TATA INSTITUTE OF SOCIAL SCIENCES, MUMBAI

MASTER’S OF HOSPITAL ADMINISTRATION (MHA)

STUDENT NAME: MARUFA FARUQI

ENROLMENT NUMBER: M2021HO021

SUBJECT: HO 2 HOSPITAL INTERNSHIP

INTERNSHIP HOSPITAL:
GCS MEDICAL COLLEGE, HOSPITAL & RESEARCH
CENTER, AHMEDABAD, GUJARAT.

Weekly Report 4:- 17th October – 22nd October 2022

17th October 2022 Monday

18th October 2022 Tuesday

• During this week, I had

19th October 2022
20th October 2022
21st October 2022
22nd October 2022
covered the Intensive Care
Unit (ICU) – details of which
are mentioned below
• Also, started working on the
new project “Quality
assessment of OPD services
using the RATER model”
• Prepared a list of the
parameters for the patients'
feedback, which will be
mentioned below
Wednesday
Thursday
Friday
Saturday

1) Details of ICU at GCS Hospital, Ahmedabad:

- An ICU is offers care for seriously ill patients requiring intensive monitoring and
multisystem support that may include mechanical ventilator support.

GCSMCH & RC has

- Adult ICU 19 beds, 3 isolation

- 8 beds in NICU and
- 5 beds in SICU
- 5 beds in PICU

All ICUs are equipped with multi parameter &cardiac monitors, defibrillator
machines, mechanical ventilators, non-invasive ventilators, ECG machines, Syringe
pumps, pulse oximeter and equipments for intubation &other invasive and non
invasive procedures and monitoring.
The ICU provides the following:
• Dedicated team of Intensive care doctors (Resident doctors, critical care
• trainees, and clinical assistants) led by a full time Senior Consultant Intensivist.
• Doctors will be available exclusively for this area round the clock, round the
year.
• A dedicateded team of nursing staff (staff nurses) led by a nurse In-charge
manages the patients.
• Support team of cleaning staff, and attendants shall assist the nursing staff as
the need be.
• Bed side services of Dietician and physiotherapy shall be available round the
clock.
 • Whenever required bedside diagnostic & therapeutic facilities like
Ultrasound, Echocardiography, Doppler, X-rays, Endoscopies, bronchoscopy
shall be available.

Equipments available in the ICU:

• Equipment provided should be suitable for the number of patient being treated.
• The Following equipment should be essentially available
• Equipment’s/ facilities provided:
• Piped O2 and compressed air and central vacuum for suctioning and means of
administering the same.
• Multi-parameter bedside (modular) monitors (with capability of monitoring ECG,
invasive & non-invasive BP, CVP, Respiratory rate, pulse ox metery) & cardiac
monitors.
• Mechanical ventilation assistance equipment including manual breathing bags
• (“Ambu-bag” Bain circuit), laryngoscope, endotracheal tubes.
• Defibrillators.
• ECG machines one in each ICU
• Thoracocentasis and tube thoracostomy sets.
• Tracheostomy and cricothyroidotomy sets.
• Infusion pumps.
• A crash cart within unit ready with drugs and equipment to handle emergency
situations as determined by the medical staff.

GENERAL INSTRUCTIONS IN ICU

Loud communication is not allowed inside the ICU.
X-ray / suctioning, change of posture, nebulization, physiotherapy etc., is done under supervision of
ICU nurse with additional supervision of a doctor where required.
Before any patient is transferred to ICU, admitting team shall discuss the case
with the ICU team with special attention to:
• Potential reversibility of basic disease
• Desire of family and patient to undergo aggressive medical care
• Financial implications of ICU care
Universal precautions to be followed at all times
Strict control on visitors’ traffic and no visitors to be allowed except in the visiting hours or as special
permission by the treating doctor.
When not in use, syringe pumps, portable pulse ox meters, ECG machine should be stored on the
designated shelves and wherever appropriate plugged into mains for charging batteries.
When not in use, ventilators and non-invasive ventilators (Bipaps) should be stored on the designated
area of the ICU and wherever appropriate plugged into mains for charging batteries.

ADMISSION CRITERIA
Intensive Care Unit (ICU) admission criteria: select patients who are likely to benefit from ICU care.
Each ICU admits patients with the following diagnosis respectively.

