Chapter 11

BACKGROUND AND
STUDY SETTING
INTRODUG'b10N
This chapter presents the rationale for selection of a public hospital setting
for the study. This is followed by a brief description of the salient features
of the hospital that are of relevance to this study.
2.1: Rafionade and Significance of the Study:
Non-profit sector: While quality has become a more accepted,
researched and implemented concept in the private and for-profit health
care sector, in lndia the non-profit sector needs more attention as it
serves a very large population under conditions of very scarce
resources. Through a search of standard databases and survey of
literature of indexed Journals, it was found that reporting from lndia was
extremely inadequate. Another report of a WHO SEAR0 Region study
of 35 countries confirms this situation of developing countries in Asia as
a whole including India. (Amala de Silva, 2000).
0 Beneficiary perceptions: Programs for internal quality audit of hospital
services in the form of Medical Care Reviews analyze clinical
processes and outcomes for taking corrective measures. Hospitals
regularly conduct for their own internal consumption, quality initiatives
related to clinical processes and outcomes, like measuring hospital
mortality rates, infection rates, prescription adequacy, follow-up and
compliance rates, readmission rates and clinical care reviews.
Assessing hospital performance quality with reference to inputs -
financial, human resource, skills, materials, drugs, and equipment - is
done for the purpose of deciding future allocations. Measures of
attainment of targets in terms of the promotive, preventive, curative,
and rehabilitative role expectations from public hospitals, are also
regularly undertaken and widely reported as inputs to policy
formulation.
 However, beneficiary assessment studies in terms of dimensions of
service quality from the point of view of external customers (clientele)
and internal customers (employees) has not been attempted in the
public sector in India. Some private corporate hospitals routinely get an
exit pro-forma filled up by their customers and I or maintain a
suggestion box system to gather feedback.
Services marketing oppoatunity: This study was designed to
understand the dimensions of service quality to facilitate application of
the services marketing triangle of internal, external and interactive
marketing to better utilize the resources, provide the basis to build
accountability and transparency from the service providers and
participation, involvement and responsibility from the customers.
0 Profile of clientele: The education, income and awareness levels of
the clientele being predominantly of the lower level, the methodological
issues in understanding their perceptions of service quality and
expectations from a health care service provider needed to be
addressed.
Strengths / Weaknesses analysis: Being a hospital in the government
sector poses attendant challenges in the areas of pricing, social cost-
benefit analysis and expectations. Services are either free of charge or
heavily subsidized and the challenge lies in how to make the providers
and clientele more responsible in facilities use. This framework is quite
unlike that of private or corporate hospitals where high revenue
services can be maximized and low yield services withdrawn or
reduced. This study identifies those weaknesses of a public hospital
that can be addressed and reduced by the use of better management
practices. The study also presents the strengths of a public sector
teaching hospital that can be leveraged for pricing decisions in future.
 Demand patterns: As against a limited available facility, public
hospitals face a peculiar demand pattern of catering to a multitude of
patients on the one hand and a range of medical conditions spanning
extremely minor ailments to those requiring super-specialty care putting
the employees and facilities under great pressure. This condition is true
regardless of whether the hospital has been conceived to function at
the primary care, first level referral, secondary referral, or tertiary
referral level. A study of the implications on service quality as perceived
by the customers can be a useful input for assessing infra-structural
requirements, job design and training of various levels of employees.
Patients' Charters: A study of this nature can provide inputs to drafting
and implementation of Patients' Charters as a pro-active measure in
order to fulfil present and future expectations of customers.
e Provider-patient inequality: Such a study can positively influence the
re-designation of a patient as a customer or client, lending more
equality to the provider-patient dyad. The perception of unequal power
relations is particularly true of government hospitals, as the services are
free or very nominally priced.
Organizational culture and governance: In addition to the customers'
perspective, a study of the organizational setting and service culture
can provide inputs for a re-think on the policies of governance of a
public sector hospital.

2.2: THE RESEARCH SETTlNG

This study was conducted in the Jawaharlal Institute of Postgraduate
Medical Education and Research (JIPMER) Hospital, a tertiary care public
teaching hospital and medical research institute operated directly under
the Directorate General of Health Services, Ministry of Health and Family
Welfare, Government of India. JIPMER, located in Pondicherry in South
India, is internationally acclaimed for the quality of its under-graduate and
post-graduate medical education programs and consistently ranks among
the top five institutions in the country.
s Key respondents: This study has sought to bring to light the service
quality expectations and perceptions of customers of this public sector
teaching hospital from the point of view of its external customers - in-
patients, and key internal customers - consultant doctors and nursing
personnel.
0 Customer locations: Being a centrally administered referral hospital in
South India, the clientele or patients seeking treatment are drawn from
all the southern states of India, predominantly from Pondicherry Union
Territory and the neighbouring state of Tamil Nadu.
0 Prohibition of Private Practice: As against the hospitals run by the
various State Governments, Central Government Hospitals preclude
private practice and hence quality perceptions can be solely attributable
to the service experience within the hospital setting for the entire range
of services availed. This service condition applies for the employees of
JIPMER and hence customer perceptions are uninfluenced by the
private practice component. Consequently, findings and suggestions
emerging from the study can be more actionable and useful as it
reduces the need to shift from the generic theory to the specific
application.
Teaching and Research affiliation: As compared to any Government
Hospital per se, JIPMER Hospital is attached to a teaching and
research institution. While these components may contribute to the
quality of care, it must also be noted that the time of the employees
gets divided between fulfilling teaching, training and research
obligations and providing patient care. Other teaching hospitals in
similar contexts could draw valuable lessons from the findings.
* Generalimtion: This study can be replicated with minimal
modifications to the other centrally administered public sector hospitals
in the country. Fufiher, it can give more impetus to increasing
accountability and transparency from all the stakeholders involved in
the system.
A brief overview of the hospital and patient care related activities of the
institute would provide fuller justification for the choice of JlPMER as the
location for the study. The following section provides only details of patient
related aspects and does not cover medical education and research
activities.

-
2.3: JIPMER A PROFILE OF HOSPlTA L AND PA TIENT CARE
This section has been prepared by selecting the relevant information from
the Hospital Records, JlPMER Handbook, and web-site www.jipmer.edu
2.3.1 : Historical Background
e Medical school 'Ecole de Medicine de Pondichery' under the French
Government, established in 1823.
Taken over by Government of India with 'de jure' transfer of
Pondicherry, in 1956.
e College building inaugurated and named 'Jawarharlal Institute of
Postgraduate Medical Education and Research', July 1964.
JlPMER Hospital started functioning from April 7966.

2.3.2: Departments
Clinical services: Anaesthesiology, Dental Surgery, Dermatology, E.N.T,
General Medicine, General Surgery, Neurology, Obstetrics
& Gynaecology, Ophthalmology, Orthopaedic Surgery,
Paediatrics, Psychiatry, Preventive & Social Medicine,
 Radio-diagnosis & Radiotherapy, Tuberculosis &
Respiratory Diseases.
Super-speciality Services: Cardiology, Cardio-thoracic Surgery, Plastic
Surgery, and Urology.
Clinical Suppopt Services: Biochemistry, Blood Bank, Microbiology,
Pharmacy, Pathology, Physiotherapy, and Radiology.
Nursing Services: Assistant Nursing Superintendents, Nursing Tutors,
Nursing Sisters and Staff Nurses to provide Emergency,
Intensive Care, and Routine Nursing services.
Auxiliary Services: Central Sterile Supplies (CSSD), Kitchen, Laundry,
Medical Records (MRD), Sanitation, Waste Management.
Peripheral Services: Urban and Rural Health Centres, Mobile Health Clinics,
Mobile Operation Theatre.

2.3.3: Patient Care Services Profile

In addition to regular outpatient and inpatient services, JIPMER hospital
offers the following services:
Emergency Medical Care: Twenty-four hour services in a separate
Casualty Block, headed by a Casualty Medical Officer, functions on all
days, and is equipped with an emergency operation theatre. Resident
doctors and Duty doctors are available 24 hours, and Consultants are
available on call as and when required.

lntensive Care: Medical, surgical, and respiratory critical intensive care

units provide critical care services for cases of heart attack, poisoning,
stroke, etc. The hospital maintains fully equipped medical (MICU), surgical
(SICU), cardiac (CICU), and paediatric (PICU) intensive care units.

Super-speciality Care: The super speciality departments provide open

heart surgery for replacement of valves, by pass of coronary arteries
(Cardiothoracic surgery), genito urinary surgery (Urology), and the Plastic
surgery department runs a Burns unit. Breast Cancer screening & Surgical
Gastroentrology clinics, Video Laproscopic surgery and Nasal Endoscopic
Sinus surgery services were added in the recent past. The Orthopaedic
centre houses modern facilities with physiotherapy and occupational
therapy units. Cobalt teletherapy and brachytherapy units are available in
the department of Radiotherapy. Department of Cardiology is equipped
with a sophisticated 'Cardiac Cath Laboratory' and specializing in non-
surgical management of heart diseases. It is emerging as a number one
centre for implantation of 'pace makers'.

