mbiosis Institute of Health Sciences

Sy

A Dissertation on

“A STUDY ON THE OCCURENCE OF DEVIATION IN SURGERIES

FROM THE PREDICTED SURGERIES IN OPERATION THEATRE &
CATH LAB.”

Submitted by
HERA. H KHAN

PRN: 20040141117

Under the guidance of

Dr. Shrikrishna Dhale

Submitted to
Symbiosis Institute of Health Sciences,
(Symbiosis International University)
in partial fulfillment of the requirements for the award of the
Degree of Master of Business Administration
2020-2022

1
 ymbiosis Institute of Health Sciences
S

CERTIFICATE

This is to certify that the Project entitled “A Study on the occurrence of

deviation in surgeries from the predicted surgeries in Operation Theatre &
Cath lab” by Ms. Hera. H Khan is the bonafide work completed under my
supervision and guidance, hence approved for submission in Partial Fulfillment
of the requirement for the Degree of Master of Business Administration in
Hospital and Healthcare Management (2020-2022).

Date: __________ ________________________________

Dr. Shrikrishna Dhale
Assistant Professor, SIHS, Pune
(Internal Guide)

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 MBA-HOSPITAL AND HEALTHCARE MANAGEMENT 2020-2022

STUDENT
DECLARATION

Name: Hera Hasan Khan

Organization: Kokilaben Dhirubhai Ambani Super

Specialty Hospital, Mumbai

Project Title: “A study on the occurrence of deviation in surgeries from the

predicted surgeries in Operation Theatre & Cath Lab.”

Declaration:

I hereby declare that the project entitled “A study on the occur of deviation in surgeries
from the predicted surgeries in Operation Theatre & Cath Lab.” has been submitted
during the year 2020-2022 under the guidance of Dr. Shrikrishna Dhale at Symbiosis
Institute of Health Sciences, in partial fulfillment of the requirements of the Master of
Business Administration (MBA-HHM) degree from Symbiosis International University.

I hereby confirm that the project I have provided is solely my own effort. I have not copied
from any other student or from any other source either against payment or free, and I did not
provide any plagiarized material in any section of my report. I further confirm that the
documents provided are genuine and have been issued by the authorized person in the
organization.

HERA. H KHAN

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 ACKNOWLEDGEMENT

I take this opportunity to express my gratitude to the people who have been involved in the
completion of this project.

First and foremost, I would like to thank Dr. Mihir Dalal, General Manager, Clinical
Administration Department, and Dr. Prakash Padaya, Senior Executive Manager, Clinical
Administration Department, who gave me the opportunity to carry out the major concurrent
project, as well as all other employees of the organization who helped me either directly or
indirectly in this undertaking.

My sincere thanks to Dr. Rajiv Yeravdekar, Dean, Faculty of Health and Biomedical
Sciences, Symbiosis International University, and Director, Symbiosis Institute of Health
Sciences (SIHS), Pune. Also, to Dr. Pramod Kumar Mishra, Head of Department of MBA
(Hospital and Healthcare Administration), SIHS, Pune and to Mrs. Devika Shetty, Head of
Placements and Training, SIHS, Pune for allowing me to undergo the major concurrent
project.

I am extremely thankful to my internal guide, Dr. Shrikrishna Dhale, Assistant Professor,

SIHS, Pune, for his constant and timely support and supervision during my project.

I heartily thank the all the teaching and non-teaching staff members of SIHS, Pune, who have
helped me either directly or indirectly during the training period.

_____________________________________

HERA HASAN KHAN

PR No. 20040141117
MBA-HHM, Batch 2020-2022
SIHS, Pune

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5
Undertaking from the PG student while submitting her final dissertation
to his respective institute
Ref. No. _________

I/We the following student(s),

Sr. No. Students name Name of the Institute & Place Email & Mobile

1. Hera. H Khan SIHS, Pune hera.khanmba2022@sihspune.org

7070578701
(Note: Put additional rows in case of more no. of students)
hereby give an undertaking that the dissertation entitled “A Study on awareness and knowledge
of application of emergency codes among the non-clinical staff” has been checked for its
Similarity Index/Plagiarism through IEC, SIU software tool; and that the document has been prepared
by me/us and it is my/our original work and free of any plagiarism. It was found that:
1. The Similarity Index (SI) was: 6%
(Note: SI range: 0 to 10%; if SI is >10%, then authors cannot communicate ms;
attachment of SI report is mandatory)

2. The ethical clearance for research work conducted obtained from: SIU
(Note: Name the consent obtaining body; if ‘not appliable’ then write so)

3. The source of funding for research was: Self

(Note: Name the funding agency; or write ‘self’ if no funding source is involved)

4. Conflict of interest: No
(Note: Tick  whichever is applicable)

5. The material (adopted text, tables, figures, graphs, etc.) as has been obtained from Yes
other sources, has been duly acknowledged in the manuscript:
(Note: Tick  whichever is applicable)

In case if any of the above-furnished information is found false at any point in time, then the University
authorities can take action as deemed fit against all of us.

Hera Khan Dr. Shrikrishna Dhale

PRN: 20040141117 (Assistant Professor)

Date: ___________

Place: __________ Endorsement by

Academic Integrity Committee (AIC)

Note: It is mandatory that the Similarity Index report of plagiarism (only first page) should be appended to the
UG/PG dissertation

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7
 ABSTRACT

Introduction:

Surgery is an invasive technique with the essential principle of physical intervention on

organs/organ structures/tissues for diagnostic or healing motives. Deviation in surgeries
means shifting or change in the categories of the surgeries. It can be a powerful treatment
alternative for an extensive range of diseases and problems. whether in a complicated,
revolutionary surgical treatment or a technique that has been used efficiently lots of times.
Deviation detection is very crucial and has been studied in other domains, such as bank or
software security. Deviations are common in hospitalized surgical patients. This project is a
comparative study process and detecting deviations using a comparison between the surgery
clearance form of patients given from the admission desk and the surgery posted form in OT.

Objective:

To determine how often the deviation take place & to know the escalation of deviation for
surgeries to patient & hospital management.

Method:

It was a comparative study, aimed at measuring how constantly the deviation in surgical
categories happened an whether this was associated with an increase in adverse clinical event
& sample size of the study is 300 respondents. The method adopted for data collection was
the pre-operative surgical clearance form & postoperative form, which contain both
qualitative and quantitative necessary details.

Results and discussion:

A total of 300 pre surgical clearance forms were collected from the admission desk and was
analyzed with post operative clearance form collected from the Operation Theatre & Cath
Lab. The results were compared for calculating the deviation in surgical categories.

Surgery is an invasive technique with the fundamental principle of physical intervention on

organs/organ systems/tissues for diagnostic or therapeutic reasons. Deviation in surgeries

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means shifting or change in the categories of the surgeries. Deviation detection is very crucial
and has been studied in other domains, such as bank or software security. Deviations are
common in hospitalized surgical patients. This project is a comparative study process and
detecting deviations using a comparison between the surgery clearance form of patients given
from the admission desk and the surgery posted form in OT.

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 CONTENTS
NUMBER TOPIC PAGE NO.

TITLE OF THE PROJECT 1

CHAPTER 1 INTRODUCTION 11-31

1.1 Introduction 11-22

1.2 Kokilaben Dhirubhai Ambani Super Speciality 23-30

Hospital
1.3 Study Question 31

1.4 Objective 31

CHAPTER 2 REVIEW OF LITERATURE 32-39

2.1 Conceptual Discussion 32-35

2.2 Literature Review 36-39

CHAPTER 3 RESEARCH METHODOLOGY 40-45

CHAPTER 4 DATA ANALYSIS & INTERPRETATIONS 46-52

CHAPTER 5 CONCLUSION AND RECOMMENDATIONS 53-59

5.1 Findings And Discussion 53

5.2 Recommendations 54

5.3 Conclusions 55

5.4 References 56-57

5.4 Annexure 58-59

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 CHAPTER 1

INTRODUCTION

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 CHAPTER 1

INTRODUCTION

1.1 Introduction

Surgery is a medical branch that may be intended to treat injuries, ailments, and other disorders in
a practical and effective way. It, may be selective or emergency, which is done for many reasons.
The patient may undergo surgery for the following reasons:

• Continuously assess the condition for diagnostic purposes

• Take a suspicious biopsy of the tumour
• Remove or repair diseased tissues or organs
• Remove the obstacle
• Reset buildings
• Redirect blood vessels (bypass surgery)
• Insert all tissues or organs
• Install medical equipment or devices.
• Improve physical appearance

Surgery involves the management of serious injuries and illnesses as they are separated from
chronic illnesses, which grow slowly, except when patients with the latest form of the disease have
to undergo surgery. Surgical procedures are used to repair damage to the body or to remove
diseased tissue that affects a person's health and quality of life. There are different types of surgery
and they can be classified based on different parameters.

The following are the various types of surgical procedures that are commonly performed in
hospitals:

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• Appendectomy: This procedure involves the removal of an infected appendix
• Breast biopsy: A biopsy is used to remove a small sample of breast tissue cells to detect
the presence of breast cancer.
• Cataract Surgery: Cataract surgery is performed to remove a cloudy lens that covers
the eye and to replace it with a clear one.
• Cesarean section Surgery: A surgical procedure to give birth to a baby if it is not
possible to have a vaginal delivery.
• Coronary artery bypass: A bypass procedure performed to restrict blood flow to the
heart using arteries (harvested from the leg or chest) and connected to the area to pass
closure.
• D&C (Dilation and curettage): D&C is a minimally invasive procedure in which the
lining of the uterus and cervical canal is emptied, closing any dead cells or debris.
• Haemorrhoidectomy: Haemorrhoid removal is performed surgically to remove both
internal and external haemorrhoids.
• Repair of a hernia: Reconstruction of an inguinal hernia is a surgical procedure in
which a mesh patch is placed over a hole in the abdominal wall to prevent the intestines
or other organs from failing.
• Hysterectomy: Removal of all or part of a woman's reproductive system, including the
ovaries, fallopian tubes, cervix, and uterus.
• Hysteroscopy: This is a diagnostic procedure in which a device is inserted into the
uterus to detect any intrauterine disturbance.
• Lower lumbar surgery: Lower lumbar surgery is used to repair damage to the vertebrae
and reduce the severity of many types of back pain.
• Mastectomy: Mastectomies are surgical procedures that can involve the removal of the
whole or part of the breast as a way to remove the cancer. The procedure may also include
possible breast reconstruction.
• Partial colectomy: Removal of a small part of the large intestine or colon that is infected
or cancerous.
• Prostatectomy: Prostatectomy involves removing all, or part of the prostate gland,
enlarged or diseased.

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 • Tonsillectomy: Tonsillectomies are used to remove diseased tonsils and adenoids found
behind the throat.

There are two main types of surgical procedures that are performed in the hospitals, laparoscopic
and traditional surgeries. Providing preventive and curative treatment and help for sufferers and
victims of accidents and also ensuring the security and protection of sufferers, staff and visitors in
the healthcare facility during an emergency or accident.

The main difference between the 2 types is that the amount of tissue that's damaged during the
course of the procedure.

General surgery involves a variety of surgical procedures that are used to treat many ailments
related to the abdomen and other organs connected to it. These organs include the esophagus, small
intestine, stomach, colon, gallbladder, liver, pancreas, bile ducts, appendix, and often thyroid
gland. They are also used to treat diseases including skin, soft tissues, chest pain, trauma, and
hernia. They also include peripheral artery surgery and endoscopic procedures such as
colonoscopy and gastroscopy. The major of medical specialties includes general surgery, plastic
surgery, orthopedic surgery, obstetrics and gynecology, neurosurgery, thoracic surgery, colon and
rectal surgery, otolaryngology, ophthalmology, and urology.

• General surgery is the parent specialty and now centers on operations involving the stomach,
intestines, breast, blood vessels in the extremities, endocrine glands, tumors of soft tissues, and
amputations.

• Plastic surgery is related to the body area and the reconstruction work of the face and exposed
parts.

• Orthopaedic surgery affects bones, muscles, tendons, muscles; fractures of the extremities and
birth defects are common goals of treatment.

• Obstetricians perform surgical procedures, while gynecologists operate to remove implants from
the uterus and ovaries.

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• Surgeons work to remove tumors from the brain, to treat brain damage caused by fractures, and
to treat broken intravertebral bones that affect the spine.

• Thoracic surgeons treat lung disorders; The subspecialty of cardiovascular surgery is concerned
with the heart and its large arteries and has become a major field of surgical effort.

• Colon and rectal surgery deal with intestinal disorders.

• Otolaryngologic surgery is performed on the area of the ear, nose, and throat (e.g., tonsillectomy),
while ophthalmologic surgery deals with eye disorders.

• Urologic surgery treats urinary tract infections and, in men, genitals.

DIFFERENT TYPES OF SURGICAL PROCEDURES:

• Open Surgery: Open surgery is the normal type of surgery and it is defined by the
staples or stiches used to close the incision.
• Keyhole surgery: : Keyhole surgery is done through veritably small lacerations in a
case's skin with the use of a fine tube with a light on the end (known as a fibre optical
light source). The surgeon carries out the operation by using special instruments fitted
through the tube. Keyhole surgery causes lower pain and trauma for the case than open
surgery, and it's used for an adding number of conditions.
• Laparoscopic surgery: Laparoscopic surgery is analogous to keyhole surgery but refers
especially to operations performed inside the abdomen and in the peritoneum (the filling
of the abdomen).
• Microsurgery procedures: Microsurgery procedures: Microsurgery procedures use
important magnifying bias, and delicate and extremely small device to operate on bitsy
structures such as small arteries, nerves, the bones of the ear or inside the eye.

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Peri operative nursing:

Peri Nursing Operative Nursing care is provided before (pre-surgery), during (Intra Operative
Period) and after surgery (Post operative period). It covers all 3 stages of surgery.

1. The pre-surgery phase

2.Internal performance phase
3.Post operative category
Pre-surgical and postoperative care are both very important to restore patients as close to their
normal physiologic condition as possible. Blood transfusions, intravenous fluids, and the use
of measures to prevent common complications, such as lung infections and blood clots in the
legs, are major features of postoperative care.

▪ Pre- Operative Phase / Care / Procedures:

➢ It is the period from which a surgical decision is made until the patient is referred to the
Operation Theatre (OT). The future patient is called during the closure of continuous
surgery. Therefore, the waiting period for the next patient does not exceed 25-30 minutes.
❖ Procedures:
➢ 3H tests, CBC NET / RT PCR: Testing of test reports. It is compulsory for patients to
undergo the above-mentioned tests before surgery. The effectiveness of CBC NET / RT
PCR is 7 days and 3H is 3 months.
➢ Collect aesthetic clearance, surgical clearance: It is obligatory to obtain an aesthetic
permit and a pre-surgical consent.
➢ Collect permit forms: Collect a copy of the authorization form generated by the login
desk.
➢ Take a Blood Permit: To take a patient's blood permit before surgery.
➢ Ready for surgery: After the completion It is the period from which a surgical decision
is made until the patient is referred to the Operation Theater (OT). The future patient is

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 called during the closure of continuous surgery. Therefore, the waiting period for the
next patient does not exceed 25-30 minutes.

▪ Intra Operative Phase:

➢ It is the time when a patient is referred to the operating table and continues until the
patient is transferred to the recovery area after surgery The rescue room on OT is also
used as a pre-surgery room.

▪ Post-Operative Phase / Care / Procedures:

➢ This phase starts from the entrance to the recovery area and continues until the client is
discharged from the care of the surgeon.
❖ Procedures:
➢ The anaesthesiologist will decide whether to take the patient to the ICU or Rehabilitation
Room.
➢ First assess the patient's priorities in the recovery room.
➢ The average time in the recovery room for patients to recover is 1-2 hours.
➢ Once the patient is stable and recovering, they are transferred to the appropriate wards.
➢ It is the time when a patient is referred to the operating table and continues until the
patient is transferred to the recovery area after surgery The rescue room on OT is also
used as a pre-surgery room.

SURGICAL PROCEDURES ARE CLASSIFIED BASED ON THE ADMISSION BASIS:

1. Elective Surgery:
➢ It's a procedure that's pre planned and grounded on cases’ choice and vacuity of
scheduling for the case, surgeon and the installation Delay of surgery has no ill effects.
➢ Examples: Hernia repair, Cataract extraction, Tonsillectomy, Hip prosthesis etc.

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2. Urgent Surgery:
➢ It's the Critical surgery that must be done with in a nicely short time frame to save
health. Generally done within 24-48 hours Examples: Removal of gall bladder,
Amputation, Appendectomy.
3. Emergency surgery:
➢ It is the Exigency surgery that must be done incontinently to save life, a body part or
function. Examples: Control of haemorrhage, Repair of trauma, perforated ulcers,
intestinal obstruction.
.

SURGERY BASED ON DEGREE OF RISK

1. Surgeries are classified Surgeries are classified into colorful orders similar as Minor,
Intermediate, Major, Major Plus, Supramajor, Supramajor B plus & Supramajor A plus
depending on the soberness of the illness, the corridor of the body affected, the complexity of
the operation, and the anticipated recovery time.

❖ Minor Surgeries:
➢ Minor surgical procedures are minimally invasive. In most cases, these are performed
laparoscopically or arthroscopically. Small incisions are made that allow surgical tools
and a small camera to be inserted into the body. This allows the doctor to perform the
procedure without damaging extensive amounts of tissue. The risk of infection is
greatly reduced and therefore the patient's recovery time is far shorter. There also are
surgical procedures that are superficial, only affecting the outermost portions of the
body.
➢ It's the Critical surgery that must be done with in a nicely short time frame to save
health. Generally done within 24-48 hours Examples: Removal of gall bladder,
Amputation, Appendectomy.
➢ Following are some main minor categories of surgeries:

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 (1) Cataract surgery:
➢ During cataract surgery, the clouded lens is removed, and a transparent artificial
lens is usually implanted. In some cases, however, a cataract could even be removed
without implanting a man-made lens. Surgical methods used to remove cataracts
include: Using an ultrasound probe to interrupt up the lens for removal.

(2) Dental restorations:

➢ If the teeth are missing, decayed, weakened or fractured, it'd need a dental
restoration. samples of dental restorations include fillings, crowns, implants,
bridges and dentures. Restorations are the numerous ways during which a dentist
can replace or restore the missing teeth or missing parts of the tooth structure, or
structures that need to be removed to stop decay which can cause pain within the
longer term.

(3) Breast biopsy:

➢ A breast biopsy may be a procedure to get rid of a sample of breast tissue for testing.
The tissue sample is shipped to a lab, where doctors who concentrate on analysing
blood and body tissue (pathologists) examine the tissue sample and supply a
diagnosis. Following are the kinds of breast biopsies:
• Fine needle aspiration (FNA) biopsy:
➢ Fine needle aspiration (FNA) biopsy is a really thin needle is placed into the lump
or area of concern. alittle sample of fluid or tissue is removed. An FNA biopsy is
be make visible if the world may be a fluid-filled sac (cyst) or a solid lump.
• Core needle biopsy:
➢ An outsized needle is guided into the lump or area of concern. It requires no cut
and cores are removed. Cores are small cylinders of tissues.
• Open (surgical) biopsy:
➢ A cut is made within the breast. Part or all of the lump or area of concern are
removed. In some cases, the lump could also be small, deep, and hard to seek out.
Then a wire localization also can be used. it's procedure during which a skinny

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 needle with a really thin wire is inserted into the breast. X-ray images help guide
it to the lump.
• Stereotactic biopsy:
➢ During this procedure, a 3D image of the breast is made from a computer and
mammogram results. This image then guides the biopsy needle to the accurate area
of the breast lump or area of concern.
• Vacuum-assisted core biopsy:
➢ A little incision is made within the breast. A hollow tube or probe is inserted
through the cut. It helps to the breast lump or mass by MRI, X-rays, or ultrasound.
➢ The breast tissue is gently pulled into the probe. Many tissue samples are taken at
the time then a spinning knife inside the tube cuts the tissue from the breast
• Ultrasound-guided biopsy:
➢ During this method ultrasound images are used of the breast lump or mass. These
pictures assess the needle to the precise biopsy site.

(4) Arthroscopy:

➢ It is a procedure for diagnosing and treating joint problems. A surgeon inserts a

narrow tube attached to a fiber-optic video camera through a touch incision about
the size of a buttonhole. The view inside your joint is transmitted to a high-
definition video monitor.

(5) Laparoscopy:

➢ Laparoscopy could also be a kind of surgery that allows a surgeon to access the
within of the abdomen (tummy) and pelvis without having to make large incisions
within the skin. This procedure is additionally mentioned as keyhole surgery or
minimally invasive surgery.

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(6) Burn excision and debridement procedures:

➢ In this procedure healthy tissues are allowed to heal and to prevent more damage
or infection, burned tissue is removed during a procedure called burn
debridement. Burn debridement are often done by several different methods.
They include surgical, chemical, mechanical, or autolytic tissue removal.

❖ Major Surgeries:
➢ Major surgery normally involves opening the body, allowing the surgeon access
to the zone where the work must be completed. It involves major trauma to the
tissues, a high risk of infection, and an extended recovery period. Most major
surgeries will leave an outsized scar.
➢ There are some main major categories of surgeries:

(1) Wound Treatment:

➢ There are three general techniques of wound treatment; primary intention, during
which all tissues, including the skin, are closed with suture material after
completion of the operation; secondary intention, during which the wound is left
open and closes naturally; and third intention, during which the wound is left open
for variety of days then closed if it's found to be clean. The third technique is used
in badly contaminated wounds to allow drainage and thus avoid the entrapment of
microorganisms.

(2) Extirpative Surgery:

➢ Extirpative surgery involves the removal of diseased tissue or organs. Cancer
surgery usually falls into this category, with mastectomy (removal of the breast),
cholecystectomy (removal of the gallbladder), and hysterectomy (removal of the
uterus) among the foremost frequent procedures.
(3) Reconstructive Surgery:
➢ Reconstructive surgery deals with the replacement of lost tissues, whether from
fractures, burns, or degenerative-disease processes, and is particularly prominent

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 within the practice of cosmetic surgery and orthopaedic surgery. Grafts from the
patient or from others are frequently wont to replace lost tissues.
➢ Reconstructive surgery also uses artificial devices (prostheses) to exchange
damaged or diseased organs or tissues. Common examples are the utilization of
metal in reconstructing hip joints and therefore the use of plastic valves to exchange
heart valves.

(4) Transplantation Surgery:

➢ Transplantation surgery involves the utilization of organs transplanted from other
bodies to exchange diseased organs in patients. Kidneys are the foremost
commonly transplanted organs.

DEVIATION IN SURGERIES:

Deviation in surgeries means shifting or change in the categories of the surgeries. Sometimes, due
to some complications exact medical condition of the patient can’t be properly diagnosed and, on
that basis, prescribed surgery category is different than the actual surgery posted in the OT

There are mainly following reasons for the deviation in surgeries:

• Context Deviation: Deviations due to patient’s particularities as anatomic specificities,

patient’s pathology, and co-morbidity; this category also considers all deviations due to
the surgical context, as operating room disruptions.
• Expert deviations: Deviations due to the surgeon who performs the surgery; this
category includes deviations due to surgical expert knowledge, and surgeons’ habits or
preferences.
• Event deviations: Deviations from the usual surgical process to correct or limit the
impact of individual adverse effect.

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 1.2Kokilaben Dhirubhai Ambani Super Specialty Hospital

Kokilaben Dhirubhai Ambani Hospital & Medical Research Institute is India’s one of the most
advanced tertiary care facilities. As the flagship social initiative of the Reliance Group headed by
Anil Dhirubhai Ambani, it is designed to raise India's global standing as a healthcare destination,
with emphasis on excellence in clinical services, diagnostic facilities and research activities. It
represents a confluence of top-notch talent, cutting-edge technology, state-of-the-art infrastructure
and, most vital, commitment. Best defined by the analogy of four pillars, this unique combination
acts as the foundation of the institution's vast range of differentiated healthcare services. It is a
private sector hospital based in Mumbai, India 750-bed capacity, 180 critical care beds, and 22
state-of-the-art modular operation theatres 1500 healthcare providers, 240 globally renowned
super specialists, and 300 paramedical. It was founded by Mr. Dhirubhai Ambani along with the
Mandake Foundation of Dr. Nitu Mandake (Cardiologist) on 25th January,2009.

Kokilaben Hospital offers doctors and patients cutting-edge diagnostic and surgical solutions as
well as the latest in IT systems. In many cases, they represent the primary of their kind within the
region. Kokilaben Dhirubhai Ambani Hospital & Medical Research Institute is fully geared in
terms of talent, technology, structure and spirit – to reshape perceptions regarding hospitals and
redefine the concept of caring. Indeed, this globally benchmarked institution marks the start of a
replacement era in Indian healthcare.

Aim

“To be a worldwide healthcare institution that mixes the simplest in medical treatment with strong
ethical principles and a culture of care and compassion.”

Integrity

To deal with all stakeholders - patients, partners, employees, vendors and the community - in a
spirit of fairness and integrity.

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Transparency

To respect the patient's right to understand at every touch point by providing information that's
clear, concise, relevant and straightforward to know.

Maximum Care

To re-evaluate every hospital system, process and procedure to ensure that patient and their loved
ones receive maximum care and comfort.

Self-Improvement

To instill a process of learning and self-improvement at every level through continuous training,
focused research and referee.

Patient Dignity

To safeguard the dignity of patients by protecting their individuality and privacy in the least times.

Social Responsibility

To dedicate itself to living up to its responsibility in social service, community health, and
environmental safety.

Patient Safety

To take responsibility in building a culture of safety and to instill a “just” culture promotes patient
safety to make healthcare safer for everyone.

Passion for Excellence

To believe having a passion for excellence in every aspect of the work we do; within the overall
delivery of service to our customers, in ensuring that we meet the highest international standards.

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Vision

To create a patient-centric, tertiary healthcare organization focused on non-intrusive quality care

utilizing vanguard technology with a person’s touch.

We aim to be a worldwide healthcare institution that mixes the simplest in medical treatment with
strong ethical principles and a culture of care and compassion. “

- Late Shri. Dhirubhai Ambani

Mission

• " To be an institution that offers comprehensive quality healthcare services under one
roof through transparent patient-centric care ensuring patient safety, privacy and dignity.
• An institution where Every Life Indeed Matters. "
• Achieve Professional Excellence in delivering Quality care.
• Ensure care with Integrity and Ethics.
• Push frontiers of care through Research and Education.
• Adhere to National and Global Standards in Healthcare.
• Provide Quality healthcare to all Sections of Society.

Key Statistics

➢ It encompasses 10 lakh sq ft of space spread over 17 floors and two basements. Its
'intelligent framework' allows for hospital staff to optimize utilization of space and
resources.
➢ It accommodates over 750 inpatient beds, allows optimal utilization of resources and
ensures privacy, dignity, comfort, convenience and the best healthcare to every patient.
However, the smooth and seamless movement of people & staff is guaranteed.
➢ Critical care unit is the largest number of critical care beds in Mumbai, with 180 ICU
beds. Special technical features in ICUs include ceiling-mounted, dual-arm pendants,
which make sure that the space round the patient isn't cluttered. Another unique feature

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 is devoted air supply that keeps the critical care area freed from any quite contamination
and infection.
➢ Kokilaben Hospital has a total of over 240 independent consulting clinics, with the
capacity to handle over 9,000 outpatient consultations every day.
➢ Movement in the hospital is managed by 30 elevators —the largest elevator bank for any
hospital in India capable of transporting 7,500 persons per hour, with different elevators
for inpatients, outpatients, staff and catering.
➢ Two dedicated elevators ensure quick transfer of patients to Operation Rooms and ICUs.
➢ The hospital’s laboratory is housed on a single floor spread over an area of over 40,000
sq ft. It offers over 3,000 routine and highly advanced diagnostic, genetic and molecular
biology tests and will serve as a referral center for second opinions.

Technology

• da Vinci Surgical System (Robotic Surgery)

• O-arm TM Surgical Imaging Systems
• Orthopaedic, ENT and Neuro Navigation Systems
• Armeo Spring, a computer-enhanced rehabilitation Device to improve hand and arm
impairments for patients suffering from strokes, brain injuries or neurological disorders.
• Lokomat Pro, a Robotic-driven Gait Orthosis and Computer-enhanced Rehabilitation
device to improve walking in neurologically impaired patients.
• Radiation Oncology Linac Suites equipped with Trilogy for radiotherapy and Novalis
Tx for precise and pain-free radiosurgeries.
• EDGETM – the most powerful Stereotactic Radiosurgery tool for cancer treatment
• Tesla MRI
• 40 Slice PET CT, SPECT and 64 Slice Dual Source CT
• The Largest Multi-Specialty Rehabilitation Complex spread over 30,000 sq. feet area
• Gait & Motion Analysis Lab for patients with cerebral palsy and stroke
• Aquatic Treadmill for sports and neurological rehabilitation
• External Counter Pulsation (ECP) machine for refractory cardiac failure

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Unique Features of the Hospital

• A Full Time Specialist System

• 300 Paramedics
• Level-1, 24-Hour Accident & Emergency Centre
• 180 Critical Care Beds
• 22 Operating Theatres
• The Largest Dialysis Centre in Mumbai with 42 machines
• 56 Patient Relative Accommodation
• State-Of-The-Art Convention Centre with capacity to accommodate 750 delegates
Services
• Dr. Nitu Mandke Convention and Exhibition Centre
• Well-equipped Pharmacy
• Other Amenities: 24-hour Pharmacy, Prayer Room, Salon and Spa, Gift Store, Travel
Desk, Patient Relative Accommodation
• ISO 22000:2018 (Food Safety Management System) audited Kitchen Facilities that
ensure safe and healthy meals for our patients and visitors.

Specialties

▪ Centers of Excellence

➢ Centre for Accident and Emergency

➢ Centre for Bone and Joint
➢ Centre for Neurosciences
➢ Centre for Cancer (Oncology)
➢ Centre for Cardiac Sciences
➢ Centre for Children

27
 ➢ Centre For Cosmetology and Plastic Surgery (Aesthetic Clinic)
➢ Children's Heart Centre
➢ Centre for Critical Care
➢ Centre for Diabetes & Bariatric Surgery
➢ Centre for Mother & Child
➢ Centre for Physical Medicine and Rehabilitation
➢ Centre for Robotic Surgery
➢ Centre for Sports Medicine
➢ Centre for Transplant (Liver, Kidney, Bone Marrow, Heart, Lung) Specialties

▪ Specialty Departments

➢ Anaesthesiology
➢ Clinical Haematology
➢ Dental Surgery
➢ Dermatology
➢ Development Disorders
➢ Endocrinology & Diabetes
➢ ENT
➢ Foetal Medicine
➢ Gastroenterology
➢ General Surgery Genetics and Molecular Medicine
➢ Hepato Pancreato Biliary
➢ Internal Medicine
➢ Interventional Radiology
➢ Laboratory Medicine
➢ Minimal Access Surgeries (MAS)
➢ Nephrology
➢ Nuclear Medicine
➢ Ophthalmology
➢ Psychiatry
➢ Pulmonary Medicine
28
 ➢ Regenerative Medicine (Stem Cells)
➢ Radiology Reproductive Endocrinology and Infertility (IVF)
➢ Transfusion Medicine (Blood Bank)
➢ Urology
➢ Vascular Surgery Clinics

▪ Super Specialist Clinics

➢ Alzheimer's & Memory Clinic

➢ Autism Clinic
➢ Breast Clinic
➢ Cerebral Palsy Clinic
➢ De-addiction Clinic
➢ Diabetic Foot Clinic
➢ Glaucoma Clinic
➢ Heart Failure Clinic
➢ Stress Incontinence Clinic
➢ Kidney Stone Clinic
➢ Osteoporosis Clinic
➢ Paediatric Oncology Clinic
➢ Pain Management Clinic
➢ Parkinson's Movement Disorder Clinic
➢ Sleep Apnoea Clinic
➢ Thalassaemia Clinic
➢ Travel Clinic
➢ Varicose Vein Clinic
➢ Voice Clinic
➢ Wilson's Disease Clinic

29
▪ Support Groups

➢ Cancer Support Group

➢ Epilepsy Support Group
➢ Kidney failure Support Group
➢ Stroke Support Group

30
1.3 Study Questions

STUDY QUESTION

• What is the compliance rate of deviation in surgical categories?

• And how often deviation in surgeries occurred from the predicted surgeries in Operation
Theatre & Cath

1.4 Objective

• To get the financial surgical estimation transparency between the hospital & the patient.

• To know the escalation of deviation for surgeries to patient & hospital management.

• To avoid last moment IP billing grievances.

31
 CHAPTER 2

REVIEW OF LITERATURE

32
 CHAPTER 2

REVIEW OF LITERATURE

2.1 Conceptual Discussion:

Surgical care has been a necessary element of health care worldwide. As the frequentness of
traumatic injuries, cancers and cardiovascular complaint continue to increase, the impact of
surgical intervention on public health systems will continue to grow. Surgery is constantly the
single remedy that can lessen the disabilities and reduce the threat of death from common
conditions. Every time, numerous millions of people suffer surgical treatment, and surgical
interventions regard for an estimated 13 of the world’s total disability- acclimated life times
(DALYs).
While surgical procedures are intended to save lives, unsafe surgical care can beget substantial
detriment. Given the ubiquity of surgery, this has significant counteraccusations the reported crude
mortality rate after major surgery is0.5-5; complications after inpatient operations do in over to 25
of cases; in industrialized countries, nearly half of all adverse events in rehabilitated cases are
related to surgical care; at least half of the cases in which surgery led to detriment are considered
preventable. WHO has accepted a number of global and indigenous enterprise to address surgical
safety? Important of this work has stemmed from the WHO Second Global Patient Safety
Challenge “Safe Surgery Saves Lives”. Safe Surgery Saves Lives set about to ameliorate the safety
of surgical care around the world by defining a core set of safety norms that could be applied in all
WHO Member States.
To this end, working groups of transnational experts were convened to review the literature and
the gests of clinicians around the world. They reached agreement on four areas in which dramatic
advancements could be made in the safety of surgical care surgical point infection forestallment,
safe anesthesia, safe surgical brigades and dimension of surgical services.
While surgical care impacts a wide variety of conditions and conditions with non-operative and
operative services, both preventative and restorative, there has been little discussion concerning
how surgery might be integrated within the health system of a low and middle- income country

33
(LMIC), nor how strengthening surgical services may ameliorate health systems and population
health. They had reviewed reports from several meetings of the working group on health systems
strengthening of the Global Initiative for Emergency and Essential Surgical Care. It's revealed no
reports which concentrated on the integration of surgical services within a health system or as a
element of health system strengthening. An abstract model of how surgical care might be
integrated within a health system is proposed, grounded on the conversations of their working
group, combined with sources from the medical literature, and exercising the World Health
Organization's abstract model of a health system.
The lack of human resources, infrastructure and facilities means the necessity for surgical services
is immense. Most district hospital operating theatres do not have dedicated staff and half lack
adequate instruments, including sutures, for common surgical procedures.
Surgery features a neglected profile in global health, taking a back seat to other priorities despite
the very fact that surgical diseases disproportionately affect the world’s poorest people. Arguably,
essential surgical care should be a part of the essential right to health care. Surgery will got to
assume a more prominent role publicly health because the balance is tipped toward an increasing
prevalence of surgical conditions.
There is no specific mention of surgery within the Millennium Development Goals (MDGs)
despite the burden of surgically–amenable disease. Additionally, there has been little mention of
how improving basic surgical care would help to realize targets within the MDGs especially
MDG4 (reduce child mortality), MDG5 (improve maternal health) and MDG6 (combat
HIV/AIDS). Traditionally surgery has been viewed as an upscale tool of last resort after a failure
of medical therapy and one that has limited value as a prophylactic intervention.
Ensuring patient safety within the OR begins before the patient enters the operative suite and
includes attention to all or any applicable sorts of preventable medical errors (including, for
instance, medication errors), but surgical errors are unique to the present environment. Steps to
stop wrong-site, wrong-person, wrong-procedure errors, or retained foreign objects are
recommended, starting with structured communication between the patient, the surgeon(s), and
other members of the health care team. Prevention of surgical errors requires the eye of all
personnel involved within the patient’s care.
Potentially preventable surgical errors have received increasing attention in recent years, although
they seem to occur relatively infrequently compared with other sorts of medical errors. The Joint