For All ICU’s: Hemodynamic instability is defined as-

a. Pulse less than 40 or more than 150 beats/ minute
b. Systolic arterial pressure less than 80 mm Hg or 20 mm Hg below the patient’s usual pressure.
c. Mean arterial pressure less than 60 mm Hg
d. Diastolic arterial pressure more than 120 mm Hg
e. Respiratory rate more than 35 breaths/ minute

A. Medical ICU
a. Pulmonary System
1. Acute respiratory failure (PaO2 less than 50 mm Hg) or (PCO2 > 45mmHg with
respiratory acidosis requiring ventilator support.
2. Pulmonary emboli with hemodynamics instability
3. Patients in an intermediate care unit who are demonstrating respiratory deterioration.
4. Need for nursing/respiratory care not available in lesser care areas such as floor or
intermediate care unit
5. Massive hemoptysis

b. Drug Ingestion and Drug Overdose

1. All drug overdoses or ingestions for the first 24 hours.
2. Hemodynamically unstable after drug ingestion
3. Drug ingestion with significantly altered mental status with inadequate airway
protection.
4. Seizures following drug ingestion.

c. Endocrine System and Metabolism related

1. Diabetic ketoacidosis complicated by hemodynamic instability, altered mental status,
respiratory insufficiency, or severe acidosis.
2. Thyroid storm or myxedema coma with hemodynamic instability.
3. Hyperosmolar state with coma and/or hemodynamic instability or Serum Glucose
more than 800 mg/dl
4. Other endocrine problems such as adrenal crises with hemodynamic instability.
5. Severe hypercalcemia (Serum Calcium more than 15 mg/dl) with altered mental
status, requiring hemodynamic monitoring.
6. Hypo or hypernatremia (Serum Sodium less than 110 mEq/L or more than 170
mEq/L) with seizures, altered mental status.
7. Hypo or hypermagnesemia with hemodynamic compromise or dysrhythmias
8. Hypo or hyperkalemia (Serum Potassium less than 2.0 mEq/L or more than 7.0 mEq/L)
with dysarrhythmias or muscular weakness.
9. Hypophosphatemia with muscular weakness (pH less than 7.1 or more than 7.7)

d. Miscellaneous Conditions
1. Septic shock
1. Hemodynamic monitoring
2. Clinical conditions requiring ICU level nursing care
3. Environmental injuries (lightning, near drowning, hypo/hyperthermia)
4. New/experimental therapies with potential for complications.
5. Infections with low platelet counts or coagulopathies.
B) SICU –SURGICAL ICU
1. After major surgery
2. After multiple trauma
3. After emergent surgery
4. Post operative complication
5. High C-Spine surgery
6. Extended burn injury
7. Severe sepsis with multiple organ failure
8. Critical care attending sees indication for intensive care.

C) PEDIATRIC ICU
a. Respiratory System
Patients with severe or potentially life-threatening pulmonary or airway disease.
Conditions include, but are not limited to:
1. Endotracheal intubation or potential need for emergency endotracheal intubation
and mechanical ventilation, regardless of etiology;
2. Rapidly progressive pulmonary, lower or upper airway, disease of high severity with
risk of progression to respiratory failure and/or total obstruction;
3. High supplemental oxygen requirement (FIO2 0.5), regardless of etiology;
4. Newly placed tracheostomy with or without the need for mechanical ventilation;
5. Acute barotrauma compromising the upper or lower airway;
6. Requirement for more frequent or continuous inhaled or nebulized medications than
can be administered safely on the general pediatric patient care unit (according to
institution guidelines).

Admission , Transfer Out and Discharge in ICU:

