Health & Hospital Management

HEALTH & HOSPITAL MANAGEMENT Collected By: Krishna
Jagrit
HEALTH & HOSPITAL MANAGEMENT
MANAGEMENT (BASIC)
Introductory Lecture jointly by Medical Superintendent & HOD
Community Medicine to highlight the Managerial issues in health &
hospital setting
Techniques.
• Power point presentation
• Case study methods.
HUMAN RESOURCE MANAGEMENT

Leadership Power point presentation supported by field study (for different
type of leadership style) skill development followed by group
discussion
Motivation • Power point presentation

• Force field analysis and case studies
MATERIALS MANAGEMENT
Principles and cycle of Materials • Power point presentation
Management • Practical Exercise (drug list of Hospital may be used)
Inventory Management • Power point presentation

[Techniques, Reorder level, Buffer • Case study methods.
Stock, Indenting Process] • Hands on Training and Practical Exercise
• visit to central store ( Check List )
Study of various registers e.g. Stock & Expiry drug register etc. followed by presentation and
discussions
BUDGETING & ACCOUNTING

Budgeting • Power point presentation
• Practical Exercise.( zero budgeting & Steps of Budgeting etc. )
Accounting • Study of Ledger and Cash Book entry.

• Presentation followed by discussions
• Practical demonstration (Direct Observation) in the account
department
MEDICAL RECORD
• Power point presentation for medical record keeping and
Storage & Retrieval System
• Practical Demonstration (Direct Observation followed by critical
analysis)
• Visit to Medical Record Department and Practical Demonstration
including of ICD classification
• International Certificate of Vaccination
QUALITY ASSURANCE & MEDICAL AUDIT

• Power point presentation
• Case study methods.
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CONTENTS
SECTION Topics
S
SECTION - A MANAGEMENT (BASIC)
SECTION - B HUMAN RESOURCE

MANAGEMENT
SECTION - C MATERIALS
MANAGEMENT
SECTION - D BUDGETING &

ACCOUNTING
SECTION - E MEDICAL RECORD
SECTION - F QUALITY ASSURANCE &

MEDICAL AUDIT
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SECTION – A
MANAGEMENT (BASIC)
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1-Introduction and Definition of Management
The importance for health and hospital management for MBBS student is well
understood and is necessary. There is lack in getting the effective outcome from the
existing health system inspite of lot of resources and funds . This is mainly contributed
by improper management . So the need of hour is this that MBBS students should have
basic practical applicability and knowledge of health and hospital management .
Management means different things of different people. We can define management as
“getting things done in right way in right time by right persons with right amount of
resources and with effective use of resources”.
“Management is defined as an art and science of abilities required doing the work in a
successful wayi.e. the technique to get the work done.”
Management may be understood as an art (& science) on following counts:
1. The knowledge of management like other arts has practical application. It is

applied to specific situations for better results. In management, managers strive
to solve the problem efficiently or make superior quality decisions to realize the
objective or meet the target with minimum efforts and resources. The application
of management knowledge is personalized, depending on the individual
manager. Though knowledge about principles, concepts and generalizations of
management remains the same, the manner in which it is used differs from
manager to manager.
2. The students gains experience with continuous application of management
knowledge to a practical situation. With the passage of time, the student gathers
more and more experience. Consequently, managers having greater experience
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of using principles of management normally became more efficient. They develop

more skills and abilities for translating management knowledge into practice.
3. Application of management knowledge calls for innovativeness and creativity. On
the basis of fundamentals of managerial knowledge, analytical abilities and
farsightedness, the student goes on discovering new ideas, relationships and
more efficient ways of doing things. It is possible only through rigorous research
and analysis, creative approach and scientific outlook on the part of managers.
Management as a science bears the following characteristics:
1. Management is a systematic body of knowledge

consisting of principles, generalizations, approaches and concepts to be applied
in practical situations. This knowledge serves as the basis for managers to
understand the process of management and problems involved in it. The
manager can manage the situation
or organization in a systematic and scientific manner only if he possesses
adequate knowledge of management and its principles.
2. The principles, generalizations and concepts of management have been developed
and formulated on the basis of observation, research, analysis and
experimentation, as is the case with the principles of other sciences.
So the management principles are universally applicable to all types of

organizations. They are generalized in nature, forming general guidelines for the
managers to practice. Management is defined as an art and science of abilities required
doing the work in a successful way. It has also been defined as the technique to get the
work done. The manager acts as the key person here, who knows how to take the work.
This is probably true because if a system does not work it means; either there is lack of
money; or the machine/ instruments are not in working order; or the people are not
working. Precisely if the former two are not in perfect condition they can be modified or
changed. But if the people do not work it is difficult to repair. In simplest term the work
management can be broken into three sub-parts as show in the figure below; which
means Manage- Mem-T (Tactfully)
Development of Management Thoughts
1. Classical or Traditional Management Approach
2. Behavioural or Neo- Classical Approach
3. Modern Approach to Management
Classical Organization Theory

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Its two major purposes were to
(1) develop basic principles that could guide the design, creation and maintenance of
large organizations, and
(2) identify the basic functions of managing organizations.

Engineers were the prime contributors to scientific management; practicing
executives were the major contributors to classical organization theory. As with
scientific management, there were many contributor to classical organization theory.
Henri Fayol should be singled out for his ideas reflect classical organization theory.
The Behavioural Approach
The behavioural approach to management developed partly because practicing

managers found that following the ideas of the classical approach did not achieve total
efficiency and workplace harmony. Managers still encountered problems because
subordinates did not always behave as they were supposed to. Thus, an increased
interest in helping managers become more effective grew. The behavioural approach to
management has two branches. The first branch, the human relations approach,
became very popular in the 1940s and 1950s. The second branch, the beahvioural
science approach, become popular in the 1950s and still receives a great deal of
attention today.
The Human Relations Approach
The term human relations refer to the manner in which managers interact with
subordinates. To develop a good human relations, followers of this approach believed,
managers must know why their subordinates behave as they do and what psychological
and social factors influence them.
The Systems Approach
The systems approach to management is essentially a way of thinking about

organizations and management problems. From the systems perspective, management
involves managing and solving problems in each part of the organization but doing so
with the understanding that actions taken in one part of the organization affect other
parts of the organization. For example, implementing a solution to a problem in the
production department of a company will likely affect other aspects of the company
such as marketing, finance and personnel. Each part is tightly linked to other
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organizational parts; no single part of an organization exists and operates in isolation

from the others. Thus, in solving problems, managers must view the organization as a
dynamic whole and try to anticipate the unintended as well as the intended impacts of
their decisions
The Four Parts of Open System Organization
Inputs Transformatio Outputs

n
Human creativity Management know-how Products
/ Services
and skills and technology
Information transforms inputs
Raw materials
Financial resources
Environmental Feedback serves as a Response to Products/ Services
Importantly, today most organizations must operate as open systems to

survive, and utilize a systems perspective to management. Managers must think
broadly about a problem and not concentrate only on the desired results
because these results will impact other problems and parts of the organization
and even in the environment beyond the organization.
The Contingency Approach
The systems approach to management advocates that managers recognize that

organizations are systems comprised of interdependent parts and that a change
in one part affects other parts. This insight is important. Beyond this, however, it
is useful for managers to see how the parts fit together. The contingency
approach can help to better understand their interdependence.
The contingency approach attempts to bridge the extreme points on this

continuum of view. Contingency theorists do not subscribe to any one best
approach to management. In their view, the situations that managers face do
differ and thus prohibit any one best prescription. However, the contingency
theorists stop short of asserting that all managerial situations are totally unique.
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Rather, they argue that situations are often similar to the extent that some
principles of management can be effectively applied. However, the appropriate
principles must be identified. This is done by first identifying the relevant
contingency variables in the situation and then evaluating those factors.
Contingency View
Very General Very Specific
System View
Contingency Purely Situational

View View
Everything is made
up system with
common
characteristics
Relationship between
management
Every situation is
techniques and
totally unique
situation can be
categorized
So, the multivariable analysis in contingency approach has proved that

many variables including employee’s personality, nature and contents of job,
motivation process and job satisfaction, etc. may collectively contribute to
productivity.
What is Scientific Management?

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Management, which is distinguished by the use and application of science and the
scientific methods in its various processes, can be defined as ‘Scientific Management’
To amplify the statement, the term means dealing with the problems of
management in a systematic way, making use of scientific methods, viz., definition
analysis, evolution, experiment and proof. .
There are seven important steps involved in the application of scientific method
in management. These are:
(1) identifying the proposition;

(2) preliminary examination of the proposition;
(3) stating tentative solutions to the proposition;
(4) thoroughly investigating the proposition;
(5) classifying the data obtained;
(6) stating tentative answer to the proposition;
stating answer to the proposition after adjustment
2-Management Function &Techniques
If objectives of a Health programme in a state District or PHC are to be achieved,

certain basic management functions are to be carried out. These functions are basically
(a) planning, (b) implementing and (c) control. This is a modern approach to
management functions.
Another way of classifying management function is in terms of (a) planning, (b)

organising, (c) activating and (d) controlling. Here, planning is to determine the
objectives and the course of action to be followed; organising is to distribute the work
among the group members and to establish and recognise needed relationship:
activating is to make the members to the group to carry their prescribed tasks willingly
and enthusiastically; and controlling is to conform the action with plans.
According to Gulliksen a more traditional classification of management function is

as follows:
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a. Planning e. Coordinating
b. Organising f. Reporting
c. Staffing g. Budgeting
d. Directing h. Evaluating
The modern classification such as planning, implementing and controlling and

innovating encompasses all the traditional groupings of management functions.
The management functions indicated below: -
Planning: The manager first outlines the job he wants to be done. He must set short
and long-term objectives for the organisation and decide on the means that will be used
to achieve them. In order to do this it is necessary for him to forecast, and be able to
evaluate the economic, social and political environment in which his organisation will be
operating, and the resources it will require for the programmes. For example, some
plans may be feasible only in times of prosperity and may be utterly impractical in a
period of resource constraint.
Organising: The manager must carry out the plan by organizing resources – personnel,
supplies, transport, finance, etc. He must establish operating procedures and reporting
relationships. The work done by subordinates will necessarily be interrelated; hence,
some means of coordinating their efforts must be provided, Coordination is , in fact, an
essential part of organizing.
Staffing: Having known the work to be done, he must find the right person for each
job. An established health service, of course, already has people filling the staff
positions. However, staffing obviously cannot be done once and for all, since people are
resigning, being promoted, and retiring. Furthermore, workers skills improve with the
acquisition of experience, or by getting additional training and acquire new skills also.
So a anager must make periodic assessment of his staff and attempt to plan each
person into the position where he can do the best job.
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Direction: Since problems and opportunities in the day-to –day work cannot be
anticipated beforehand, job descriptions must be stated in general terms. The
manager ,while providing day-to-day to his subordinates , must make sure that they
know the results he expects in each situation, help them to improve their skills, and , in
some cases, tell exactly how and when to perform certain tasks. A good manager
makes his subordinates feel that they can’t to do the job in best possible way, not
merely work well enough to get by.
Coordination: The manager has to inter-relate the various activities contributing to

the achievement of an objective. This is an important function of management to blend
all the activities into a unified action
Reporting: The manager has to report the progress of achievement to his superiors
regularly. The progress needs to be assessed from records and reports, which will also
be useful for monitoring and evaluation.
Budgeting: The manager has to prepare a budget, and monitor expenditure. At the
end of the year he has to assess the financial performance.
Control/Evaluation: This function helps the manager to determine how well the jobs
have been done and what progress is being made towards the goals. He must therefore
know what is happening so that he can step in and make changes if the organization is
deviating form the path he has set for it. A mechanism of control is required for
systematically judging progress towards goals.
Certainly a person who does above management functions is a manager.

He carries out these functions by observing certain principles of management.
These principles are nothing but fundamental statements or truth which provide
direction to thought or action. These are: i. Unity of Comand; ii. Hierarchical
Structure; iii. Span of control; iv. Clarity in role and responsibility; v. Well defined
duty list and vi. Delegation. Further, in performing the management functions,
several skills, tools, and techniques of management are being used by them.
The district health organization is having some form of managerial process for
health development, even if such process may not be well standardized; yet
there does exist process by which managers are attempting to systematize the
delivery of health care in community in and integrated way.
To sum up the management functions can defined as:
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1) To achieve an effective utilisation of human resources for the achievement

of organization goals.
2) To establish and maintain an adequate organisational structure and a
desirable working relationship among all the members of an organization
by dividing the organizational tasks into functions, positions, jobs and by
defining the responsibility, accountability, authority for each job and its
relation with other job/ personnel in the organisation.
3) To secure the integration of the individuals and groups with the
organization by reconciling individual/group goals with those of and
organization in such a manner that the employees feel a sense of
involvement, commitment and loyalty towards it. The absence of this
integration will allow development of frictions, personal jealousies and
rivalries, prejudices, personnel conflicts, cliques, factions, favouritism and
nepotism. These will produce inefficiency and result in failure of the
organisation.
4) To generate maximum development of individuals/groups within an
organisation by providing opportunities for advancement to employees
through training and job education or by offering transfers or by providing
retraining facilities.
5) To recognise and satisfy individual needs and group goals by offering an
adequate and equitable remuneration, economic and social security in the
form of monetary compensation, and protection against such hazards of
life as illness, old age, disability, death, unemployment etc. with adequate
compensation and security, employees work willingly and cooperate to
achieve an organization’s goals.
6) To maintain high morale and better human relations inside an organisation
by sustaining add improving the condition so that employees may stick to
their job for a longer period.
MANAGEMENT IN HEALTH CARE INSTITUTIONS
Health care institutions are unique in several ways. In the first case these are the only
places where we come across wide skill differential among the people working there. On
the one hand we see highly skilled physicians and paramedics, on the other hand very
large number of people who are easily substitutable. Managing an organization
characterized by such a high level of differential knowledge throws up unique
management problems. Second dimension is added because of their criticality. Their
ability to make an impact on the well being of the community is undisputable. Third
dimensions, as an out growth of the previous one, is communities’ dependence on the
health care institutions. The fourth and most compelling reason is the need for better
management of these institutions, so that they can be run profitably and add value to
society. The last issue is the most important. Unless this aspect is not properly looked
into, the way the entire manufacturing and financial sectors are being taken over by the
multinationals; the same destiny is likely to happen with our health care institutions.
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All these call for proper organization of these institutions. And one of the
fundamental requirements of proper organization is to develop methodically
trained professionals who will be able to infuse meaning and purpose for the
institutions, and also add value to the stakeholders. To achieve this the first
requirement is to develop trained manpower who will be in charge of these
institutions. Towards this end awareness about the scientific principles is the
first step.
So, the relevance of management in health care institutions are as follows:
Planning Primary Health Service Programme
a.1 Forecasting Functions
Assessing and Forecasting the Demand for Primary Health care (i.e. curative,
preventive, promotive and rehabilitative) services in a given area according to
the existing health problems in the area.
Assessing and Forecasting the Requirements (to deliver the primary health care
services) to meet the demand for primary health care, in terms of:
- Physical Facilities (including movable and immovable infrastructures) for

PHCs, Sub-Centres, Dispensaries, Referral Hospitals, Laboratories, Camps,
other national health and family welfare programmes such as National
Malaria Eradication Programme, Leprosy Control Programme, Family
Welfare Programme;
- Equipment, to deliver primary health care services, such as for minor OT,
OPD surgical, laboratory, field work, camps;
- Material such as drugs, vaccine, laboratory chemicals, syringes, needles,
sterilizers, thermometers, cotton, soap, health education materials;
- Personnel, such as forecasting health personnel requirement, planning
recruitment policies and procedures, and planning training modules;
- Financial requirements for all the above requirements.
a.2 Assessing Resources Available
The health worker (at all level) has to assess the available resources, within his
area of operation, for rendering primary health care services in terms of –
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Physical Facilities (including movable and immovable infrastructure)
available
Equipments available;
Materials available;
Personnel available;
Finance available.
a.3 Matching demands and requirements (forecasted) with available

resources)
Demand for Primary Health Care and Requirements needed to meet the demand
(a.1)are matched with available resources (a.2) at
- Physical Facilities level

- Equipment level
- Materials level
- Personnel level
- Financial level
Define Programme Objective and targets for the local area of operation.
a.4 Planning of Schedule
Scheduling of Operations: Introducing time framework into the outcomes of the

effort of matching demands and requirements (a.3.i); thus, keeping in view the
programme targets, scheduling of operations/ activities, in terms of curative,
preventive, promotive and rehabilitative components of primary health care
services, is planned;
Scheduling of Resources, in terms of physical facilities, equipment,

material, personnel and finances, so as to achieve time oriented targets of
primary health care programme as planned.
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a.5 Planning of controlling and monitoring designs
Planning items to be controlled and monitored.
- Regular items concerning preventive, curative, promotive and

rehabilitative services.
- Contingency items such as outbreak of diseases.
- Anticipated items such as during festivals, shadies.
Planning Procedure to control and monitor Primary Health Care
services.
- formats( documents/reports/records/designs and procedures)

- frequency of monitoring;
- personnel for monitoring;
- procedural manual for monitoring.
Planning Procedure to React to Monitored Reports:
- Analysis of Data
- Summarizing Data
- Decision Making
Similarly, personnel engaged in the implementation of primary health care services/

programmes need to perform the following functions and as such appropriate health
management training be imparted to them.
Implementing Primary Health Care Services Programme
b.1 The primary health care services programmes are implemented
Schedule of operations are prepared

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Resources are mobilized as per plan schedule
Organise Programme Activities
- Physical facilities activities such as securing a building with adequate

space and facilities, arranging furniture, beds, equipment etc., inside the
building, vehicle maintenance.
- Equipment and materials activities such as procurement, stock-taking,

inventory control, distribution and storage.
- Personnel recruitment and training activities such as training of multi-

purpose workers, community health volunteers, health assistants, health
workers and dais.
- Financial activities such as accounting, auditing, application of financial

rules.
- Co-ordinating activities such as co-ordination with central depot for

procuring necessary drugs, chemicals and materials, coordination and
cooperation with other institutions in the block, establishing working
relationship with block development officer, coordination between activities of
health assistants, coordination between the activities of health workers.
Motivating Activities:
-Providing effective leadership while organising camps, meetings, health

education talks and demonstration, display of posters, exhibitions and films.
-Participating in village health committee and village panchayat meetings.
-Providing guidance to health assistants, health workers, community health

volunteers in treating minor ailments.
-Providing technical guidance to community health volunteers and encourage

them.
-Supervise the work of health assistants, health workers and community

health volunteers.
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-Human relations activities such as having liaison with block development

officer and development officer and his staff, community leaders and social
welfare agencies.
-Communication activities
-Mass communication activities such as demonstrations, exhibitions, display

of posters and films.
-Verbal communication activities such as giving education talks, addressing

staff meetings.
-Written communication activities such as writing reports to government on

primary health care services.
Controlling and Monitoring Programme activities:
- Scrutinizing programmes of staff to check whether they are in line with the
achievement objectives.
- Receiving reports from periphery.
- Evaluating programmes of staff with respect to objectives, spotting, significant

deviations, ascertaining causes and taking remedial action to improve work of
staff.
Evaluation of Primary Health Care Services/ Programme
c.1 Performance Appraisal
Time-oriented targets as indicated in a.4 are evaluated in terms of:
- Physical Performance
- Financial Performance
c.2 Draw lessons from the performance and give feedback to the planning
office
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As a matter of fact, the list of functions as enumerated under Planning,

Implementing and evaluating primary health care services/ programmes are
performed in varied degrees by different cadre of health workers rendering
primary health care services. The list, indeed is exhaustive of functions and as
such can be used even as a check list.
CONFLICT MANAGEMENT – CASE STUDY
Structure
1.0 Objective
1.1 Introduction
1.2 Exercises
1.3 Case Study
1.4 Let Us Sum Up
1.0 Objective
After under going this unit, the students shall be able to:
1. Explain the nature and type of conflict in hospital set up

2. Describe the methods and strategies of conflict management
3. Develop a win-win or I am O.K. You are O.K attitude.
Introduction
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Hospitals are the institutions that primarily provide curative and rehabilitative services to the
community. They deploy a large manpower whose management is too complex and paramount. For
achievement of goals of hospital services and effective management, it is desired to ascertain and to
understand the interpersonal and inter group behaviour to reduce conflicts within hospital work
climate.
The potential for conflicts in hospitals is apparent. It has a wide range of varied manpower,
highly specialized to just skilled to semiskilled –gathered together under one roof. The administrator
is continually facing and attempting to solve individual or inter-personal or departmental conflicts.
The unexpected and emergency treatments often situations of stress that do lead to conflicts in
either expected goals and goals pursued or expected roles and performed roles. Sometimes there are
inter-professional conflicts in perceiving each others performance of roles. Even consumer
expectations and level of services and neglect, leads to difficulties and misunderstandings. Conflict
situations adversely affect the quality of patient care and client satisfaction.
Research reports substantiate that hospital manager or administrators spend 20 per cent of
their time dealing with conflicts. Hence their ability to handle and manage conflict behaviour has
become substantial over the decade. As a first step, hospital administrators must recognize the forces
leading to conflicts in a hospital set up in order to manage them effectively. Such situation gives rise
to conflict. This occurs because people demonstrate different feelings about what is logical or natural,
socially desirable, less desirable and undesirable, good or bad, sound or unsound in their perceptions.
Basically conflict is an issue of perception. So long one is unaware of conflict, for him it does
not exist. It is bliss for him or others. People vastly differ in the perception and the impact those
differences make, give rise to issues. These issues have their valence. However it is important how
one transcends the boundary or limits of his perception to communicate internally or interpersonally
to deal with the issues and come up with solutions. Extreme position or stand taken on an issue
promotes conflict.
Therefore, conflict is an indication that situation is threatening, devastating or on a point of

breaking. Conflicts are unproductive and dysfunctional. Those can delay or prevent the attainment of
a goal or frustrate an individual. In hospital situation conflict is inevitable. Best way to approach is to
anticipate conflict. In an organisation like hospital, many situation could be labeled as potentially
conflictive due to extent of sharing of resources, active inter dependence, professionalism and
specialization and goal and role incompatibility. Conflict occurs at individual, interpersonal, group
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and organisational levels of a hospital. A good manager/leader should identify conflict early and try
to resolve that before individuals take positions and freeze to them.
Exercises
Exercise 1 - Managing a Conflict at Your Work Place
A B C
Conflicting Event What you did? Consequences
(Describe Situation objectively) (write evaluative statements (describe the effects of
about your approach) your approach)
D E F
Feelings What better could you have done? New Feelings
(describe your negative/ (write statements disputing (positive/negative)
positive feelings) your approach at B)

With respect to the Exercise 1 above, imagine/recall a recent situation in your work place where your
responsibility as a manager was to manage the conflict. Complete all the columns shown above. Please
put down your responses on a separate sheet of paper.
Exercise 2: Rate yourself in terms of evaluating and resolving conflicts at your work place for last
five years.
Resolution approach Rank

• Preventing conflict
• Suppressing the conflict
• Avoiding the conflict
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• Laughing at the conflict

• Using false emotions for distracting the conflict
• Eliminating the conflict
• Accepting the conflict
• Recognising the value of conflict
• Encouraging interpersonal criticism
• Enhancing the conflict
• Inducing the conflict
• Managing the conflict
1.1 Case Study

A Case for Role Play in Conflict Management
Room No. 10. CMO’S Office
It was a fine morning. On the day of the monthly meeting at CMO’s office at the district Badgam,
Dy. CMO’s, MO’s from various CHC’s and PHC’S, a few specialists, BEE’s, Supervisors and LHV’s
were seen roaming around the committee room where the meeting would be held by the CMO.
Mr. Kumar a BEE from one of the PHC’s had fixed up a prior appointment with the CMO’s PA
in connection with discussing some problem. As he approached the R. No. 10, where the PA was sitting,
he saw a BMO, from a different PHC, Dr. Kapoor chatting with the PA. He waited for sometime outside.
As the time of the meeting was approaching nearer, he went inside the PA’s room and reminded the PA of
his appointment. At this Dr. Kapoor got very much irritated and annoyed for this interruption and shouted
at him to leave the room calling him an idiot. Mr. kumar felt crest fallen and start moving out of room
murmuring and protesting. Mr. Kumar with tears in his eyes reported the matter to other BEE,
Supervisors, and LHV’S standing in the corridor outside. All of them got infuriated and took it as an
insult to the whole group. In the process other members of the group Dy. CMO’s, MO’S and other
specialists also started flocking around Mr. Kumar to know what had happened. After knowing the details
they advised Mr. Kumar to forget about the issue and seek the fresh appointment with the PA. At this a
strong reaction came from BEE/Supervisors/LHV’S group resulting into BIG SHOUTS, ABUSES,
HEATED ARGUMENTS AND EVEN SOME PHYSICAL ATTACKS. Suddenly 2 groups MEDICAL
AND PARAMEDICAL were formed---- all MO’s, Specialists on one side and
BEE’s/Supervisors/LHV’S on the other. Slogans like “WE WANT JUSTICE-----------WE WANT
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RESPECT” could be heard from BEE/SUPERVISOR’S/LHV’S group. The CMO,.Mr. Sharma came out
of his Room after hearing the loud voices. He further heard the loud staments like------------“YOU
ALWAYS HARRAS, DISCRIMINATE, AND SUPPRESS THE PARAMEDICAL GROUP INSPITE
OF THE FACT THAT OUR INPUT OF THE WORK IS MAXIMUM.” Hurriedly one of the BEE’s
briefed Dr. Sharma about what had happened. After hearing he called Mr. Kumar and a few from his
group to his room. The group requested Dr. Sharma for immediate justice in the form of a written
apology from Dr. Kapoor to Mr. Kumar who for his no fault was badly insulted. At this, Dr. Sharma was
shocked. After this Dr. Sharma also called Dr. Kapoor and a few of his group members inside to hear their
version inform them about the APOLOGY demanded by the other group. They refused to do the same.
At this point Dr. Sharma was wondering how to conduct the monthly meeting. He started thinking
as how to end this conflict between MEDICAL AND PARAMEDICAL GROUP. He decided to
arrange a direct CONFRONTATION MEETING BETWEEN THESE TWO GROUPS.
Questions for Case Study Analysis
• What are the main issues here?

• Why are these issues important?
• Whose problem is this?
• What precisely are his objectives?
• What possible courses of action are open?
• How realistic is each of the actions/solutions proposed?
• What are their possible effects?
The case can be further converted into a Role Play with following objectives:
• To develop conflict management skills in managers

• To clarify concepts and explore new ideas on conflict and conflict management
• To identify ways of dealing with conflicts in the organisations
1.2 Let Us Sum Up

To achieve goals of hospital services and effective management hospitals deploy a large
manpower which varies from skilled to semiskilled and their management is too complex and
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paramount. Same time the high consumer expectations and level of services leads to difficulties and
misunderstandings which results in conflict and it adversely affect the quality of care and client
satisfaction. Hence it is necessary for a hospital administrator to know how to manage such situations
in a hospital.
Negotiation
Negotiating means “Conferring with another so as to arrive at a settlement of

some matter”, we are continually negotiating a sale, a loan, a lease, a change, a new
method of working. Negotiating is a skill more and more needed today. There are
three things to keep your eye on:
1. People prefer a negotiated settlement to a state of continual war.

2. The arrangement should not only be fair but appear so.
3. Both sides should gain something.
Negotiating on merits tries to improve on this by asking how we can together reach a
fair settlement.
Step 1: Separate people factors from the issues.
People factors and disputed issues, both are involved in negotiating, both are
important. The point, however, is to keep them separate.
Step 2: Focus on interests, not on positions. Look beyond the positions people
take to the interests behind them. The more you know about real needs, the more
likely an agreement in which both sides benefit. A clash of positions does not
necessarily mean a clash of interests.
Step 3: Invent mutually beneficial options. Use your imagination to create a list of
possible situations. The ability to create mutually beneficial agreements is the sign of
effective negotiator. Separate idea getting from idea evaluation. Make the list first;
evaluate afterwards. Try to get yourself and the other party to face the problem, not
each other.
Step 4: Use objective (both party independent) criteria. Seek for a standard
independent of you both which is fair. If such a standard is not available, at least agree
on a fair procedure.
Step 5: Know you best alternative to a negotiated agreement. Before you enter
negotiations, you must know what your best alternative is, if you fail to reach an
agreement. This is your floor. If you know it, it gives you confidence as you negotiate;
know exactly, what your best options is if you fail to reach an agreement. Then you will
not be likely to agree to anything unfair.
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TIPS TO IMRPOVE YOUR NEGOTIATING SKILLS

1. Get as much objective data as possible before you start e.g. the going, market or
statutory rates and similar data. This gives you an objective criterion. The more
expertise, the more objective data on both sides, the narrower the area of
disagreement. So don’t out smart but out prepare.
2. Agreement must be fair and appear so. People are satisfied with fair solutions.
Establish precise goals at the outset of the negotiation. “You want a high price
and I want a low price. Let us try to reach a fair price.”
3. Show that there must be, not just will (‘I want’) but, a rational basis or principle
for the settlement. “On what principle are your basing that offer?”
4. Use questions more than assertions as you negotiate. Assertions create
resistance. Questions get answers. Questions keep the other party I the
relationship; statements can drive them out; e.g. “would this be a fair solution?”
5. Listen more, talk less. Let the other party do most of the talking. Don’t be afraid
of a little silence. Frequently after silence the other party reveals significant
data, but listen actively. Go beyond positions. Identify interests.
6. Express your own interest clearly. Case Study
Negotiation is not abdication. Go for a
solution you both can feel good about. Win-win or no Deal. Go for what you
both want. Search for results that would be fully acceptable to both.
7. Offer low-cost-to-you items but high-value-to-other party.
A 8.
health-centre
Keep cool. team
Don’t leader calls don’t
get angry; a meeting to child
let your consider complaints
be hooked. Let that have been
the feelings go
maderight
aboutonthe treatment
past of pregnant
you. Using women at the
‘You’ aggressively cutscenter since the arrivalManage
off communication. of two
criticism
recently wisely.
qualified midwives.
9. If agreement, check by example: who will do what, when etc.
The womenyour
10.Keep whoeyehaveoncomplained are not
the relationship as present
well as at the meeting
interests: Don’tbut
let are represented
short-term gain
prejudice
by the long-term
health visitor relationships.
to whom they have spoken at home. The midwives concerned are
not present either; they are represented by the senior midwife. No other staff are
present.
The health visitor speaks first and says that several women have complained that the
new midwives are too young and too busy. “They are young enough to be our
daughters” said one woman. Another said “They order us about as if we were their
children”. “They take so long with each case that the clinic does not finish until after
dark” said a third woman. “They take blood from us but refuse to give us injections as
the old midwives did” said a fourth woman.
The health visitor says she thinks the young midwives are indisciplined and
incompetent and that the older midwives (one of whom is her husband’s sister) ought
not to have been retired.
The senior midwife responds by saying that, in the past two months, the number of
women attending antenatal clinics has doubled, partly as a result of health education
programmes in the village, but partly because the new midwives are more popular
with many of the poorer women. The increased numbers at the clinic have meant that
some of the more educated women are being asked to wait longer to be seen and they
do not like this. The new midwives are more conscientious about antenatal
examinations and this is one reason for the clinics taking longer.
The senior midwife agrees that they lack experience and because of this she has taken
responsibility for prescribing treatment herself. She says that she has stopped the
practice of giving vitamin B injections because tablets are cheaper and that she no
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Questions
1) Was it wise for the supervisor to have invited only the health visitor and the
senior midwife to this meeting?
2) Shouldn’t the women who made the complaint and the midwives themselves be
present?
3) What conflicts are inherent in this situation?
4) What do you see as the causes of the conflicts?
5) What steps can the supervisor now take to reduce these conflict and to try to
repair the damage already done?
6) What other – possibly more effective – approaches to these conflicts might the
supervisor have taken?
7) Discuss the supervisor’s approach, and consider suggestions for possible
alternative approaches?
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STRESS AND ITS MANAGEMENT