34
Commission has collected data on reported sentinel events since 1995 with operation consistently
ranked because the most often cited reason 1. In 2008, the year that most up-to-date data are
available, there have been 116 operation sentinel events reviewed. Although specialty specific
statistics aren't included on the Joint Commission’s internet site, no surgical specialty is immune
from surgical errors. Classic examples within the specialty of obstetrics and gynecology include
wrong procedures, like ligation without consent.

35
2.2 LITERATURE REVIEW:

In the Journal of Health Services Research and Policy in the year 2006, Costs, Risks and Benefits
of Surgery was included in a list of 26 books which considered to have been leading in changing
health services and health care policy over the previous century and a half. How did Costs, Risks
and Benefits of Surgery come to be written?
In the early 1970s was characterized by a growing acknowledgement in medicine, public health
and the social sciences that contemporary health provision was neither evidence-based nor
necessarily what people would prefer, given true choices. The great variation in health care
utilization rates observed across countries and communities gave rise to legitimate questions about
macro-economic effectiveness and efficiency. In the Archie Cochrane's book Effectiveness and
Efficiency: Random Reflections on Health Services asserted and justified the view that much of
modern health care was not based on reasonable evidence about efficacy or safety.
In Cochrane’s book, it was especially popular in the USA, exemplified by Cochrane's recollection
Codman had proposed and implemented systematic assessment of the top results of surgery at his
hospital in Boston. Apart from it questions about the use of discretionary surgery had been raised
in the 1930s by Glover's demonstration of widely varying rates of tonsillectomy, in the late 1960s
and early 1970s witnessed an explosion of studies documenting unexplained inter- and intra-
national variations in surgical rates.
Every study raised fundamental questions about what was health care for, and ultimately for whose
benefit. When such different amounts of it were being delivered to apparently similar patient
populations with similar outcomes, it was not possible any longer to entertain the notion that all of
it was unambiguously beneficial and appropriate. The variations in cost were also very clear
(surgery is expensive), but the benefits and the consequent risks of these variations were much less
obvious. It seemed irrational to stay so ignorant when it had been so unclear that greater
expenditure resulted in greater aggregate benefit. It is given that the general level of uncertainty
evident throughout health provision, about the effects of most treatments, questions about how
much health care is best for communities cannot generally be resolved by knowing whether
treatment A is best (or not) than treatment B, among a selected group of patients. The justification
offered for top rates of surgery was often that prophylactic procedures (cholecystectomy and
hysterectomy, for example) prevented problems within the long run. However, although

36
prophylactic surgery with modern infection control and anesthesia might well fulfil the needs of
individuals, what were the costs for communities? Moreover, did the community want to use its
resources during this way, given other options? Why was there no strong evidence that, within
developed countries a minimum of, more health care resulted in measurably better health? Was
health care running Down with itself in places, on basically spurious inferred clinical benefit
grounds?
Also, they move to Harvard University with two of their experimenters who had contributed to the
surgical variation’s substantiation — John Bunker and Jack Wennber who handed a
encouragement to address some of these quandaries. Fred Mosteller, Professor of Statistics at
Harvard, and Howard Hyatt, Dean of the Harvard School of Public Health, had formerly planned
to have multidisciplinary forums, accompanied by a mess at the Faculty Club, and Bunker
converted them that the questions raised by the surgical variations data should be addressed.
The base for this kind of question and indeed numerous of the methodologies to address them had
formerly entered motivation from the creation, in the School of Public Health, of the Centre for
the Analysis of Health Practices (CAHP) in the early 1970s.
During the course of the series, it came apparent that although randomized trials were essential for
assessing the relative graces of some specific procedures, other exploration styles were demanded
as well, particularly as utmost of the issues sounded to concern well- established, but differing,
surgical practice styles about which individual surgeons weren't sufficiently uncertain to tolerate
arbitrary allocation. Likewise, the questions raised went beyond simply clinical issues, and were
therefore only incompletely amenable to better substantiation about attributable clinical issues. For
illustration, what was the part of redundant health care provision compared to other services? It
was plant that the acceptable clinical outgrowth information might come from routinely collected
data, reviews, modelling, or experimental studies — at least enough to suggest suppositions.
In India, there's an absolute need to enable accurate assessment of the standard of care for
individual cases with use for relative analysis of data addressed the problems with quality of
outgrowth dimension, substantially some models reduced the number of variables with clear
disadvantages using multifactorial analysis. The need for it can give an effective index of
outgrowth threat came necessary.
This study has been done specifically for vaticination & divagation in surgical cases. It uses
statistically significant, readily available 1 physiological and 6 operative mortality and morbidity

37
predictor variables also. A single scoring system applicable to all surgical cases would be an ideal
means for easing a relative surgical inspection. Several scoring systems have colorful degrees of
delicacy when prognosticating mortality, yet morbidity for further common complication in
optional surgery, which is nearly widely ignored.
There had been also plant the differences in preoperative and intraoperative threat factors to be
acclimated ahead comparing surgical issues. Still, the process is fraught with methodological and
policy challenges.
They've proposed ongoing surgical exploration in structure, process, and outgrowth with no real
agreement. The problem is analogous to grading colorful degrees of coma previous to the universal
use of the Glasgow Coma Scale. Indeed, now volume rather than quality exploration is a
concerning active issue in surgery. Also, there's an adding need to be suitable to give details of
prognosticated outgrowth, so there are no recriminations if the case dies while relating weakness
and strength to ameliorate the quality of the surgeon's daily morbidity and mortality conference.
The surgical literature has numerous papers addressing the question of how the quality of surgery
needs to be stylish measured. A large number of indicator predictor variable measures live more
in some specialties, for illustration, cardiothoracic surgery. The Society of Thoracic Surgeons
requests their surgeons to fill in a data distance on every case to add to the public data bank for
quality control.
The outgrowth threat assessment in surgery was assessed as an abecedarian pillar to any surgeon.
Therefore, they proposed to surgeons in academic centers a presumptive system to attack their
incuriosity of outgrowth threat dimension and inter center variability. It's still unclear that why the
diversion in surgical order from the prognosticated bones occurs so frequently. The time has come
to determine the prognosticated outgrowth precisely of the general surgery operations. The
recommendations are the following that can be espoused to backing are:
(1) To borrow and apply a simple honored threat scoring systems, for illustration, POSSUM or
NSQIP equations in each surgical department filled by a elderly occupant or attending about a
specific operation.
(2) To produce a departmental and central public score data registry from a timely systematized
collection exercise using a standard score distance.
(3) To start to compare outgrowth data among surgeons in each training position, for illustration,
elderly surgical residents across the nation to extend the exercise for attendings. and

38
(4) To modify the current predictor models for variables that are specialty and original practice
specific. This operation can be fluently espoused.
Later, similar academic centers can extend the exercise to supplemental community hospitals in
association with associates in other countries willing to meet the challenge of outgrowth dimension
in surgery in our period. The birth of an “International Society for Surgical Outcome " will be a"
necessary wrong “to track the quality of surgery and to bandy pathways to clinical excellence.