Activity Responsibility
1. Prepare bed to receive patient after Staff Nurse, Sister In-
receiving information (from ER, charge/senior most nurse
Ward, OPD, OT etc.); inform duty
doctor.
2. Receive patient on designated bed Staff Nurse, Sister In-
(transfer from trolley etc. safely). charge/senior most nurse
3. Quick nursing assessment of patient Staff Nurse, Sister In-
is done and vital signs are recorded. charge/senior most nurse
Appropriate monitoring devices are
applied
4. Quick assessment of patient by ICU ICU doctor on duty
doctor who will initiate immediate
treatment. Thereafter doctor will
assess regarding patient condition
and treatment from case records,
discuss with any doctor
accompanying and take
detailetakingstory from patient
relatives/attendants.
5. Take over from nursing staff Staff Nurse, Sister In-
accompanying the charge/senior most nurse
patient, including case records,
medications already
administered, review IV access and
IV fluids and drug
infusions on flow, other invasive
devices (arterial/CVP
lines, epidural catheter, ICD, Foley’s
catheter, Ryles
 tube etc.), orthopaedic devices (e.g.
external fixtures,
traction etc.), Cervical collars etc.;
enquire on surgery
performed, any special
nursing/medical instructions
for the patients etc
6. Make entries in admission book and Staff Nurse, Sister In-
census. charge/senior most nurse
7. Check about panel if corporate/TPA Staff Nurse, Sister In-
patient charge/senior most nurse
8. Medicines available in hospital Staff Nurse, Sister In-
pharmacy is used as per doctor’s charge/senior most nurse
prescription and billed for. All other
medicines are to be brought by
relatives.
9. If MLC case, MLC number is Staff Nurse, Sister In-
documented on file (if charge/senior most nurse
not recorded already)
10. Check for valuables (money, Staff Nurse, Sister In-
jewelry, watch, cell phone etc.), charge/senior most nurse
hand over to nearest relatives
available after obtaining signatures,
name, and relationship (on the
case file).
Remove dentures, spectacles, contact lenses
and hearing aid if patient is unconscious or
in altered sensorium and hand over to
relatives. Once the patient is conscious and
alert, these items may be used by the patient
again after permission from doctors.
11. Change patient into hospital clothes Staff Nurse, Sister In-
and hand over 1the patient clothes to charge/senior most nurse
relatives.
12. Explain to relatives about hospital Staff Nurse, Sister In-
routine – including visiting time, charge/senior most nurse
need to bring medicines etc from
time to time, approximate times of
consultant rounds and any other
clarification required by the patient’s
relatives. Ask relatives to keep a set
of clean clothes for the patient with
themselves at all times (required at
time of discharge).
13. Note contact details regarding close Staff Nurse, Sister In-
relatives especially mobile and land charge/senior most nurse
line numbers whenever available.
14. Nurses to follow treatment advised Staff Nurse, Sister In-
by doctors in writing. Any verbal charge/senior most nurse
order in emergency should be
written down by doctor afterwards
(signatures, name,date and time)
 15. ICU doctor shall first do a quick Staff Nurse, Sister In-
survey of the patient, stabilize the charge/senior most nurse
patient. Then he shall take a detailed
history and record the same on the file. All
ICU doctors are authorised to prescribe
medications during emergency/ initial
stabilization phase. All regular medications
are to be authorized by either the
admitting consultant team or the ICU
consultant(s).

Transfer from ward to ICU will be

The patient is shifted to ward on
consultant primary (admitting) or ICU team order.

Inform ICU duty doctor and consultant

Inform relatives and check with them what

category of bed they want to shift to. Direct them to front office regarding availability
and cost of beds/rooms etc.

Inform concerned ward sister before shifting. Patient to be shifted only when
bed is available and ready in the ward.

Inform receiving ward sister about panel/TPA, free patient, MLC etc.
Staff nurse from ICU to accompany the patient to the ward during transfer. File all
investigation reports, ICU charts etc. and hand over to receiving ward sister – explain
in detail about patient’s condition, medications being administered, current and any pending lab
reports etc.

Procedure in case a patient Discharge Against Medical Advise (DAMA)

Counsel patient and relatives regarding risk of leaving before being declared fit for discharge.
ICU doctor/consultants

Obtain written declaration/consent on the case file regarding intention to leave against medical advice
in patients’ or closest relative’s/attendants’ own handwriting mentioning they understand the risks
involved.

Ask relatives to clear bill – send to billing department. Send updated bill card to billing
department at the earliest.

Ask relatives to provide patient’s own clothes. If unable for some reason – bill for a set of clothes and
send the patient in the same.

Ask relatives to arrange for transport/ambulance.

Patient discharged after billing clearance slip is received. Hand over original copy of DAMA
summary, and investigation report after taking written receipt. If required transport on wheel
chair/trolley to the vehicle arranged for by the relatives.
 2) Project on Quality assessment of OPD Services using a RATER Model Questionnaire:

The RATER model

The RATER model helps in measuring the quality of services rendered, the acronym stands for:

Reliability
Assurance
Tangibles
Empathy
Responsiveness

TABLE 2: DIMENSIONS OF RATER MODEL

Dimension Explanation

Tangibles Well-functioning equipment as per the scope of services.