2.3.4: National Health Programs

9 Family planning, Leprosy Eradication, Malaria control, Prevention of
Blindness, ICDS, Control of AIDS, Expanded program of immunization.
0 The department of Psychiatry is recognized as one of the five National
Drug De-addiction Centres in the country.
Q The department of Microbiology is recognized as a Centre for Sero-
surveillance of HIV Infections and Viral Hepatitis.
Q AFP surveillance is conducted by department of Paediatrics, which is
also equipped with a Neonatology Unit.
Q The department of Pharmacology runs one of the six Adverse Drug
Reaction Monitoring Centres in the country and recently a Sleep
Laboratory has been set up to study sleep disorders.

2.3.5: Citizens' Charter

The hospital has drawn up a Citizens' Charter containing all information
about the following: General Information, Profile of Services including
Outpatient, Inpatient, Emergency, and Intensive Care, Possible Service
Standards, Service Timings, Special Clinics, Equipment and facilities,
 - - - - - -- - - - -

Amenities for patients and atiendants, Complaints Redressal Procedure,

Mortuary Services, and finally, the Responsibilities of the User. (The text of
the Citizens' Charter is presented as an Annexure).

2.3.6: Hospital Bed Strength: Total In-patient Beds = 860.

List A k k t B*

Medicine 129 Psychiatry

Cardiology 20 T.B. & C.D.
1 Neurology 12 Radiotherapy 8
1 Dermatology 39 Paediatrics 69
Surgery Cardio Thoracic Surgery 23
Urology Paediatric Surgery 25
Plastic Surgery 18 Casualty
Orthopaedic Surgery 58
Ophthalmology 37 TOTAL
E.N.T. 30 NOTE:
1 Dental 4 / 'Separate lists have been drawn up to 1
Obstetrics & Gynaecology 110 indicate that patients of these
(incl. Post Partum) departments are not included in this
Special Wards 65 study. The hospital makes no such
division.
[ TOTAL 667
Source: JlPMER Handbook,1999

2.3.7: Key Hospital Statistics 2000 -

Trends:
Considering the year 1998 as the base, the strength of
Outpatients treated has shown an increase of 4.71 percent. The
number of Inpatients served by the hospital has shown an
increase of 19.04 percent. Data regarding geographical
 distribution of inpatients sewed by the JlPMER hospital reveal
that about 78.5 percent of the users come from states outside
Pondicherry, although a major share of this group belongs to the
neighbouring state of Tamil Nadu. The 21.5 percent of patients
from Pondicherry who have used the services of the hospital,
also includes the employees and their dependents.
The hospital outpatient department attracts more than 4000 patients daily
not only from Pondicherry but also from the surrounding states of
Tamilnadu, Andhra Pradesh, Karnataka and Kerala. The inpatient
departments have 860 beds distributed among various medical, surgical
and super specialities. [Note: All figures are in Thousands]

Outpatients: 1277.078
Out-Patient New Cases : Pondicherry - 48.777, Others - 178.521
Casualty Attendance : 107.7
Bed Occupancy Rate: 117.3
Operations performed : 45.06 Deliveries: 9.416
Laboratory Investigations: Biochemistry: 773.593
Microbiology: 77.665
Pathology: 123.024

The following graphs and tables show the trends of patients' usage of the
hospital's services. In the tables showing outpatients and inpatients
served, the percentage change has been calculated using the year 1998
as the base in order to give an indication of usage. It must be noted that
during the three-year period there has not been a corresponding
enhancement of infrastructure and other resources. The geographical
distribution of patients has been presented over a period of twenty years
i.e., 1978, 1988, and 1998.
 --

Figure 2.3a: Trend of Outpatients at JlPMER

atients

Source: Hospital Records

Table 2.3a: Trend of Outpatients at JlPMER

Outpatients increase (%)

Year (number) (base year '97)
I

Source: Hospital Records

Figure 2.3b: Trend ~f Inpatients at JIPMER

Source: Hospital Records

Table 2.3b: Trend of inpatients at JlPMER

Inpatients increase (%)

Year (number) (base year '97)

1997 37,741

1998 38,504 763 (2.02)

1999 41,394 3,653 (9.68)

2000 44,925 7,184 (1 9.04)

