the waste does not adversely affect human health and the environment.

7. PRESCRIBED AUTHORITY

(1) The Government of every State and Union Territory shall establish a prescribed authority with such members as may be specified for granting authorisation and implementing these rules. If the prescribed authority comprises of more than one member, a chairperson for the authority shall be designated.

(2) The prescribed authority for the State or Union Territory shall be appointed within one month of the coming into force of these rules.

(3) The prescribed authority shall function under the supervision and control of the respective Government of the State or Union Territory.

(4) The prescribed authority shall on receipt of Form 1 make such enquiry as it deems fit and if it is satisfied that the applicant possesses the necessary capacity to handle bio-medical waste in accordance with these rules, grant or renew an authorisation as the case may be.

(5) An authorisation shall be granted for a period of three years, including an initial trial period of one year from the date of issue. Thereafter, an application shall be made by the occupier/operator for renewal. All such subsequent authorisation shall be for a period of three years. A provisional authorisation will be granted for the trial period, to enable the occupier/operator to demonstrate the capacity of the facility.

(6) The prescribed authority may after giving reasonable opportunity of being heard to the applicant and for reasons thereof to be recorded in writing, refuse to grant or renew authorisation.

(7) Every application for authorisation shall be disposed of by the prescribed authority within ninety days from the date of receipt of the application.

(8) The prescribed authority may cancel or suspend an authorisation, if for reasons, to be recorded in writing, the occupier/operator has failed to comply with any provision of the Act or these rules :

Provided that no authorisation shall be cancelled or suspended without giving a reasonable opportunity to the occupier/operator of being heard.

8. AUTHORISATION

(1) Every occupier of an institution generating, collecting, receiving, storing, transporting, treating, disposing and/or handling bio-medical waste in any other manner, except such occupier of clinics, dispensaries, pathological laboratories, blood banks providing treatment/service to less than 1000 (one thousand) patients per month, shall make an application in Form 1 to the prescribed authority for grant of authorisation.

(2) Every operator of a bio-medical waste facility shall make an application in Form 1 to the prescribed authority for grant of authorisation.

(3) Every application in Form 1 for grant of authorisation shall be accompanied by a fee as may be prescribed by the Government of the State or Union Territory.

9. ADVISORY COMMITTEE

The Government of every State/Union Territory shall constitute an advisory committee. The committee will include experts in the field of medical and health, animal husbandry and veterinary sciences, environmental management, municipal administration, and any other related department or organisation including non-governmental organisations. The State Pollution Control Board/Pollution Control Committee shall be represented. As and when required, the committee shall advise the Government of the State/Union Territory and the prescribed authority about matters related to the implementation of these rules.

10. ANNUAL REPORT

Every occupier/operator shall submit an annual report to the prescribed authority in Form 11 by 31 January every year, to include information about the categories and quantities of bio-medical wastes handled during the preceding year. The prescribed authority shall send this information in a compiled form to the Central Pollution Control Board by 31 March every year.

11. MAINTENANCE OF RECORDS

(1) Every authorised person shall maintain records related to the generation, collect ' ion, reception, storage, transporation, treatment, disposal and/or any form of handling of bio-medical waste in accordance with these rules and any guidelines issued.

(2) All records shall be subject to inspection and verification by the prescribed authority at any time.

12. ACCIDENT REPORTING

When any accident occurs at any institution or facility or any other site where bio-medical waste is handled or during transportation of such waste, the authorised person shall report the accident in Form Ill to the prescribed authority forthwith.

13. APPEAL

Any person aggrieved by an order made by the prescribed authority under these rules may, within thirty days from the date on which the order is communicated to him, prefer an appeal to such authority as the Government of State/Union Territory may think fit to constitute :

Provided that the authority may entertain the appeal after the expiry of the said period of thirty days if it is satisfied that the appellant was prevented by sufficient cause from filing the appeal in time.