Visually appealing and pleasant physical environment

Adequate and well-groomed employees

The organization is being able to meet promised time-frames for

responding

Reliability Approaching customer problems in a reassuring manner

Acting in a dependable manner

 Keeping up to date, accurate records

Being able to tell exactly when the service will be

performed, if notbeing able to explain delays
Responsiveness

Timely addressal of queries and complaints

Assurance Employees behaving in a trust worthy manner

Feeling of safeness by customers when transacting with

employees

Employees behaving in a polite manner

Providing each customer with individualized attention

Empathy
Being able to comfort patients

Questionnaires developed using the RATER model aim to first measure the customer
expectation and then their perception of a service provided. Correspondingly the gaps between
what is delivered and what customers expected can be assessed from the difference.
Conceptual framework:

DIRECT OBSERVATION
QUESTIONNAIRES
TERTIARY CARE HOSPITAL OUT PATIENT DEPARTMENT COLLECTED FROM PATIENTS IN
THE OPD

ANALYZE DIMENSIONS OF
RELIABILITY, ASSURANCE,
TANGIBLES, EMPATHY AND
RESPONSIVENESS THROUGH
OBSERVATION
ANALYZE DIMENSIONS OF
RELIABILITY, ASSURANCE,
TANGIBLES, EMPATHY AND
RESPONSIVENESS THROUGH ANALYZE QUALITY OF
ANALYSIS OF DATA COLLECTED SERVICES PROVIDED IN THE
WITH THE QUESTIONNAIRE OPD OVERALL

FORMULATE SUGGESTIONS
AND FEEDBACK FOR
PROVIDING BETTER QUALITY
OF CARE BASED ON THE GAPS
IDENTIFIED

CONCEPTUAL FRAMEWORK OF THE STUDY

RATER MODEL QUESTIONNAIRE TO BE USED FOR THE PROJECT:

Rate the following factors associated with the services offered in the out-patient department on
a scale of 1-5 ( 1 being the lowest, 5 being the highest) based on how much you expect from
the service. Also rate on a scale from 1-5 for how satisfied you were with the actual services
delivered to you (your perception about the service received).

Reliability:

• Convenient working time of the OPD.

EXPECTATION:
1 2 3 4 5
 PERCEPTION:
1 2 3 4 5

• Reasonable waiting time for consultation.

EXPECTATION:
1 2 3 4 5

PERCEPTION:
1 2 3 4 5

• Convenience to reach the various consultation rooms and pharmacy in the

OPDEXPECTATION:
1 2 3 4 5

PERCEPTION:
 1 2 3 4 5

Assurance:

• Trustworthy OPD staff

EXPECTATION:
1 2 3 4 5

PERCEPTION:
1 2 3 4 5

• Polite OPD staff

EXPECTATION:
1 2 3 4 5

PERCEPTION:
1 2 3 4 5

• Sense of security in the

hospitalEXPECTATION:
1 2 3 4 5

PERCEPTION:
1 2 3 4 5
Tangibles

• Adequate seating area

EXPECTATION:
1 2 3 4 5

PERCEPTION:
1 2 3 4 5

• Provision for entertainment in the waiting

areaEXPECTATION:

1 2 3 4 5

PERCEPTION:
1 2 3 4 5

• Clean toilets

EXPECTATION:
1 2 3 4 5

PERCEPTION:
1 2 3 4 5

• Sufficient ventilation

EXPECTATION:
 1 2 3 4 5

PERCEPTION:
1 2 3 4 5

• Adequate registration

countersEXPECTATION:
1 2 3 4 5

PERCEPTION:
1 2 3 4 5

• Appropriate signage and boards for

directionEXPECTATION:
1 2 3 4 5

PERCEPTION:
1 2 3 4 5

Empathy

• Personalized attention to patient needs

EXPECTATION:
1 2 3 4 5

PERCEPTIO
N:
1 2 3 4 5
 • Readiness to help by the hospital staff

EXPECTATION:
1 2 3 4 5

PERCEPTION:
1 2 3 4 5

• Doctor’s explanation about the

treatmentEXPECTATION:

1 2 3 4 5

PERCEPTION:
1 2 3 4 5

Responsiveness

• Ease of taking appointment

EXPECTATION:
1 2 3 4 5

PERCEPTION:
1 2 3 4 5

• Promptness of service

EXPECTATIO
N:
 1 2 3 4 5

PERCEPTION:
1 2 3 4 5

• Prompt response to patient

requestsEXPECTATION:
1 2 3 4 5

PERCEPTION:
1 2 3 4 5

• Acknowledgement of complaints and

inquiriesEXPECTATION:
1 2 3 4 5

PERCEPTION:
1 2 3 4 5

EXPECTATIO
N: