This document discusses quality initiatives at Dr L H Hiranandani Hospital, an NABH accredited hospital in Mumbai. It provides an introduction to the hospital's history and mission of providing quality healthcare. It outlines how quality is emphasized at every level of care delivery, from interactions with security and cleanliness to nursing, doctors, and leadership. Charts show high patient satisfaction ratings. Best practices for maintaining quality include reviewing feedback, clear communication, identifying issues, and responding to complaints promptly. The hospital aims to be the preferred choice for healing through its commitment to continuous quality improvement.

1. A NABH Accredited Hospital
Dr L H Hiranandani Hospital
“Your family hospital TM”
“ To be the preferred choice for healing and good health”

2. A NABH Accredited Hospital
Achieving Patient Delight
With Quality
Dr (Col) V M P Thomas
Associate Vice President
Operations & Projects
Dr L H Hiranandani Hospital

3. A NABH Accredited Hospital
Structure of Presentation
 Introduction
 Quality at every level
 Our experience
 Conclusion

4. A NABH Accredited Hospital
Introduction – Genesis
 Dr LH Hiranandani Hospital Powai
 Conceived in the honor of Padmabhushan Dr L H Hiranandani
 Arguably the fastest hospital project in India
 Broke ground in Nov 2002
 Commissioned 22 Feb, 2004
 Expansion work begins 28 Nov 2008
 Completion – March 2011
 Hiranandani Hospital Thane
 25 July, 2004
 Hiranandani Multispecialty Hospital Thane
 Foundation stone – 17 Sep 2011

5. A NABH Accredited Hospital
Introduction – Focus and strategy
 The Trustees were desirous that the hospital emulate
global standards in healthcare, empathize with patients
and attend to all who applied for assistance
 The hospital’s focus thus encompassed
 Hiranandani Gardens township initially
 The country and then the International scene
 Public charitable trust hospital
 Thus strategically the hospital while being a Trust
hospital was to strive to render the best health care
 This being in line with the below stated mission

6. A NABH Accredited Hospital
Introduction – Mission Statement
“To be the preferred choice for healing and
good health”

7. A NABH Accredited Hospital
Introduction – Quality Policy
“We are committed to rendering the best
available medical treatment to our patients.
Therapy will be evidence based and will
emulate global standards in every sphere.
We will strive to improve the quality of care
at every given time, thus ensuring patient
satisfaction”

8. A NABH Accredited Hospital
Introduction – Values
 Respect and Dignity – Compassion and caring for the
whole person – body and soul
 Continuous Improvement – In every sphere and
emulate global standards
 Teamwork – Many hands, many minds, with a single
purpose
 Service – Enhancing community health by delivering
superior value in high quality cost effective healthcare
 Pride – In ourselves, our hospital and our work

9. A NABH Accredited Hospital
Introduction – Quality
 There are many definitions of quality and possibly text
books written about how one defines quality
 There is one simple definition – Quality is the result
when a task is performed with the greatest care
 In healthcare the watch word is ‘CARE’.
 Care thus will translate into quality and that results in
the happiness quotient - DELIGHT

10. A NABH Accredited Hospital
Introduction
Patients do not care how much you know
They want to know how much you care

11. A NABH Accredited Hospital
Quality at every level
 Every time a patient or family members
interact with a staff member, the patient has an
opportunity to rate us as Delighted, Satisfied
or Dissatisfied
 These are our “Moments of Truth”
 We try to control these experiences by
assuring that all interactions are handled
respectfully and to the best of our ability

12. A NABH Accredited Hospital
Quality at every level
Greeting at the door by the
security person

13. A NABH Accredited Hospital
Quality at every level
Cleanliness of the lobbies and elevators

14. A NABH Accredited Hospital
Quality at every level
Clarity of Interaction with
directions to the information desk
room of the
patient

15. A NABH Accredited Hospital
Quality at every level

16. A NABH Accredited Hospital
Quality at every level
 Nurses
 Backbone of healthcare delivery
 Highest quality of care & motivation
 Overseas training and external audit
 Soft skills, communication & grooming
 Leadership & managerial skills
 Cadre review
 Altered pay structure

17. A NABH Accredited Hospital
Quality at every level
 Doctors
 Judicious blend of full time & part time
 Incentives to get the best out of them
 Full time doctors taken as partners
 Revenue share does not limit the capacity to earn
 Support to part timers by CME & awareness
programmes

18. A NABH Accredited Hospital
Quality at every level

19. A NABH Accredited Hospital
Quality at every level

20. A NABH Accredited Hospital
Quality at every level
 Senior leadership has created an environment
of
 Constant focus on performance improvement
 Team work
 Innovation
 Work force safety
 Fiscal performance
 Process to identify errors and address them

21. A NABH Accredited Hospital
Quality at every level
 Strategic planning process has human resource
development as an integral part of the plan
 Hospital staffing
 Adequate for current hospital operations
 Regular salary review
 Salaries are marked to market
 Good selection process to ensure the correct fit of
the individual into the organisation

22. A NABH Accredited Hospital
Quality at every level
 Organisation nurtures a culture of motivating
employees to perform well as a team and as
individuals
 Constant training & retraining at all levels
 Best employee every month
 Best department
 Employee satisfaction survey is carried out annually
with trends indicating decreasing dissatisfaction
levels and attrition since inception
 Considerable multitasking – individuals capable of
taking on each others responsibility at various levels