INTRODUCTION
Human beings around the globe have been putting untiring efforts to achieve the
goal of business, peaceful living and stress-free life. As the times are progressing,
achievements of this goal seems to be a distant reality. The processes of technological
advancement in almost all spheres of human life have ushered in micro – task
specializations, greater competitions which have influenced the delicate network of
human relationships and values. Man has been reduced to mere insignificant cog in the
wheel of this revolution; generating in him a sense of powerlessness, meaninglessness,
social isolation and normlessness, a situation so aptly described by Merton as
‘Annihilation’. As a result, considerable turmoil and traumas, psychological
contradictions, physical disabilities are giving rise to enormous stress in him. The
stressful situations have registered a steep increase in numbers, magnitude and
complexities. There is consensus among psychiatrists and psychologists that stress is
manifested at different levels - psychological, physical and behaviouraL Stress studies
conducted in organizational setting have examined stress primarily from psychological
angle such as stress reactions, neuroticism, tension, anxiety, depression, irritation,
psychological fatigue and boredom etc. Many other studies have examined job related
stress factors like satisfaction, withdrawal, behaviour and propensity to leave. The
physiological symptoms of stress such as blood pressures, cholesterol and behavioural
level symptoms have also been extensively studied.
CONCEPT & DEFINITION OF STRESS
Robert Goldenson (1984) states that stress is a state of physical or psychological strain
which imposes demands for adjustment upon the individual. Stress can be internal or
environmental, brief or persistent. If stress is excessive or prolonged, it may overtake
the individual's resources and lead to breakdown of organised functioning. Stress is also
a multi - dimensional concept and its manifestations are psychological in nature. It is a
neutral term, its negative aspect is generally associated with 'distress' indicating a
person being exposed to noxious stimuli and the positive aspect is associated with
'eustress' implying a sense of euphoria. The medical explanation of stress is the body's
general response to environmental situations. It is known that tolerance level for stress
in the face of deadlines, time pressures, meeting high standards of performance and
even working with inadequate resources vary from person to person. This implies that
in all individuals , there is an optimum level of stress under which he performs to his
capacity. Since stress influences the level of performance, all organisations are
concerned about it and attempt at designing strategies to overcome the negative
dimension
Tips on Stress Management

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Learn how to spot your stress warning signals, and then act on them
Do not be afraid to talk about situations that you find stressful.
Take a stroll when you are stressed it can help restore your perspective
Avoid the habit of taking work home with you every night.
Try to be aware of any changes in your eating and drinking patterns.
Learn form those who do not suffer from stress.
Avoid routinely working late and at weekends.
If you suffer from regular headaches or insomnia, see a doctor.
Make a note of anything that you can find that helps you to relax.
Listen to what your body tells you as objectively as you can.
Ask yourself if other people find you stressful to work with.
Keep a diary of the days that you feel highly stressed.
Treat yourself to something you want but would not normally buy.
Make sure your desk is as near a window as possible.
Use travel time to plan your day or switch off-not to do extra work.
Spend an hour or two alone each week, away from work and family.
Identify like-minded colleagues, and work with them to adapt to change.
When learning new technology, start slowly and build confidence.
Try to set up an office near other people: isolation can be stressful.
Assess the stress factors of any new job before you accept it.
Always be flexible in your attitude you may not know the full story.
Plan an active part in improving the quality of office life.
Arrange to have lunch with your partner or a close friend once a week.
Listen carefully to what your children say to you.
If you live near your work, walk or cycle to work a few times a week.
Go for a jog or swim at lunchtime to alleviate stress.
Start each day stress –free by tidying your desk the night before.
Keep an executive toy to “play” with during breaks.
Ask a colleague to let you know when you appear to be stressed.
Jot down problems on a day-to-day basis, and see if a pattern emerges.
• Set realistic goals so that you do not feel stressed by too many failures to meet
deadlines.
Never knowingly embarrass people by asking for help they cannot give.
Try to take a five-minute break from your work every hour or so.
• Cross each job off you “to do” list when the job is done, it is satisfying to see a list
shrink.
• Write faxes and letters early in the day-your communication skills will deteriorate
as your tire.
• Do not ignore your problems acknowledge them as they arise.
• Avoid people and situations that tempt you to behave in ways you are not happy
with.
Exercise can be a short term solution to anger.
Be honest about your reasons for rejecting a task.
Practice yoga or a similar exercise routine to help you relax.
Offer help only if you have time to follow it up.
Respect other’s opinions, do not feel you always have to be right.
Do not make major decisions too quickly.
When talking with a colleague banish all interruptions.
Plan activities for each weekend. Try not to let the days just drift past.
List to your favourite song this will help you to relax.
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Avoid eating or drinking heavily just before you go to bed.

• When lying down to relax your body, start by relaxing your toes, and work your
way upwards.
Join an evening class every year, and start to learn something new.
Take a holiday that allows you to pursue a hobby.
Breakfast like a king lunch like a prince, and dine like pauper.
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3 - Motivation And Leadership

Motivation
Introduction
The inducement to the people to contribute as effectively and as
efficiently as possible is called motivation. It is a process of stimulus and
response. It is nothing but an act of inducement. Human motives are based on
needs. Some of our needs are primary and some of them are secondary.
Food, cloth, shelter, water, air, sleep, sex are some of the primary needs
and affiliation, status, love and affective, self-assertion are some of the
secondary needs of human being. These needs may vary in intensity and
according to situation and time, but these are the motivating factors about
which a manager must know.
Performance of a group of individual depends on the needs of the group
as well as of individual who are forming the group. Group’s needs may not be
the same as that of individuals but given a common goal the individuals who are
forming the group may come to identify themselves with the group’s needs. The
sole responsibility of the manager is to recognize the group’s need without
unduly and the imaginately compromising the needs of individuals who as a
group have extended their helping hand for the accomplishment of a given task.
The manager creates and then maintains necessary environment for the
accomplishment of the objectives. This he does by motivating – inducing the
people to work for the attainment of the objectives.
Definitions
“Motivation is the act of stimulating someone or oneself to get a desired course
of action, to push the right button to get desired action.” It is nothing but an act of
inducement.
Motivation as something that moves the person to action and continues him in
the course of action already initiated.” It refers to the way a person is enthused at work
to intensify his desire and willingness to use his potentiality for the achievement of
organizational objectives.
Robert Dubin has defined – “Motivation means a process of stimulating people to

action to accomplish desired goals”.
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Motivation has close relationship with the behaviour of human beings. It explains
how and why the human behaviour is caused. Understanding the needs and drives and
their resulting tensions helps to explain and predict human behaviour, ultimately
providing a sound basis for managerial decision and action.” Thus, motivation is a term
which applies to the entire class of urges, drives, desires, needs and similar forces.
Essential of Motivation includes Productivity, Competition , Comprehensiveness ,

Flexibility.
TYPES OF MOTIVATION
Motivation may be classified as follows:
(1) Positive and Negative motivation

(2) Extrinsic and Intrinsic motivation
(3) Financial or Non-financial motivation
(1) Positive and Negative Motivation

Positive motivation is the process of attempting to influence the employees
behaviour through the possibility of reward. It is achieved by fulfilling the varied needs
of individuals and the group. The impact of positive motivation is that it brings about
integrity to the purpose, inculcate in the individuals and the group a sense of
belongingness and a strong affiliation for which the organization stands.
Negative motivation denotes consequences or reactions which people seek to

avoid, e.g. dismissal, demotion, group disapproval etc. In such a situation people work
only to obtain a square meals. In fact there is no motivation. There is absence of
integrity to the purpose and conviction to what organization stands for and detachment
between the individuals and the organization.
(2) Extrinsic and Intrinsic Motivation

Extrinsic motivators arise away from the job. They do not occur on the job. These
factors include wages, fringe benefits, medical reimbursement etc. Thus, they are
generally associated with financial incentives.
Intrinsic motivators occurs on the job and provide satisfaction during the
performance of work itself. Intrinsic or internal motivators include recognition, status,
authority, participation, etc.
(3) Financial and Non-financial

Financial motivators are those which are associated with money. They include
wages and salaries, fringe benefits, bonus, retirement benefits etc.
Non-financial motivators are those which are not associated with monetary
rewards. They include intangible incentives like ego satisfaction, self-
actualization and responsibility. The role of financial and non-financial incentives
are important in motivation activities.
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Case Study on Motivation
A case of a Community Health Volunteer who motivates a

leprosy patient to accept treatment
Pathardih is a Block in the Bankura District, West Bengal. It covers an area of 259 square
miles and has a population of approximate 10, 00,000 living in 185 villages. The main occupation
is agriculture. The literacy rate is 22.6 per cent; the languages spoken are Bengali and Santhali.
The religions are Muslim, Hindu, and Adibasi.
Working in Pathardih Block is one community health volunteer who is 24 years. She has
been allotted two villages, including Nodia where she resides. She likes the CHV jobs assigned to
her and feels that people loves her and trust her as their own. The Lady Health visitor from
Pathardih PHC supervises her.
In Nodia village lived a man named Vivek, who suffered from leprosy. He lived with his
family – a wife, two sons, three daughters, mother and widow sister. His two sons, aged 16 and
14 years, work in the field with him. He has six bighas of land. His three daughters are aged nine
years, six years and three years. Vivek’s family has been living in the village for five generations
and is known to all.
Vivek suffers from leprosy, but he resents anybody from the PHC visiting his house. In
fact, he is in the habit of shutting the door in the face of any health worker coming to visit his
house. His behavior toward health worker is always rude. The Health Visitor decided to hand
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over the case to the CHV in Nodia village, hoping that she will be able to visit the patient in his
home.
The CHV began by meeting the wife of the patient. During discussion in the kitchen, the
CHV volunteered to meet her husband personally at any time convenient to him. Several days
later, the CHV again visited the house, this time to find that Vivek was at home. Vivek was very
much annoyed to see the CHV in his house and showed his annoyance by shouting that he had
repeatedly warned all health staff not to visit his house. He threatened to use violent means to
keep health workers away form his house. The CHV quickly departed and later reported the
incident to her supervisor, the Lady Health Visitor.
The case of Vivek was serious because he used the common pond for bathing. Also, he
was living with his family members which made chances of spreading infection very high.
Furthermore, Vivek’s wife was 32 years old and capable of bearing more children, so it was
important to gain access to Vivek so as to treat his leprosy. Until now, he refused treatment.
Several weeks later, at the insistence of the Health Visitor, the CHV again visited Vivek’s
house and pleaded with his wife for an interview with him. She agreed to arrange a meeting but
warned that she would not be held responsible for any adverse consequences. A few minutes
later, Vivek entered the kitchen where he threatened the CHV as soon as he saw her. He said he
was going to beat her with a broom stick for having entered his house. The CHV remained calm,
even though she was frightened, and due to her tactful handling of the situation, Vivek calmed
down. The CHV took the opportunity to inform the family that she would be arranging a big film
show in the village. She has been searching for a suitable place to hold it. She asked Vivek, if he
could kindly spare his front courtyard for holding the show. Vivek’s ego was elated, and he
agreed to the proposal.
The CHV visited Vivek’s house three or four times during the next weeks to discuss
arrangements for the film show. During these visits, she also mentioned family planning and
other health topics. Vivek even allowed her to give some medicine to the youngest child who
was suffering from diarrhoea.
In the meantime, arrangements were made for the film show in the courtyard of Vivek’s
house. The CHV went door to door to invite the villagers for the amusement. The show was a
great success and created a spirit of joy and satisfaction in the village. One of the films on health
topics created much impact in the village. Villagers appeared to be very interested to know
about infection, water borne diseases, and the breeding places of mosquitoes. They became
conscious of the bad effects of unclean living, the need of early treatment of diseases, and the
advantages of having a small family.
Vivek was very pleased with the success of the film show, and one of the health films
made a deep impression on him. In fact, on seeing the film, he became convinced of the need for
early treatment of infectious diseases like leprosy. But Vivek believed that disease is given by
God can be cured only by God, so there is no need to take treatment from the PHC. Better to do
puja and ask God to cure the disease. Vivek thought puja was the best treatment for leprosy.
Although he would not say so, Vivek knew he suffered from leprosy and in fact had lost all hope
of getting cured. He feared rejection by his family and by the village; that is why he did not want
the health workers to be seen visiting his house. He feared this would alert the village to his
disease and result in rejection.
Some weeks later the CHV was again visiting Vivek’s house, where she was now
welcome. Vijaya Dashmi being just over, Vivek’s wife offered the CHV some sweets, as is the
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custom. With some convincing excuses, the CHV at first avoided taking the sweets. Vivek
realized why the CHV refused taking sweets in his house, and said: “Please do not feel that you
must make excuses. I know why you refuse the sweets. I understand your reluctance. “Vivek’s
emotional words greatly moved the CHV, and she immediately accepted the offered sweets and
ate those. This greatly surprised Vivek. He realized that the CHV considered him as a friend and
had a sincere interest in his health and welfare. Vivek and his family and the CHV then entered
into a long discussion about leprosy. The result was that Vivek became convinced of the need for
treatment for the good of the family and neighbors. He agreed to visit the PHC, provided the CHV
would accompany him.
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Questions:
1. If you were the health visitor, how would you have handled the case of Vivek?
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
2. Why was the CHV successful in handling this case?
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
3. What does this case teach about management of a leprosy programme?
………………………………………………………………………………………
………………………………………………………………………………………
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LEADERSHIP
Definition
Leadership is a dynamic force essential for success in any human group effort.
Without leadership no organization or enterprise can flourish.Leadership is an important
aspect of managing. It can be rightly said that management works when the manager
lives up to his role as leader.
Leadership has been defined in various ways. However, all the concepts
of leadership have certain common characteristics. In the context of
management practice, the following definition given by a western research
authority has particular validity: “leadership may be defined as an humanized
activity or activities influencing group people to act for achievement of common
specified goal or goals.” The most essential element in leadership is
management of human resources. Leadership is personality in action under
group conditions.
Leadership is Influencing people to follow the achievement of common
goals. It is the ability to exert interpersonal influence by means of
communication towards the achievement of goals.Leadership is the relation
function between an individual and group around some common interest and
behaving in a manner directed or determined by them.
This definition has been further analyzed on the basis of the following implications:
(i) Leadership involves other people that is subordinates or followers those who
are willing to accept his direction. Group members give acceptance to the
position of leader and make leadership process possible, because leadership
without group has little or no meaning.
(ii) The position of leader represents power which is backed by formal authority,
his personality traits and group acceptance.
(iii) Leadership is a process of influencing the behaviour of group members,
Leader influences the member to move in given direction by making use of his
power position.
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Leadership styles are characterized into four behavior types S1 to S4:

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• S1: Directing/Telling Leaders define the roles and tasks of the ‘follower’, and
supervise them closely. Decisions are made by the leader and announced, so
communication is largely one-way.
• S2: Coaching/Selling Leaders still define roles and tasks, but seek ideas and
suggestions from the follower. Decisions remain the leader’s prerogative, but
communication is much more two-way.
• S3: Supporting/Participating Leaders pass day-to-day decisions, such as task

allocation and processes, to the follower. The leader facilitates and takes part in
decisions, but control is with the follower.
• S4: Delegating Leaders are still involved in decisions and problem-solving, but
control is with the follower. The follower decides when and how the leader will be
involved.
Of these, no one style is considered optimal or desired for all leaders to possess.
Effective leaders need to be flexible, and must adapt themselves according to
the situation. However, each leader tends to have a natural style, and in
applying Situational Leadership he must know his intrinsic style.
Development levels
The right leadership style will depend on the person being led – the follower.
Blanchard and Hersey extended their model to include the Development Level of
the follower. They stated that the leader’s chosen style should be based on the
competence and commitment of her followers. They categorized the possible
development of followers into four levels, which they named D1 to D4:
• D1: Low Competence, High Commitment – They generally lack the specific skills
required for the job in hand. However, they are eager to learn and willing to take
direction.
• D2: Some Competence, Low Commitment – They may have some relevant skills,
but won’t be able to do the job without help. The task or the situation may be
new to them.
• D3: High Competence, Variable Commitment – They are experienced and

capable, but may lack the confidence to go it alone, or the motivation to do it
well or quickly.
• D4: High Competence, High Commitment – They are experienced at the job, and
comfortable with their own ability to do it well. They may even be more skilled
than the leader.
Development Levels are also situational. I might be generally skilled, confident

and motivated in my job, but would still drop into Level D1 when faced, say, with
a task requiring skills I don’t possess. For example, many managers are D4 when
dealing with the day-to-day running of their department, but move to D1 or D2
when dealing with a sensitive employee “issue”
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The development level is now called the performance readiness level (Hersey,
Blanchard, & Johnson, 2008). It is based on the Development levels and adapted
from Hersey’s Situational Selling and Ron Campbell of the Center for Leadership
Studies has expanded the continuum of follower performance to include
behavioral indicators of each readiness level.
• R1: Unable and Insecure or Unwilling – Follower is unable and insecure and lacks
confidence or the follower lacks commitment and motivation to complete tasks.
• R2: Unable but Confident or Willing – Follower is unable to complete tasks but has
the confidence as long as the leader provides guidance or the follower lacks the
ability but is motivated and making an effort.
• R3: Able but Insecure or Unwilling – Follower has the ability to complete tasks but
is apprehensive about doing it alone or the follower is not willing to use that
ability.
• R4: Able and Confident and Willing – Follower has the ability to perform and is
confident about doing so and is committed.
IMPORTANCE OF LEADERSHIP
Leadership may be regarded as important part of managing process. The

manager becomes more effective and efficient if he is a good leader. Without
having the qualities of a good leader he may find it difficult to direct the
activities of subordinates for achieving organizational objective. More so, the
success, development and growth of organization depends on the leadership
qualities of its managers. Significance of leadership can be understood on the
following grounds:
i Guiding and Inspiring Subordinates

ii Securing Co-operation of the Members
iii Creating Confidence among Employees
iv Creating Conducive Work Environment
v Implementing Change
vi Representing the Members
vii Maintaining Discipline among Members
FUNCTIONS OF A LEADER
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To understand the basic nature of leadership, which is considered a part of

directing function, one should look into the role played by the leader in a group.
The role of leader can be defined in terms of various functions performed by
him. Leader performs these functions in every situation. He takes initiative to
form a group by bringing members together, infuses life in it and makes it to
form a group by bringing members together, infuses life in it and makes it
operational for seeking common goals. He also establishes interpersonal relation
with members, inspires them, guides them and helps them to march in the given
direction. He takes care for the members by making adequate provisions to
satisfy their personal needs and interest so that members can stay in a group for
a longer period of time. Broadly, it is a leader who makes group march towards
the achievement of objective to perform in a better way and maintains high
morale among the members of the group led by him.
American Management Association, the following are the five functions of leadership
(a) Leadership renders a service (by multiplying the contribution of every

individual who is its beneficiary).
(b) Leadership makes decision (not a reckless shooting from the hip but a
calculated searching for the weighing of facts).
(c) Leadership elicits response (leading others to sufficient understanding to
motivate the response necessary to accomplish the task at hand).
(d) Leadership achieves results (by guiding human energy in a definite
direction for a specific purpose).
(e) Leadership is willingness to be different (a discipline and standard of
performance higher than that followed by non-leader).
On the basis of above viewpoints regarding role and functions of leadership more
common functions may be enumerated as under:
(1) Motivating Members

(2) Morale Boosting
(3) Support Function
(4) Satisfying needs of Members
(5) Accomplishing Common Goal
(6) Representing Members
(7) Creating Confidence
(8) Implementing Changes
1.1 Case Study

Senior CMO Adhikari – A Case on Leadership Styles
Dr. Adhikari is a senior CMO in a hospital in Delhi. He has been a senior CMO for quite
some time and has been rated by many as one of the most effective Doctor with good administrative
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skills. He has been considered an intelligent, tactful and effective leader by all concerned including
his superiors.
As part of his organisational duties Dr. Adhikari directs four units of his hospital through his
competent controlling skills and aggressive executive influence. These units are given the name of
units ABC and D within the hospital, and are headed by Dr. Kapoor, Dr. Afzal, Dr.Vidya and Dr.
Shastri respectively. All these four doctors working with Dr. Adhikari care for his guidance and
advice whenever they receive from him in the day to day functioning of their respective hospital
units.
During a particular week, Dr. Adhikari went on an inspection of four units under his control.
First, Dr. Adhikari went on a round of unit a [physiotherapy] which was working under the
able charge of Dr. Kapoor. In this Unit, achieving day to day goals had become some kind of a
routine for the group because, these goals and the procedures for achieving them had become very
well known to all involved in achieving them as well as to the patients and during the round Dr.
Adhikari was informed that some of the items recommended for implementation of patient welfare
had not yet been completed by the group. Dr. Adhikari told Dr. Kapoor to get the things done by
giving some incentives to his subordinates as also closely monitor their performance. He also
requested Dr. Kapoor to keep him informed on the progress achieved as and when convenient.
Dr. Adhikari then went on a round of unit B [Psychiatry], which was working under the
charge of Dr. Afzal. In this unit also, the overall goals were well understood and supported. However,
as the situation will have it. Dr. Adhikari was expected to turn out high quality work and service with
the help of this unit. During questioning he found that some of the items recommended for
completion had not been implemented, he became a little thoughtful. After some time he advised Dr.
Afzal to increase his coordinational efforts amongst his staff by paying a little more attention to his
interpersonal relations with them through good communication and counseling.
Thereafter, he went on to undertake his inspection of the other units C [ICU] and D [Blood
Bank], the nature of whose work, he perceived as challenging. Life in these two units was known to
be rough and many risks were involved in taking decisions for implementing goals. In these two units
redefining goals often became necessary and the central issues were those of commitment of all
involved rather than of competence. Accordingly, junior doctors of `chosen’ abilities were put in
charge of these two units.
As far as the chosen in-charges of Units C and D are concerned, Dr. Vidya is a unit in-charge
of standing and many senior doctors have been quite satisfied with the way she conducts her work in
her unit. Dr Vidya’s unit has shown good results again and again and has also received appreciation
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from patients and attendants. There are many senior persons in Dr. Vidya’s unit who along with the
in-charge have shown a high sense of responsibility and are almost self-motivated to achieve results
for the unit.
Further, Dr. Shastri has been the in-charge of Unit D for a year or so. He has been a good
subordinate and it is felt by many that he may establish himself as a good Unit in-charge, as well.
Once again, on to Dr. Adhikari’s inspections of his units.
Dr. Adhikari started with Unit C which was headed by Dr. Vidya. There he found that some
of the items suggested for improvement in the previous report had still not been implemented by Dr.
Vidya and her team. Dr. Adhikari made a casual mention of these items to the in-charge and closed
the topic as far as this issue was concerned. He went on to other items on his inspection list for that
unit.
After completing his inspection in Dr. Vidya’s unit, Dr. Adhikari went to inspect Dr. Shastri’s
Unit D. in this unit also he noticed that a number of suggestions which were made in the last
inspection report had not been implemented so far by Dr. Shastri and his team. He felt rather bad
about such state of affairs and told the Unit in-charge to personally look into these and do something
early. Dr. Adhikari, however, indicated that any difficulty faced by Dr. Shastri in implementing the
suggestions could be discussed with him and he will be glad to help.
Questions
1. Do you find any difference in the leadership style of Senior CMO Dr. Adhikari in inspecting the 4
Units i.e. A, B, C & D?
2. Could you also discuss the appropriateness or otherwise of the leadership styles referred to in
question 1 above
1.2 A Rating Scale to Assess Teamwork
Criteria Strongly Agree Undecided Disagree Strongly
disagree
Agree
1
5 4 3 2
1. Cooperation: “Team
members work well
together”.
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2. Communication: “Our
ability to give and
receive necessary
information is one of our
strengths”.
3. Goals: “Goal setting is
truly a team activity”.
4. Creativity: “innovation is
encouraged and
rewarded”.
5. Conflict: “Disagreements
are faced up to and
worked fully through”
6. Support: “Praise,
recognition, etc. are
given enthusiastically”.
7. Mutual respect: “Team
members show
appreciation to one
another and avid
sarcasm,
put downs, etc.
8. Commitment: “Everyone
is dedicated to
furthering team goals.”
9. Cohesion: “Team
members see
themselves as
a tight-knit group
10.Pride: “People feel good

about being a team
member”.
11.Decisions: “Everyone has
the fullest opportunity to
participate in decisions
that affect the group.”
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12.Atmosphere: “The
climate is such that
people are willing to put
forth their best effort”.
13. Openness: “Everyone is
encouraged to say what
is on his/her mind
without fear of reprisal”.
14.Trust: “Team members

feel that no one in the
group will take
advantage of them in
any way”.
15.Assessment: “The
team reviews its own
functioning regularly
on a frank and open
basis.”
16.Identification: “I feel
that I am treated as a
full member of this
team and feel very
much part of it.”
17.Leadership: “Our team
leader is a key to our
effectiveness”.
18.Feedback to leader:
“The boss is very
open to suggestions
about the
improvement of his/her
performance”.
1.3 A Rating Scale to Assess Team Communication

Criteria Strongly Agree Undecided Disagree Strongly
disagree
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Agree 1
5 4 3 2
1. Team members listen to

each other
2. The team leader listens
to all group members
3. Everyone feel free to
level and to be candid
with every one else.
4. All team members
“check things out” with
all concerned before
action is taken.
5. Openness: “Everyone is
encouraged to say what
is on his/her mind
without fear of
reprisal”.
6. Trust: “Team members
feel that no one in the
group will take
advantage of them in
any way”.
7. Assessment: “The team
reviews its own
functioning regularly
on a frank and open
basis.”
8. Identification: “I feel that
I am treated as a full
member of this team and
feel very much part of
it.”
9. Leadership: “Our team
leader is a key to our
effectiveness”.
10.Feedback to leader:
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“The boss is very open to

suggestions about the
improvement of his/her
performance”.
CASE STUDY ON LEADERSHIP
A Case on working through a local religious leader to

introduce family planning service
The Primary Health Centre Sultanpur had Dr. Swarup as Medical Officer In-charge , Sri.
Avtar Singh as Block Extension Educator (BEE), four Lady Health Visitors (LHVs), ten Auxiliary
Nurse Midwives (ANMs) and 14 Male Health Workers. Dr. Swarup was worried because he was
falling behind the target of sterilizations fixed for this PHC. He called a meeting of his staff to
review progress of family planning targets achievement. The meeting was organized to identify
workers and villages giving very poor response. Dr. Swarup wanted to make use of suggestions
by his staff for improving the performance of villages with poor response.
In this meeting concern was expressed because in the past eight months the relatively
big village of Sultanpur had no case of sterilization. Transferring another male health worker to
Sultanpure village was one of the several suggestions made at the meeting. Dr. Swarup
considered all the suggestions and decided in favour of transferring an additional health worker.
He presented this decision of transfer in the form of challenge, which motivated several good
male health workers to volunteer for the transfer.
The BEE explained in the meeting that Muslims mostly populated Sultanpur village, and
one of the reasons for the poor performance was the fact that Muslims as a group were not
coming forward to accept the family planning programme. After further discussion, Dr. Swarup
selected one male health worker, Mr. Rajababu, who had excellent family planning performance
records in the past several years, as the new health worker for Sultanpur. Mr. Rajababu was
given the transfer order at the end of the meeting.
Next week Mr. Rajababu with his family and all their belongings shifted to Sultanpur. The
village was fairly big with a population of about 5000 people. Roughly 95 per cent of the
population were Muslim. Illiteracy in the village was very high. A large majority of the population
worked as poor agricultural laborers. There was a big, important Jama Masjid in the centre of the
village. The maulavi of this masjid, Mr. Farooqi, was a highly respected person in the village and
several other neighboring villages. The Jama Masjid and its maulavi dominated the happenings
within the village. The maulavi also ran a Madrasa for village children, and practically every
family sent their children to this school. In case of severe illness or misfortune, Mr. Farooqi was
invariably consulted and approached for his blessings. In all-important matters such as births;
deaths, marriages and divorces people sought his advice. He was invariably involved in all major
decisions in the village.
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Mr. Rajababu decided, on the basis of past experience, that the only way he could make
family planning services available to the community was through their recognised leader, Mr.
Farooqi . He also knew that success depended on giving highest regards and respects to the
religious values of the population. Therefore, one of the first things he did was to contact Mr.
Farooqi, introduce himself and explain the type of health services he can give to the village. He
explained that his programme gave special emphasis to the health of women and children. He
assured Mr. Farooqi that before doing anything in the village, he would ask his approval and also
his involvement. Mr. Rajababu also shared his concern about the poverty and very poor health of
mothers and children in some families. The mention of children touched a sympathetic cord in
the heart of Mr. Farooqi. Very recently, several children of the village had suffered a heavy
attack of diarrhoea and measles. Some children had even died. But Mr. Farooqi asked how a
male can work among the women and children. Mr. Rajababu assured him that a clinic for
mothers and children could be organized with assistance of a lady health worker. After more
discussion, it was agreed to begin such a clinic on a weekly basis.
The weekly clinic soon became popular. Acceptance of the EPI programme was quick,
because of the recent sad experiences with the epidemics of diarrhoea and measles. Mr. Farooqi
and Mr. Rajababu developed mutual respect and confidence. One day Mr. Farooqi asked Mr.
Rajababu about the possibility of posting a female health worker permanently at the clinic. Mr.
Rajababu took Mr. Farooqi to Dr. Swarup, and in the course of their discussion, Dr. Swarup
agreed to keep a lady health worker permanently at the clinic and make it a health sub-centre.
During the inauguration of the sub-centre, Mr. Farooqi was given the place of honour on the dias.
On that day Mr. Rajababau distributed free literature to the guests explaining about the maternal
and child health programme, including the need to space children for better health of both
mothers and children. He distributed the literature quietly and the guests were allowed to carry
home any booklet they wanted.
One evening, about a week after the opening of the sub-centre, Mr. Rajababu was
surprised to find Mr. Farooqi coming to his home. Mr. Rajababu welcomed Mr. Farooqi warmly in
his home, and then took the initiative of talking about how family planning was necessary for the
health and economic welfare of the families in the village. He specifically referred to poor
families with a large number of children and their pitiable condition. He mentioned about the
family planning services that could be made available at the sub-center, and encouraged Mr.
Farooqi to talk about family planning with people in the village. Mr. Rajababu also gave examples
of other villages where people of all religions, castes and economic groups were accepting family
planning.
About a month after the discussion, Mr. Farooqi agreed that this sub-centre could give
family planning services to women who needed it. He gave his permission only after Mr.
Rajababu assured him that there would be no unusual propaganda.
Exercise management styles-- 1