SCHEDULE I
(See Rule 5)
CATEGORIES OF BIO-MEDICAL WASTE

------------------------------------------------------------------------------------------------------------------------
Option Waste Category Treatment & Disposal
------------------------------------------------------------------------------------------------------------------------
Category No. I Human Anatomical Waste
(human tissues, organs, body parts) incineration@/deep burial*

Category No. 2 Animal Waste
(animal tissues, organs, body parts carcasses, bleeding parts, fluid, incineration@/deep burial*
blood and experimental animals used in research, waste generated
by veterinary hospitals colleges, discharge from hospitals, animal
houses)

Category No 3 Microbiology & Biotechnology Waste
(wastes from laboratory cultures, stocks or specimens of micro- local autoclaving/micro-
organisms live or attenuated vaccines, human and animal cell waving/incineration@
culture used in research and infectious agents from research
and industrial laboratories, wastes from production of biologicals,
toxins, dishes and devices used for transfer of cultures)

Category No 4 Waste sharps
(needles, syringes, scalpels, blades, glass, etc. that may cause disinfection (chemical treat-
puncture and cuts. This includes both used and unused sharps) ment@01/auto claving/micro-
waving and mutilation/
shredding"

Category No 5 Discarded Medicines and Cytotoxic drugs
(wastes comprising of outdated, contaminated and discarded inc ineratio n@/destruct ion and
medicines) drugs disposal in secured
landfills

Category No 6 Solid Waste
(Items contaminated with blood, and body fluids including cotton,
dressings, soiled plaster casts, lines, beddings, other material incineration@
contaminated with blood) autoclaving/microwaving

Category No. 7 Solid Waste
(wastes generated from disposable items other than the waste shaprs disinfection by chemical
such as tubings, catheters, intravenous sets etc). treatment@@ autoclaving/
microwaving and mutilation/
shredding##

Category No. 8 Liquid Waste
(waste generated from laboratory and washing, cleaning, house- disinfection by chemical
keeping and disinfecting activities) treatment@@ and discharge
into drains.

Category No. 9 Incineration Ash
(ash from incineration of any bio-medical waste) disposal in municipal landfill

Category No. 10 Chemical Waste
(chemicals used in production of biologicals, chemicals used in chemical treatment@@ and
disinfection, as insecticides, etc.) discharge into drains for
liquids and secured landfill
for solids
------------------------------------------------------------------------------------------------------------------------

@@ Chemicals treatment using at least 1% hypochlorite solution or any other equivalent chemical reagent. It must be ensured that chemical treatment ensures disinfection.

## Multilation/shredding must be such so as to prevent unauthorised reuse.

@ There will be no chemical pretreatment before incineration. Chlorinated plastics shall not be incinerated.

* Deep burial shall be an option available only in towns with population less than five lakhs and in rural areas.


SCHEDULE II
(see Rule 6)
COLOUR CODING AND TYPE OF CONTAINER FOR DISPOSAL OF BIO-MEDICAL WASTES
Colour Conding
Type of Container -I Waste Category
Treatment options as per

Schedule I

Yellow
Plastic bag Cat. 1, Cat. 2, and Cat. 3,

Cat. 6.
Incineration/deep burial


Red
Disinfected container/plastic bag Cat. 3, Cat. 6, Cat.7.
Autoclaving/Microwaving/

Chemical Treatment

Blue/White

translucent
Plastic bag/puncture proof Cat. 4, Cat. 7.

Container
Autoclaving/Microwaving/

Chemical Treatment and

destruction/shredding

Black
Plastic bag Cat. 5 and Cat. 9 and

Cat. 10. (solid)
Disposal in secured landfill



Notes:

1. Colour coding of waste categories with multiple treatment options as defined in Schedule I, shall be selected depending on treatment option chosen, which shall be as specified in Schedule I.

2. Waste collection bags for waste types needing incineration shall not be made of chlorinated plastics.

3. Categories 8 and 10 (liquid) do not require containers/bags.

4. Category 3 if disinfected locally need not be put in containers/bags.


SCHEDULE III
(see Rule 6)
LABEL FOR BIO-MEDICAL WASTE CONTAINERS/BAGS



HANDLE WITH CARE

Note : Lable shall be non-washable and prominently visible.


SCHEDULE IV
(see Rule 6)
LABEL FOR TRANSPORT OF BIO-MEDICAL WASTE CONTAINERS/BAGS

Day ............ Month ..............
Year ...........
Date of generation ...................

Waste category No ........
Waste class
Waste description

Sender's Name & Address Receiver's Name & Address
Phone No ........ Phone No ...............
Telex No .... Telex No ...............
Fax No ............... Fax No .................
Contact Person ........ Contact Person .........
In case of emergency please contact
Name & Address :

Phone No.
Note :
Label shall be non-washable and prominently visible.