39
 CHAPTER 3

RESEARCH METHODOLOGY

40
 CHAPTER 3

RESEARCH METHODOLOGY

Methodology is an analytical, formal, evaluation of the processes used inside the study area. This
includes a theoretical evaluation of the strategies and ideas identified with the fact’s organization.
generally, it includes terms which include analytical model, theory, process and quantitative or
qualitative strategies.

A procedure is not supposed to include solutions-thus it is not the same as a method. Instead, it
provides the theoretical basis for understanding the process, collecting techniques, or so-called
"best practices" can be applied, for example, to calculate a particular outcome.

Research is a logical and systematic analysis of a given topic for new and useful information.
Scientific methodology is a systematic way to problem solving. It's a way to learn how to get the
work done. Essentially, methods used by researchers to describe, explain and forecast the
phenomenon are called methodologies of analysis.

RESEARCH DESIGN

A good research design has characteristics such as: problem identification, time required to
conduct research project and cost analysis, the research design seeks to ensure that the right data
are obtained and collected accurately and economically. The pure and simple structure is a research
design for a study which directs the collection and analysis of data. In this project the two main
types of research design are used:

41
➢ Exploratory Research:

All research projects start with the study of discovery. This is a preliminary move, and is absolutely
necessary to describe the issue properly in hand. The main focus is on finding out thoughts and
points of view. The exploratory approach is particularly useful in breaking large and unclear issues
into smaller, more precise sub-problem statements. Exploratory work is also used to make the issue
under investigation more familiar.

➢ Comparative Study:

This study is the act of comparing two or more things with a view to discovering something about
one or all of the things being compared. This study helps to define the organization structure of
the subjects as well as give the differential points between the subject’s matter. Comparative
studies are investigations to analyze and evaluate, with quantitative and qualitative methods, a
phenomenon and/or facts among different areas, subjects, and/or objects to detect similarities
and/or differences.

Sampling:

A plan was developed for the most effective collection of information when deciding the purpose
of the project. Decisions have been made on the data points, the sampling process and the methods
of study. Research is essentially a systematic enquiry that discovers facts through objective,
verifiable methods of discovering the relation between them to deduce from them particular
principles of rules.

Primary data: It includes data collected directly from the Kokilaben Dhirubhai Ambani, Super
Speciality Hospital in Mumbai, to meet the direct requirements of the investigation at hand.

Secondary data: It includes data from journals, websites and reference books.

Sampling Plan:

Non– probability sampling was endorsed for the survey to be conducted. They selected
customers based on ease of access. But convenience sampling was performed for primary data
collection. Depending on the object of the inquiry a sufficient number of sample units is chosen

42
intentionally or planned in this method, so that only the appropriate items reflect the true
characteristics of the population are included in the survey.

Sampling Size

A sample size of 300 patients whose Pre & Post Operative forms were collected from
Admission desk & Operation Theatre. Also interviews of Head Nurse & some other nursing
staff of Operation Theatre were conducted for 5-10 minutes about the awareness and
knowledge of surgical procedures and deviation in surgical categories and their adverse
effects.

Sampling Unit

The collection of data was done by collecting the Pre & Post Operative forms from Admission
desk & Operation Theatre. The survey was carried out via personal interviews to test the effect of
surrogate ads on the behavior purchasing customers to purchase the surrogate goods. The personal
interview method is better for understanding each individual response than other methods such as
telephone interviews, mailing questionnaires etc. I have selected the Retrospective research design
for my research.

METHODOLOGY ADOPTED

• Pre Operative forms of patient collected from Admission desk

• Post Operative forms of patient collected from Operation Theatre

RESEARCH DESIGN

Comparative Study

DATA COLLECTION METHODS

• Primary Data Collection Method

• Secondary Data Collection Method

43
PRIMARY DATA COLLECTION

Primary data collection approaches are as follows:

• Pre & Post Operative forms of patient collected from Admission desk & Operation Theatre
• Interviews

SECONDARY DATA COLLECTION

Secondary data collection approaches are as follows:

• Journals
• Internet

SAMPLING TECHNIQUES

Basis of Convenience Sampling (Non-Probability)

STASTICAL TOOLS

Following MS Office tools are being availed while preparing the project:

• MS Excel: Pictorial & graphical representation of data

• MS Word: Preparation of project & other reports

METHODS FOR PRESENTATION OF DATA

• Traditional method of data representation i.e. Pie chart, Bar chart etc.

Sample size:

Sampling Technique: The Project will be non-probability sampling.

Research Type: The project will be comparative study.

44
Tools for analysis

➢ Pie-chart (Circular diagram divided into sections, indicating relative magnitudes or

frequencies)

The data was collected from the Pre & Post Operative forms of patient collected from
Admission desk & Operation Theatre and then converted to the Excel format for analysis and
pictorial representations, as well as for observations and suggestions.

Face to face interaction was done with the Head Nurse & some other nursing staff of Operation
Theatre at a time. The duration of one interaction was 10-15 minutes.

METHODOLGY

✓ Study Area: Operation Theatre & Admission Desk of Kokilaben Dhirubhai Ambani Super
Speciality Hospital, Mumbai

✓ Study Period: 1st July,2021 – 2ND September,2021

✓ Study Type: Comparative Study

✓ Study Sample Size: 300 samples

✓ Sampling Type: Purposive Type of Non-Probability Sampling.

✓ Method of Data Collection: Pre & Post Operative forms of patient collected from
Admission desk & Operation Theatre.

✓ Tool Used: Microsoft Excel.

✓ Type of Data Collection: Mixed (Both qualitative and quantitative data was collected).

45
 CHAPTER 4

DATA ANALYSIS & INTERPRETATIONS

46
 CHAPTER 4

DATA ANALYSIS & INTERPRETATIONS

1.Level of Complexity Category in Surgical Procedures:

Fig No. 1

Interpretation:

Above mentioned figure is the different categories of the surgery. To calculate the number of the
deviation occurs from the predicted surgery this above-mentioned figure is used. If the number is

0 = No Deviation

1 = If the deviation goes 1 category upward

2 = If the deviation goes 2 category upward

3= If the deviation goes 3 category upward

-1= If the deviation goes 1 category downward

-2= If the deviation goes 2 category downward

-3= If the deviation goes 3 category downward

-4= If the deviation goes 4 category downward.

47
2. Compliance rate of Total Deviation in the sample:

Graph No. 2

DEVIATION
-2 -4
-1 -3
2% 0%
2 4% 0%
3%
1
7%

0
84%

Interpretation:

As shown in the Fig. Out of 300 OT surgeries and Cath lab cases, only 48 cases have deviations,
i.e., only 16% cases have deviations. However, the remaining 84% procedures are of same
category that is posted in OT & the clearance generated.