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Expected outcome
---------------------------------------------------------------------
The trainees are expected to know various management styles.
Instructio ns to Trainees -------------------------------------------------------------------
In the exercise, five managers in the health sector are presented to you. They all
have some kind of problem which is expressed as a case. After each case, five
alternative solutions are given.
STEP 1
Please mark, for each case, the alternative that would best suit your own way of
behaving, if you were this manager.
Mark the alternative by circling the capital letter corresponding to the chosen
alternative. Only mark one alternative per case.
Case 1
Mrs. Sharma is head of the female ward of the district hospital. Lately she has
noticed that one of her nurses often talks to a nurse from the male ward. She
was doing it when there was a lot of work to be done. There was even once a
problem with a patient whom she forgot to attend to. The other nurses in Mrs.
Sharma's ward seem to be getting irritated about this situation.
a) Talk to the nurse and tell her that she should have fewer talks with the
other nurse. Inform the head of the other ward about this situation.
b) Talk to the nurse and tell her what you have seen lately. Try to find out
why she is doing it See what you can do about it. Ask what she thinks is the best
solution.
c) Tell that nurse that you have often seen her talking to the other nurse and
that you think it harms the work in your ward. You suggest that she should talk
to the other nurse on other occasions or at times when it can do no harm, and
tell her to take into account the reactions of her colleagues.
d) Before you give your own opinion, try to find out why she is doing this and
whether she is aware of the consequences of her behavior.
e) Do nothing' at the moment. It would be unwise to make a big thing about

such a minor incident.
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Case 2
The District Health Officer regularly has talks (once every month) with the
Medical Officers of PHCs. These talks are individual. The last few times he
noticed that one of the Medical officers was complaining about his work. He said
that he had too many patients and that his present work was too boring. Up to
now the supervisor did not pay much attention to it. He thinks that there is a
lack of motivation.
a) Tell him that you can understand his problem, that you had the same
problems yourself when you worked as a fieldworker. Suggest that even minor
changes in patients can be seen as a success and that it is not his fault that
progress is very slow. He might also talk about this to his colleagues, to find out
how they react to this problem.
b) Tell him that, in your experience, this problem occurs with everyone. He
had better not think about it too much and he should try to get over it. The
sooner these ideas are out of his mind, the better it will be for him.
c) It is better not to take action. He probably has some problem and this will
eventually go away. If he wants to talk about it, he should not do so with me
because I see too little to have a good relationship with him.
d) Ask questions about his complaints. Try to find out what are the reasons
behind it. When did it start?
e) Try to find out what his complaints are and tell hint that you are here to
help him to do his work well. Look for solutions, and ask for the fieldworker's
solutions..
Case 3
The district health officer is the chairman of a meeting about the future of the
communicable disease control programme. Members are:
• Head of malaria control,
• Head of leprosy and tuberculosis control,
• Head of district hospital.
Because he is pretty well informed about the intentions of these members. He

knows that most of them have hidden objectives. Nevertheless, he needs to get
these people to work together for the sake of future policy.
In other words, in this meeting the district medical officer expects “Hidden
Agenda”.
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If you were district medical officer, what would you do?
a) Find out the real motives of the members of the meeting and present a
proposal for future policy.
b) Try to create an open atmosphere which allows for constructive and

cooperative working relations and look for a solution together.
c) Tell in the meeting that you have the impression that there are a lot of
different ideas about this subject and that you advise the meeting to consider
two or three possible solutions which you already have in mind.
d) Keep quiet about "hidden agendas” Although you know they exist, the
group members will never admit to them and that will embarrass you. Moreover
it is better to talk about this in private.
e) Listen carefully to what everybody has to say and encourage people to

elaborate on their points of view. In this way you will get a clear opinion of their
respective positions.
Case 4
Dr. Singh is head of a community health centre which has an out-patient
department (OPO) and an in-patient (IPD). The OPD used to "borrow" nurses
from the IPD for very short period of time, but only when they had a lot or
people waiting. In this way, the health centre could render good service and this
temporary loss of nurses was no problem for the IPO. Lately, however, the OPD
has been using two IPO-nurses almost constantly. This situation arose gradually
and now the IPD is complaining about a shortage of manpower and not being
able to cope. They have to work longer hours and take shorter breaks. The head
nurses of these two units cannot find a solution.
If you were Dr Singh, what would you do?
a) At the moment keep things going the way they are. The present crisis will
probably pass.
b) Get the two head nurses together and find a solution that is acceptable to
the three of you.
c) First, get the two nurses back to the IPD and then make a scheduled for
borrowing manpower from the IPD on the basis of the old situation.
d) Suggest to the two head nurses' that the most important task is to render
services to all patients and that it must be possible for them to come up with a
feasible solution to this problem. Maybe they can organize their work differently
or change, . Procedures for patients.
e) Before taking any action, first try to find out what is happening. Have
separate interviews with the head nurses and encourage them to tell you how
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they feel about this situation; how they se that things have gone wrong lately.
Case 5
You are a district medical officer. During the last monthly rneeting of the district health
management team, this was chaired in your absence by the Deputy. CMO, trivial issues
between members of the team kept coming up, so that only half of the planned agenda
could be finished .The usual agenda is set for tomorrow’s meeting but you fear that you
might not be able to finish half of it.
How do you plan to act if trivial problems are brought up again?
a) Leave the agenda as it is and spend extra time hearing the oplf7lOn of all
members of the team.
b) Each time an issue is brought up which could be caused by trivial rivalry
consult the persons involved and look for a solution which is acceptable to all .
c) Have the issues summarized and refer them to the district development
committee.
d) Refuse to accept the issues as being relevant to the purpose of meeting
e) Tell the meeting that you are aware of the problem, and propose that the
meeting consider a number of transfers.
Step 2
In the diagram below, circle the letters which correspond to the solutions you have
selected in each of the cases.
DI LA GA TC ST
Case 1 E D C A B
Case 2 C D A B E
Case 3 D E A C B
Case 4 A E D C B
Case 5 D A E C B
TOTAL
Where,
DI-- DODGE THE ISSUE
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LA--LISTENING ACTIVELY
GA--GIVE ADVICE
TC--TAKE CHARGE
ST--SITTING TOGETHER (supportive supervision)
Step 3
In the above table, each row represents a case and each column a management style.
In how many columns do circle appear; or; how many styles did you use?
In which Column did you put most of the circles; or; which style did you use most
frequently?
Discuss your answer with your facilitator

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Exercise teams and team leaders - management styles

1. Reflect and recollect whom you consider to be a leader. Write down why you
consider that person a leader? Discuss the definition of leadership on the plenary
and attempt to reach and consensus definition. Write down the definition derived
thought group consensus in the space give below:
(e.g. Adolf Hitler, mother Teresa etc. )
Based on the discussion develop a list of key qualities of a successful leader.
A. …………………………………………………………………………………...
B. …………………………………………………………………………………...
C. …………………………………………………………………………………...
D. …………………………………………………………………………………...
E. …………………………………………………………………………………...
F. …………………………………………………………………………………...
G. …………………………………………………………………………………...
H. …………………………………………………………………………………...
I. …………………………………………………………………………………...
J. …………………………………………………………………………………...
K. …………………………………………………………………………………...
L. …………………………………………………………………………………...
[Every mother has a stand that her child wouldn’t die due to hunger. Is this a
leadership quality? ]
2. Interview a a representative sample of manages in your medical college [HODs,

medical superintendents, director, director administration, PRO, etc.] And try to
find out their preferences for various management styles. Discuss the situation in
which they succeeded or are / were unsuccessful.
3. Which management style or which leadership style might be most appropriate

when a decision needs to be made quickly?
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4. Which it style might be most appropriate when trying to introduce long-term

organizational change within a voluntary organization which requires ‘everyone to
be on board’?
5. As a team member - which style would you prefer to be managed by?
6. As team leader - which style you prefer to manage by?
7. Which style might be it is easier for a manager to manage by? Is this always the
case? explain your answer
8. Have you ever experienced situation where a team leader or manager adopted the
style in order to deal with a problem within the team when it may have been more
appropriate for them to adopt a different or alternative style?
EXERCISE
There are nine situations are given. Now what will be yours style of leadership?
Situation 1
You have recently joined as the District Tuberculosis Officer and have constituted a
team to accomplish a new task assigned to your Centre. In spite of enthusiasm and
rapport among members, you find that they lack the necessary planning and
managerial competency. What action would you take?
1. Plan the task in detail, and arrange training programmes for them in deficient areas.
2. Encourage the team to find solutions to their problems.
3. Plan the tasks, distribute assignments and supervise their work.
4. Discuss with members, and help them to learn planning and monitoring
competencies.
Situation 2
You are the District TB Officer. An enthusiastic Health Educator willing to serve
people is posted in your Centre. The other members of the center welcome him ad
provide the needed support. The Health Educator is required to hold and IEC campaign.
You would
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1. work out the details of the campaign, individual responsibilities, and monitoring
arrangements hold a meeting of the staff, and share the plan with them,
encouraging them to make the campaign a success.
2. work out the details of the campaign, decide targets in details, assign responsibilities
to each one according to their competence, and supervise their work in the field
every day to make the campaign successful.
3. tell the group the importance of the task, communicate to them their strengths and
your confidence in them and join them in working out the details of conducting and
monitoring the campaign.
4. communicate to the staff the requirements of the campaign, and let them work out
the details, including monitoring, and be available for any help required.
Situation 3
You are in charge of a TB clinic. The members working with you are a
good team, are competence and have enough relevant experience. However,
you find that the members need to be reminded frequently to do their work.
What action would you take?
1. Define team members’ responsibilities and closely supervise their work.