SCHEDULE V
(see Rule 5 and Schedule 1)
STANDARDS FOR TREATMENT AND DISPOSAL OF BIO-MEDICAL WASTES
STANDARDS FOR INCINERATORS:

All incinerators shall meet the following operating and emission standards

A. Operating Standards

1. Combustion efficiency (CE) shall be at least 99.00%.

2. The Combustion efficiency is computed as follows:


%C02
C.E. = ------------ X 100
%C02 + % CO

3. The temperature of the primary chamber shall be 800 ± 50 deg. C°.

4. The secondary chamber gas residence time shall be at least I (one) second at 1050 ± 50 C°, with minimum 3% Oxygen in the stack gas.

B. Emission Standards


Parameters Concentration mg/Nm3 at (12% CO2 correction)

(1) Particulate matter 150
(2) Nitrogen Oxides 450
(3) HCI 50
(4) Minimum stack height shall be 30 metres above ground
(5) Volatile organic compounds in ash shall not be more than 0.01%

Note :

• Suitably designed pollution control devices should be installed/retrofitted with the incinerator to achieve the above emission limits, if necessary.

• Wastes to be incinerated shall not be chemically treated with any chlorinated disinfectants.

• Chlorinated plastics shall not be incinerated.

• Toxic metals in incineration ash shall be limited within the regulatory quantities as defined under the Hazardous Waste (Management and Handling Rules,) 1989.

• Only low sulphur fuel like L.D.0dLS.H.S.1Diesel shall be used as fuel in the incinerator.

STANDARDS FOR WASTE AUTOCLAVING:

The autoclave should be dedicated for the purposes of disinfecting and treating bio-medical waste,

(I) When operating a gravity flow autoclave, medical waste shall be subjected to :

(i) a temperature of not less than 121 C' and pressure of 15 pounds per square inch (psi) for an autoclave residence time of not less than 60 minutes; or

(ii) a temperature of not less than 135 C° and a pressure of 31 psi for an autoclave residence time of not less than 45 minutes; or

(iii) a temperature of not less than 149 C° and a pressure of 52 psi for an autoclave residence time of not less than 30 minutes.

(II) When operating a vacuum autoclave, medical waste shall be subjected to a minimum of one pre-vacuum pulse to purge the autoclave of all air. The waste shall be subjected to the following:

(i) a temperature of not less than 121 C° and pressure of 15 psi per an autoclave residence time of not less than 45 minutes; or

(ii) a temperature of not less than 135 C° and a pressure of 31 psi for an autoclave residence time of not less than 30 minutes;

(III) Medical waste shall not be considered properly treated unless the time, temperature and pressure indicators indicate that the required time, temperature and pressure were reached during the autoclave process. If for any reasons, time temperature or pressure indicator indicates that the required temperature, pressure or residence time was not reached, the entire load of medical waste must be autoclaved again until the proper temperature, pressure and residence time were achieved.

(IV) Recording of operational parameters

Each autoclave shall have graphic or computer recording devices which will automatically and continuously monitor and record dates, time of day, load identification number and operating parameters throughout the entire length of the autoclave cycle.

(V) Validation test

Spore testing :

The autoclave should completely and consistently kill the approved biological indicator at the maximum design capacity of each autoclave unit. Biological indicator for autoclave shall be Bacillus stearothermophilus spores using vials or spore Strips; with at least 1X104 spores per millilitre. Under no circumstances will an autoclave have minimum operating parameters less than a residence time of 30 minutes, regardless of temperature and pressure, a temperature less than 121 C° or a pressure less than 15 psi.

(VI) Routine Test

A chemical indicator strip/tape the changes colour when a certain temperature is reached can be used to verify that a specific temperature has been achieved. It may be necessary to use more than one strip over the waste package at different location to ensure that the inner content of the package has been adequately autoclaved

STANDARD FOR LIQUID WASTE:

The effluent generated from the hospital should conform to the following limits

PARAMETERS PERMISSIBLE LIMITS

PH 63-9.0
Susponded solids 100 mg/l
Oil and grease 10 mg/l
BOD 30 mg/l
COD 250 mg/l
Bio-assay test 90% survival of fish after 96 hours in 100% effluent.

these limits are applicable to those, hospitals which are either connected with sewers without terminal sewage treatment plant or not connected to public sewers. For discharge into public sewers with terminal facilities, the general standards as notified under the Environment (Protection) Act, 1986 shall be applicable.

STANDARDS OF MICROWAVING

1 Microwave treatment shall not be used for cytotoxic, hazardous or radioactive wastes, contaminated animal car casses, body parts and large metal items.

2. The microwave system shall comply with the efficacy test/routine tests and a performance guarantee may be provided by the supplier before operation of the limit.

3. The microwave should completely and consistently kill the bacteria and other pathogenic organisms that is ensured by approved biological indicator at the maximum design capacity of each microwave unit. Biological indicators for microwave shall be Bacillus Subtilis spores using vials or spore strips with at least 1 x 101 spores per milliliter.

STANDARDS FOR DEEP BURIAL

1. A pit or trench should he dug about 2 meters deep. It should be half filled with waste, then covered with lime within 50 cm of the surface, before filling the rest of the pit with soil.

2. It must be ensured that animals do not have any access to burial sites. Covers of galvanised iron/wire meshes may be used.

3. On each occasion, when wastes are added to the pit, a layer of 10 em of soil shall be added to cover the wastes.

4. Burial must be performed under close and dedicated supervision.

5. The deep burial site should be relatively impermeable and no shallow well should be close to the site.

6. The pits should be distant from habitation, and sited so as to ensure that no contamination occurs of any surface water or ground water. The area should not be prone to flooding or erosion.

7. The location of the deep burial site will be authorised by the prescribed authority.

8. The institution shall maintain a record of all pits for deep burial.


SCHEDULE VI
(see Rule 5)
SCHEDULE FOR WASTE TREATMENT FACILITIES LIKE INCINERATOR/ AUTOCLAVE/ MICROWAVE SYSTEM

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A Hospitals and nursing homes in towns with population of 30 lakhs by 31st December, 1999 or earlier
and above
B. Hospitals and nursing homes in towns with population of below
30 lakhs,
(a) with 500 beds and above by 31st December, 1999 or earlier
(b) with 200 beds and above but less than 500 beds by 31st December, 2000 or earlier
(c) with 50 beds and above but less than 200 beds by 31st December, 2001 or earlier
(d) with less than 50 beds by 31st December, 2002 or earlier
C. All other institutions generating bio-medical waste not included by 31st December, 2002 or earlier
in A and B above
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FORM I
(see rule 8)
APPLICATION FOR AUTHORISATION
(To be submitted in duplicate.)
To

The Prescribed Authority
(Name of the State Govt/UT Administration)
Address.

1. Particulars of Applicant

(i) Name of the Applicant
(In block letters & in full)
(ii) Name of the Institution:
Address:
Tele No., Fax No. Telex No.

2. Activity for which authorisation is sought:

(i) Generation
(ii) Collection
(iii) Reception
(iv) Storage
(v) Transportation
(vi) Treatment
(vii) Disposal
(viii) Any other form of handling

3. Please state whether applying for resh authorisation or for renewal:
(In case of renewal previous authorisation-number and date)
4.

(i) Address of the institution handling bio-medical wastes:

(ii) Address of the place of the treatment facility:

(iii) Address of the place of disposal of the waste:

5.

(i) Mode of transportation (in any) of bio-medical waste:

(ii) Mode(s) of treatment:

6. Brief description of method of treatment and disposal (attach details):

7.

(i) Category (see Schedule 1) of waste to be handled

(ii) Quantity of waste (category-wise) to be handled per month

8. Declaration

I do hereby declare that the statements made and information given above are true to the best of my knowledge and belief and that I have not concealed any information.

I do also hereby undertake to provide any further information sought by the prescribed authority in relation to these rules and to fulfill any conditions stipulated by the prescribed authority.

Date : Signature of the Applicant

Place : Designation of the Applicant


FORM II
(see rule 10)
ANNUALREPORT
(To be submitted to the prescribed authority by 31 January every year).

1 . Particulars of the applicant:

(i) Name of the authorised person (occupier/operator):

(ii) Name of the institution:

Address

Tel. No

Telex No.

Fax No.

2. Categories of waste generated and quantity on a monthly average basis:

3. Brief details of the treatment facility:

In case of off-site facility:

(i) Name of the operator

(ii) Name and address of the facility:

Tel. No., Telex No., Fax No.