48
3. Compliance rate of Specific Numbers of Deviation:

Graph No. 3

DEVIATION
300

252
250

200

150

100

50
20
9 11 6
0 1 2 1 1
0
0 1 2 -1 -1 -2 -2 -3 -3 -4 -4
-50

Series1 Series2

Interpretation:

As mentioned in the graph, out of 48 deviated cases; in 20 cases there were found deviation of 1
Category upward, 9 cases were 2 categories upward, 11 cases had 1 category downward deviation,
6 cases had 2 categories downward, 1 case for 3 category downward & 1 cases of 4 category
downward from the predicted surgical category.

49
4. Compliance rate of Procedures which faced Deviation:

DEVIATIONS FOUND IN PROCEDURES

Sub aortic memberane & muscle resection
RPLND
Robotic Radical Cystoprostatectomy
Laproscopic Cholecystectomy
Segmental Mandilectomy
RUOT Relief
R TKR
Stellato Ganglion Block
Axis Title

TURP+ BNI
Total Knee Replacement
Excission Left Buccal Mucosa
TURP+ BNI
Cartoid Stenting

Bronchoscopy
TURP+ BNI
Cystoscopy + Stent Removal
-5 -4 -3 -2 -1 0 1 2 3
DEVIATION RATE

Interpretation:

As shown in the graph; mainly cases of procedures like Sub aortic membrane & muscle resection,
RPLND, Robotic Radial Cystoprostatectomy, Laparoscopic Cholecystectomy, Segmental
Mandilectomy, RUOT Relief, TKR, Stellato Ganglion Block, TURP, BNI, Excision of Buccal
Mucosa & Cartoid Stenting have faced Positive Deviations or Deviations to upward category from
the predicted category ; whereas Bronchoscopy some cases of TURP +BNI & Cystoscopy +Stent
Removal have Negative Deviations or Deviations to downward category from the predicted
category.

50
5. Compliance rate of Adverse Effect:

POST-OPERATIVE ADVERSE EFFECT

AFTER DEVIATION

12%

Adverse Effect after Deviation

Normal after Deviation
88%

Interpretation:

Above figure; represents that only 12 % i.e., 6 cases surgical deviated cases show post – operative
adverse effects. Remaining 88 %, i.e., 42 cases don’t show any adverse post – operative effects
after shifting the surgical category from the predicted ones. Negligible number of patients undergo
surgical resection, which may result in some trouble in physiological and psychosocial symptoms
from scars associated with the adverse effect post-surgery. Some common symptoms of Post –
operative Adverse Effects are frequency of discomfort, itching, nausea, sensations of numbness,
vomiting and overall troublesomeness.

51
 CHAPTER -5

CONCLUSION AND RECOMMENDATIONS

52
 CHAPTER -5

CONCLUSION AND RECOMMENDATIONS

5.1Findings and Discussion

➢ As the study shows out of 300 surgeries and Cath lab cases, only 48 cases have deviations,
i.e., only 16% cases have deviations. However, the remaining 84% procedures are of same
category that is posted in OT & the clearance generated.
➢ It’s a comparison methodology analysis. Out of 300 cases amount of deviation was
significantly very less.
➢ Although hyper deviation is seen in some patients, as we can’t eliminate deviation
completely.
➢ After the surgery is done Patients are shifted in Recovery area and are kept under
observation minimum for 6 hours for monitoring & 2 & half days for Therapeutic.
➢ If the patient is a day-care patient, then he will be discharged within 8 hours or a ward
patient then will be shifted in wards.
➢ In general, surgical category deviation; 6 cases surgical deviated cases show post –
operative adverse effects. Remaining 42 cases don’t show any adverse post – operative
effects after shifting the surgical category from the predicted ones.
➢ There are many reasons due to which adverse post – operative effects happen, such as
disagreement between preoperative care plans and observed clinical management.
➢ Some Pathological and intra-operative procedure complications are independent predictors
of deviation in surgery. Prolonged length of stay can be predicted by age, multiple
procedures and deviation.
➢ Some common symptoms of Post – operative Adverse Effects are frequency of discomfort,
itching, nausea, sensations of numbness, vomiting and overall discomfort.
➢ There are no recommended guidelines to reduce the Deviation in the surgery and treatment
is based more on the surgeon’s experience.

53
 ➢ In some cases, Deviation from the anaesthetic care plan also ooccurred, when surgical
prediction was inaccurate and independently associated.

5.2 Recommendations

• Consultants should inform the deviation to the patient/relatives circulated to billing/

admission department.
• Need to implement escalation metrics from IP Billing Department.
• Communication between the consultant and the patient’s relatives will be more transparent
so that the admission desk will generate a new clearance form to avoid last minute billing
grievances.
• Automatic notification should be sent on the patient UHID or the registered mobile no or
email id if there is deviation in surgery category for the further process to be done easily.

5.3 Conclusions

The deviation occurred from the predicted surgery is studied through pre & post-surgical
clearances patients forms of the hospital. The project guides in improving the knowledge about
hospital building and helps in the betterment of the hospital and service to the people in the
community. Deviation in surgical category occurs due to lack of co-ordination between the
consultant, admission desk & patient. And due to Escalation metrics. As shown in the study the
deviation cases in this hospital are very less. As surgeries are based on diagnosis and pre
assumptions, it is impossible to eliminate the chances of deviation completely. Whenever deviation
in surgeries occurs the surgeons stops the procedure and informs the relatives & ask for their
consent to further continue on. There are no such evidences that proves that post-surgical adverse
effects are associated with deviation in surgeries. Although a very minor post deviated surgical
adverse effects are found due to various other reasons.

54
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(https://www.sciencedirect.com/science/article/pii/S1040738319300814)

[13] Kennedy, E. D., Fairfield, C. J., & Fergusson, S. J. (2015). A neglected priority? The

importance of surgery in tackling global health inequalities. Journal of global health, 5(1),

010304. https://doi.org/10.7189/jogh.05.010304

[14] Patient Safety in the Surgical Environment from ACOG Clinic.

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(www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2010/09/patient-safety-in-

the-surgical-environment)

[15] Monitoring the Building Blocks of Health Systems: A Handbook of Indicators and Their
Measurement Strategies. Cited 563 times.World Health Organization, Geneva Accessed 2 Oct 14

(http://www.who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf)

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 ANNEXURE

QUESTIONNAIRE FOR THE INTERVIEW

[1] What are the primary responsibilities of a surgical technician/ nurses?

[2] If an infectious disease discovered during surgery, what do you do?

[3] What is the role of the first scrub and why they are important?

[4] Is it necessary to wear PPE during surgery?

[5] What steps are taken to ensure an operation room is sanitized?

[6] What are the major sanitation guidelines?

[7] What are the processes to account for medical equipment and waste after surgery?

[8] What is the protocol for handling specimens?

[9] Why is post-operation patient care so important?

[10] Why Deviation in Surgical Category occurs?

[11] What are the procedures, if a deviation occurs in between the surgery?

[12] If Deviation occurs either the deviated surgery is continued or first it is informed to patient’s

relatives or take the concern from them?

[13] What are the specific reasons of post- surgery Adverse Effect.

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[14] Is Adverse post- surgery effects is associated with the Deviated Surgery?

[15] What are some major problems or challenges that are faced in-between or after the deviation

in surgery?

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