23. A NABH Accredited Hospital
Quality at every level
 ISO 9001:2000 / 9001:2008 QMS
certification, NABH & NABL
 Except for the ISO 9001:2001 – without external
consultants
 System based approach
 Perfect documentation
 1800 documents with 26000 pages created
 Environment which fosters and requires
 Legal
 Ethical behaviour
 Ethics committee evaluates ethical issues

24. A NABH Accredited Hospital
Our experience


25. A NABH Accredited Hospital
Our Experience - 2008

26. A NABH Accredited Hospital
Our Experience - 2009

27. A NABH Accredited Hospital
Our Experience - 2010

28. A NABH Accredited Hospital
Our Experience
 Patient feedback
 Performa clearly indicates shortcomings
 Collected and analyzed for both IPD and OPD
 Regular feed back from doctors in meetings
 Ability to review complaints quickly and resolve
them effectively and promptly by
 Complaint aggregation
 Root cause analysis
 Immediate implementation
 Complaints are reviewed by the apex management
group

29. A NABH Accredited Hospital
Our experience
Patient Delight Jan - Jul 2012
60
50
40
30
%
20
10
0
Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12
Months
Excellent Good Unsatisfactory

30. A NABH Accredited Hospital
Conclusion – Best Practices
 Review and share the monthly comment reports. It's the
fastest way to know what's working and what's not
working for your patients. And you can quickly recognize
individuals or teams who were complimented.
 Communicate about Service Excellence widely and often.
You can make service an agenda item in staff meetings,
put service information on bulletin boards. Be creative
and have fun with it.
 Prepare scripts for patient processes and encounters. You
can select a common, routine patient process and create a
service map (i.e. what happens when and who does it).
Walk in the patients shoes and look ways to help the
patient understand and manage the process better.

31. A NABH Accredited Hospital
Conclusion – Best Practices
 Consider adding the following phrases to your patient
communication:
 Please
 May I
 Thank you
 Explain the rituals to patients. You know what's going to
happen and why, but most patients don't. One of the biggest
complaints of patients is that they aren't kept well informed.
 Keep track of patient likes and dislikes. Some patients (i.e.
patients receiving radiation therapy or rehabilitation) have
multiple recurring visits. They appreciate that you remember a
favorite drink or snack.
 Remember that service recovery is everyone's responsibility. If
a patient complains to you, you own the complaint. And you
need to be provided with the resources and skills needed to
fulfill this responsibility.

32. A NABH Accredited Hospital
Conclusion – Best Practices
 Evaluate service issues from both a systems as well as a
people perspective. If the system doesn't work, think of
ways to change the system to be more patient-friendly.
But never underestimate the power of a smile and a kind
word.
 Identify and manage the "high leverage" processes like
call light response time, pain management, admissions
and discharge. These are the processes that are likely to
raise patient anxiety. Anticipate this and address their
need for explanation and reassurance.
 Increase "face time" with patients whenever possible. If
possible, sit with patients while you do your
documentation. They will perceive that you've spent more
time with them.
 “Wish" people in the hallways. When patients see staff
smiling and greeting others, the environment seems less
cold and more friendly.

33. A NABH Accredited Hospital
Conclusion – Best Practices
 Identify high risk patients (either from a clinical
standpoint or a service standpoint) and do a call back
just to see how they're doing.
 Keeping the place clean is everyone's job.
 Be a "Secret Shopper." Examine processes and first
impressions through the eyes of the customer. A great
way to check phone etiquette is to call your own
department. Or walk onto a unit and imagine what the
patient sees, hears, feels.
 Create a "service disaster plan." Identify the worst
possible service scenario for patients and what you
might do about it. Then you're prepared (rather than
panicked) in case it really happens.

34. A NABH Accredited Hospital
Conclusion – Best Practices
 Manage noise. You may impact the noise level on
your unit by turning the lights down. Or implement a
"quiet hour."
 Clearly establish the difference between "red rules"
and "green rules." "Red rules" are rules that you never
break, no matter what. Rules around smoking and
propping doors are examples of "red rules." "Green
rules" are rules that you can bend, depending on the
circumstances. Sometimes you need to bend the rules
a little to satisfy a patient.
 Remember the "Grandmother Rule" - Do what you
say you're going to do, when you say you'll do it and
do it right the first time.

35. A NABH Accredited Hospital
Conclusion – Best Practices
 Overestimate time frames. Then try to exceed their
expectations.
 Remember the "Iron Law of Customer Service" -
Respond to customer complaints within 24-48 hours.
That doesn't mean you have to solve the problem - if
you can, great. But you need to acknowledge the
problem and let them know when you can get back to
them.
 Implement a "no negativity day" on your unit. The
impact of that may surprise you.

36. A NABH Accredited Hospital
Conclusion
The adopted best practices are not only adding
to Customer Delight but are propelling the
hospital towards its cherished mission
“To be the preferred choice for healing and good
health”

37. A NABH Accredited Hospital
Conclusion
 By applying for and receiving the National Accreditation
for Hospital and Healthcare Providers (NABH) and being
the first hospital in Mumbai to do so, Dr L H Hiranandani
Hospital has demonstrated a commitment to quality
health care. Quality health care is crucial to our people's
welfare and it is important to have organizations that are
willing to measure themselves against national standards
Dr Sujit Chatterjee MD
Chief Executive

38. A NABH Accredited Hospital
Thank you