Source: Hospital Records

Figure 2 . 3 ~ : Outpatients New Cases Geographical Distribution

200000

150000

a OOOOO
50000

L J
Source: Hospital Records

Table 2 . 3 ~ :Outpatients New Cases Geographical Distribution

Year Pondicherry Other States Total

Source: Hospital Records

 2.4: ORGANIZATIONAL S'bRUG'6URE
Figure 2.4: P a ~ i aOrganizational
l Chart

MEDICAL SUPERINTENDENT
Hospital Sewices

CONSULTANTS
Edn. & Hosp. Serv.
CHIEF NURSING / / MEDICAL OFFICERS 1
A I CASUALTY ' 1
/ SENIOR RESIDENTS / 1 1 / CLINICAL SUPPORT SERV I
I

P.G. RESIDENTS
NON P.G. RESIDENTS 1' I ' / AUXILIARY SERVICES

DEPUTY NURSING SUPDT.

I ASST. NURS. SUPDTS. /
I NURSING TUTORS I
NURSING SISTERS

Source: Original - constructed for the study

NOTES:
1. Consultants hold teaching designations - Director Professor, Professor, Associate
Professor, and Assistant Professor.
2. Resident Doctors under the supervision of consultants lend medical services and
undergo training.
3. In the nursing hierarchy, Asst. Nursing Superintendents, Nursing Sisters, and Staff
Nurses are the direct caregivers to patients.
4. Medical Officers supervise casualty / emergency, clinical support, auxiliary, and
peripheral services. They manage teams of employees responsible for the
respective services i.e., labs, medical records, pharmacy, sanitation, etc.
5. This chart presents only the portion of the hospital structure involved in patient care.
2.5 : HOSPITAL SERVICE PROCESSES
Figure 2.5~1:
SERVICE PROCESS: Entry As Outpatient

Records Clinic

L_ Admit as inpatient No
Y y 1* and Exit

Operation Theatre
U u
Post-operative care
u V
Outcome
Cured / Relieved Status quo / Worse Death

u u
I Referral & Discharge 1
EXIT EXIT EXIT

Source: Original - constructed for the study

NOTES:
1. Medical Records Dept. issues Case Sheets to patients and sends them to
appropriate Outpatient department clinic for getting consultants' services. Waiting
time can go up to more than two hours.
2. Patient faces long wait for Lab investigations, X-ray, as prescribed. Advised to return
at a later date for result and further consultation.
3. Diagnosed during next visit, given medical and follow-up advice. Collects available
medicines free from hospital pharmacy and exits. If needed, admitted as inpatient, if
bed available. Sometimes, patient has to make multiple visits for getting a bed.
4. For inpatient, treatment processes are at bedside if patient too ill to move, or guided
for investigations if support staff available and willing. Consultants take treatment
and training "ward rounds" along with their teams, spending time at patients' bedside
as per the medical needs and complexities of the case.
5. Patient given Discharge Summary with follow-up advice, referred to super-speciality
care (other public hospitals) if needed, or, in case of death, transferred to mortuary
and relatives advised immediately, to takeover within three days.
Figure 2.5b: SERVlCE PROCESS: Entry Yhro. Casualty / Emergency

+ Casualty /Emergency 3

.v V
Yes No
Intensive Care Unit Admit as inpatient?

4 V V
Yes
Transfer to inpatient ward

Source: Original - constructed for the study

NOTES:
1. Patient who enters the hospital via Casualty or Emergency Services Department is
given first aid as needed and kept under observation in the casualty ward.
2. Transferred to lntensive Care Unit if necessary, Emergency Surgery performed if
necessary, or admitted as inpatient and transferred to inpatient ward.
3. Subsequent processes are as already detailed in the previous figure.
4. While all patients are able to recall their outpatient service experience in the hospital,
most patients are not able to recount their experiences at the Casualty or Emergency
department. Patients rely on information provided by key accompanying person(s).
CONCLUSdON:
This hospital offers a unique setting among the public hospitals due to the
following factors: a) it is administered directly by the Ministry of Health,
Government of India, with service terms and conditions different from
individual state-run hospitals. Doctors here do not take up private practice
and all services delivered can be directly and completely attributed to the
hospital setting. b) it is a teaching hospital offering undergraduate and
postgraduate programs and hospital services are a part of the training and
research activities. c) although a referral hospital, due to lack of adequate
facilities in the surrounding area, the hospital treats routine as well as
referred patients with differing illness severity. The same reason makes
this hospital fairly representative of the patient population of the
neighbouring Tamil Nadu State and of parts of South India.
The inpatient population has been chosen for this study, patients being
derived from most of the clinical service departments of the hospital to
ensure representativeness of views.