4. Category-wise quantity of waste treated:

5. Mode of treatment with details:

6. Any other information:

7. Certified that the above report is for the period from


Date ............................... Signature ...........................................

Place.............................. Designation..........................................


FORM III
(see Rule 12)
ACCIDENT REPORTING
1. Date and time of accident:

2. Sequence of events leading to accident

3. The waste involved in accident :

4. Assessment of the effects of the accidents on human health and the environment,.

5. Emergency measures taken

6. Steps taken to alleviate the effects of accidents

7. Steps taken to prevent the recurrence of such an accident


Date ............................... Signature ...........................................

Place.............................. Designation..........................................

Hospital Administrators should see to the SEXUAL intrests of Handicapped/Disabled patients!!

As we know, the human sexual and reproductive functions can be physically and psychologically impaired . It is also obvious that these functions can be indirectly affected by a great number of nonsexual injuries, disorders, disabilities, and diseases, indeed, the damage may well be compounded by ignorance and negative social attitudes. Thus, as a rule, physically or mentally handicapped persons find themselves confronted with special sexual problems of their own.


In our society the handicapped and disabled, such as amputees, paraplegics and quadriplegics, and the victims of cerebral palsy, may receive much valuable medical help, but very little support in developing their sexual interests. On the contrary, under the pretext of "protection", their families, friends, doctors, nurses, and teachers often deny them any opportunity to become sexually active or even explicitly discourage them. Many people simply assume that a serious physical or mental handicap precludes any hope for a rewarding sex life. However, this assumption is false. Except for extremely serious cases, in which the sheer need to survive requires all available energy, some form of sexual pleasure is always possible. The fact that this simple truth is not widely recognized only reflects the sensual poverty of our culture.


The situation is especially difficult for those handicapped or disabled patients who have to live in hospitals or nursing homes, or similar institutions. In such places patients usually have very little privacy and little opportunity to meet other people from the outside. Living areas are segregated according to sex. In addition, the staff is often prudish and intolerant. Many doctors, in fact, do not know that their patients are capable of sexual enjoyment and thus never think of discussing the subject. Thus, the men and women in their care remain without guidance, and many possible sexual alternatives are left unexplored. Furthermore, many hospital administrations feel that they cannot permit any sexual activity on their premises, because this would bring them in conflict with the law, and, unfortunately, this concern may be justified. Conservative employees or relatives of patients who disapprove of non marital sex might bring suit against the institution. Finally, since many patients are incapable of coitus and therefore practice other forms of sexual intercourse, they may well be guilty of "sodomy" or "crimes against nature" as defined in many IPC CODES. This is another reason why doctors may be reluctant to help their patients with necessary sexual experimentation's. Needless to say, all of this applies not only to long-term,

Unfortunately the situation is same for many people who are hospitalized for only a few months or even weeks and, during that time, are needlessly deprived of sexual intercourse. Not every illness demands sexual abstinence, but virtually no hospital offers its patients an opportunity to become intimate with visiting spouses or lovers. On the other hand, in case of a serious illness, lovers may not even be allowed to visit at all, because they are not officially recognized "family members". Such a regulation is especially insensitive to homosexual patients.

Clinical sex research has shown that a great many of even severely handicapped persons can enjoy sex if they are willing to raise their sexual consciousness and to break out of conventional patterns.

Thus depriving them for there sexual options and life inside hospital for long is questionable and needs a second thought in all hospitals and place where we keep such people for treatment for long, in fact, hospital administrators should changed their policies and now allow their patients to find sexual satisfaction.

Unusual problems are faced by the mentally handicapped, especially those who are institutionalized. Still, in principle, everything said above also applies to them. In the past, they were often treated as if they had no sexual interests or sexual rights.. The necessary privacy should be provided by their families or by the institutions to which they are confined. On the other hand, the mentally handicapped also have to be protected against sexual exploitation. This can be done by personal attention, appropriate institutional regulations, and sensible criminal laws.

Where sterilization seems desirable and unavoidable , informed consent should be obtained. Yet, as a matter of policy, the least restrictive alternative should always be preferred. As long as nobody else is harmed, all handicapped and disabled persons are entitled to full sexual fulfillment according to their a