2. Let the groups work out ways of improving performance.
3. Work with the team to solve the problem.
4. Supervise more frequently and help the team to overcome the difficulties they
encounter.
Situation 4
As District TB Officer your targets have been increased by 25% this year. One of
your Block Treatment Centres has a tem of committed and efficient workers, and last
year it was rated the best out of ten Centres supervised by you. You have high
expectations from this Centre. What action would you take?
1. Revise the responsibilities of the members in the light of the new targets, and
provide needed support to them for their achievement.
2. Participate in the group’s discussion to develop an action plan.
3. Let the team develop a detailed plan, and provide them the needed support.
4. Emphasize the importance of the new targets, and set targets for each member of
the team.
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Situation 5
You have recently joined as the Principal of a training institution. The staff of the
institution is efficient. However, they see training as a burden. There is no team spirit
in the institute. You have been asked to organize a series of five orientation
programmes for community participation in the next three months. What action would
you take?
1. Prepare the programmes and timetable, and discuss with the group the facilities
they need to implement them.
2. Plan the details of the programmes, various person’s deadlines, and supervise
the progress.
3. Plan and work out details of implementation with the staff.
4. Let the groups work out detailed plans and provide them the needed facilities.
Situation 6
As the head of the hospital you have noticed that doctors and nurses in the OPD
are neither competent nor prompt. They lack enthusiasm to attend the patients. In an
emergency situation the nurses provide no timely help. Doctors refuse to operate in
less equipped operation theaters. What action would you take?
1. Share your concern with the staff, express the urgency of improving the situation
and your trust in the team, let them work out the detailed solutions; you may join them
in this exercise.
2. Call a staff meeting, share your concern and ask them to give suggestions.
Based on the suggestions, prepare details of responsibilities and supervision, and
encourage them to implement them.
3. Call a meeting of the heads of the department & sections, give them the targets
for services, cleanliness etc. Arrange necessary training, and closely monitor (twice a
week) the improvement in the situation.
4. Suggest that the heads of the sections and departments deal with the situations
and bring about improvement.
Situation 7
You are a district TB officer. In one of your treatment centres, performance has been
declining rapidly for the last six months. Although the doctor is competent, he says he
is not responsible for the decline in performance. He feels that even though the
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members of this particular Centre know their work, they seem to be unwilling to take
responsibility and do not work as a team. What action would you take?
1. Discuss with the team and the doctor the need to improve the situation, set
targets and remove any difficulties faced by them.
2. Ask the doctor to let the workers form teams of their choice and supervise them.
3. Share your concerns with the doctor and let him and the team work out their own
solutions.
4. Reorganize the team, set targets and responsibilities, and monitor the teams’
progress.
As a TB Control Programme Manager your responsibilities involve management of

material and men, which are equally important for the success of the programme. Yet,
while managing materials is a function of knowledge of such techniques as planning,
financial budgeting, resource allocation, etc., management of people poses a greater
challenge. It is so because people bring with them their values, attitudes and work
cultures, which make working together as a team often a difficult proposition. An
understanding of these factors is essential for the leader of the team who is often faced
with questions such as: How do I bring together the people? How do I identify a
common goal and motivate the members to work for it? How do I facilitate the process
of growth and development of the individuals which pursuing the goals of the
collectivity? How do I evolve and sustain individual initiative? These are some of the
challenges you are likely to face as a TB Control Programme Manager. Thus, the skill
which helps you most in the successful implementation of the programme is your
leadership style and its effectiveness in the given situation.
Leadership is an individual’s effort to influence the behaviour of others. There

are many definitions of leadership, but the one common theme that runs through each
of them is the ability to inspire confidence and support among the group members to
achieve the programme goals. Leadership is a function of three factors: the leader, the
group members or the team, and the situations/condition. Thus, leadership is
determined by not only the characteristics of the leader but by the team and the
situations that prevail in the origination. A particular course of action or leadership
style, which worked in a particular situation, might not work or may be disastrous in
another. Therefore, effective leadership requires a greater understanding of the people
and the situation and the ability to use the appropriate style in the given situation. For
example, providing detailed guidelines for task performance, determining the job duties
of the team members and supervising them closely and regularly may be effective in a
situation where the team members do not have requisite skills or understating of the
problem and the situation demands error-free, efficient and time bound performance of
the team. This approach may be totally inappropriate if the team members are
specialists in their own sphere, have the ability to decide and understand the problem
and the situation demands innovative solutions or on the sport decision-making.
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The purpose of leadership development at the TB Control Programme Manager’s

level is to develop skills to motivate, commit, support and guide the team members to
achieve the programme goals. It should be remembered that leaders are also members
of the groups, influencing them and being influenced by them. Leaders cannot operate
in isolation and groups with tasks to perform cannot do away with leaders.
ROLE PLAY- 1
The medical officer-in-charge of a small, isolated PHC has been selected to take part in a special adult immunization
project. Every adult in three selected villages in his area will be immunized. The PHC will have to close for three days, since
the entire staff of this small PHC will be needed to work on the immunization project.
A message explaining the project has already been sent to the leader of each village. The PHC staff meets to plan how
to carry out the project and schedule the work.
Two role-play exercises will be held for the meeting called by the medical officer. In the first role-play, the medical
officer plans the project by himself. In the second role- play, he involves the entire team in planning the project.
Role Play I
Step 1:The trainer will ask five participants to form a group. Each participant will choose a role as
medical officer, health assistant (F), health worker (M), health worker (F), village health guide. The
other participants in the class will observe the role-play.
Step 2:Participants taking roles should study the following information:
The medical officer has received instructions on a special adult immunization project which will
involve the entire PHC staff. He has not shared this information with staff members. This medical
officer is in the habit of planning all the work at the PHC. His attitude toward his staff is, ‘Do what I
say and don’t ask questions.’ He calls a meeting of the staff and gives these orders:
The PHC will close for the first three days of October to carry out a special immunization project
in Village A, Village B, and Village C.
The Health assistant (F) is to coordinate activities in Village A.
The health worker (F) is to coordinate activities in Village B.
The health guide is to notify all people in Village C, and see that they attend the immunization
clinic.
Health worker (M) is to transport supplies to all three villages.
The medical officer, in making this announcement, tries to ignore the suggestions and protests
of other members of the staff. He wants to end the meeting as quickly as possible and get back to
work. The health assistant (F) has been promised vacation leave during the first week of October to
attend the marriage of a cousin. She protests loudly. The health worker (F) protests that Village A
being her native place, she should not have been asked to coordinate activities in Village B.
The health worker (M) protests that to reach Village C an overnight trip is necessary and he
does not want to leave the PHC unguarded on the night while being responsible for the security of the
PHC. The health guide also protests that cooperation from Village C people will be unlikely because
they were treated rudely by the visitors last time they took part in a special project.
Step 3:The participant taking the medical officer’s role calls the meeting. He announces the special
project. The role- play lasts about fifteen minutes.
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Role Play 2
Step 1
The trainer will ask a second group of participants to repeat the role-play.
Participants who will take part in this second role-play should study the following
information:
The medical officer has received instructions on the special adult immunization project. He
decides to consult with the staff how to carry out this project. At this PHC staff members feel free
to make suggestions. The medical officer often takes their advice.
This medical officer is in the habit of involving his staff in planning work at the PHC. He
respects staff members’ opinions and finds that they often make good suggestions. He calls a
meeting of the staff to plan the immunization project. He explains the project and suggests this
plan:
The health assistant (F) should coordinate activities in Village A, which has no health
guide.
The health worker (F) should coordinate activities for Village B, which has no health guide.
The health worker (M) should be responsible for transporting supplies to all three villages.
The health guide should coordinate activities for her Village C.
After you suggest this plan, you ask for other suggestions from the staff. The health
assistant (F), health worker (M), and village health guide, all use the roles described in
Role-Play 1.
Step 2
The participant playing the medical officer’s role conducts the meeting. The staff
should agree on a work plan for carrying out the immunization project. This
role-play lasts twenty minutes.
Questions:
1. Compare the two role-plays and discuss the effect of team involvement in
planning work at a PHC.
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Place yourself in any of the group and narrate a better strategy in such situation.
Multiple choice questions

Leadership
1. The process of directing othe rs towar ds accompl ishmen t of ob jectives is : (a)
Communic ation ( b) Contr olling (c) Managing (d) Leading
2. "Lead ers are bor n, not made " this argum ent is suppo rted b y:
(a) Trai t theor y (b) Situational theory (c) Lead ership contingency mod el (d) Mana geria l grid
3. The Scientific mana gement mo veme nt of early 1 930 's em phasised on : (a) Concer n
for task (b) Conce rn for r elationship (c) a + b (d) Non e
4. The leadership conti ngenc y mode l was pr opounde d by:
(a) Rob ert R Blak e (b) Fr ed E Fiedler (c ) Wil liam I Reddin (d) F. W. Taylor
5. Rensis Li kert's ex tensive research 's implic ation was that the idea l and most producti ve leader
behav iour for indu stry is:
(a) Task centered (b) Empl oyee ce ntered (c) a + b (d) None
6. Most desirable le ader beh aviour as per ma nager ial grid is
(a) Co untry club (1 ,9) (b) T eam ma nagem ent(9,9) (c) Imp ove rished (1,1) (d) Mid dle Road (5,5)
7. An ess enti ally autho ritative lead er believes is:
(a) Theory X of mo tivation (b) The ory Y of mo tivation ( c) a + b (d) None
8. The manageri al gri d dep icting vario us leader ship styles in four qua dran ts was give n b y: (a) Robert R Blak e
and Jan e Mouto n (b) Fr ed E F iedler (c) Will iam I R eddin (d) F.W. Tayl or
9. The human re latio ns mo vement emphasized on:
(a) Co ncern for Task ( b) Concer n for relationship (c) a + b (d) None
10. In the manage rial grid the leadersh ip st yle of high structure and high con side ration is refer red to as :
(a) Middl e Road (5,5) (b) Impo verished (1,1) (c) Team (9,9) ( d) Task (9,1)
11. In the manager ial grid the leader ship style of low structure and low conside ration is referred to as:
(a) Imp overished (1,1) (b) Tas k (9,1) (c) M iddl e Road(5,5) (d) Team (9,9)
12. In the managerial g rid the leadership style of high structure and low cons ideration is referred to as:
(a) M iddl e Road(5,5) (b) Task (9 ,1) (c) Team (9,9) (d) None
13. The tri -dimensionalleade r effectiveness model was propounded b y:
(a) Ro bert R Blake (b) Fre d E Fie dler (c) William I R eddin (d) F .W. Taylor
14. The Book "The Functions of the Executive" is authored b y:
(a) W illiam I Reddin (b) Robert R Blake (c) Thomas Harris (d) C hester I Bar nard
15. The Book " The M anageri al Grid" has bee n authored by:
(a) Fre d E Fied ler ( b) Robert R Bl ake ( c) W illiam I Redd in (d) F.W. Taylor
16. The conti nge ncy approach emphasizes the view point that what manag ers do in prac tice dep ends on:
(a) Wor ker (b) Sit uation (c) Task ( d) Mana ger
17. Leadership is the funct ion o f:
(a) Leader (b) F ollowe rs (c) Si tuation s (d) All ar e co rrec t
18. Directing must be consistent with which of the follow ing:
(a) Orga nisati onal po licies ( b) Proce dur es (c) Job d escrip tions ( d) Al l are correc t
19. The leadership styl e where a leader leaves the group entirel y to it self is called: (a) A utocra tic
(b) Democra tic (c ) Consult ative ( d) La isez fa ire
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FILL IN THE BLANKS

1.___________ ______________ is the activity of influencing peoples to strive
willingly in group objectives.
2.__________In style of leadership the l eader central izes power and
decision making into h imse lf.
3.______________________________________Leade rship i s a function of
leader, followers and _______________________ _
4._______Lea dership = f (1, f, s) wherein '1 ' stands for _'f' stands for ______
___________________________________ and 's ' stands for_______ ___________
5._______________________________________________"Lea ders are born not
mad e" this st atement is supported by ________________ theory of leadership.
6._____________________________________In ma nageria l grid th e
leadership st yle of ________________________ structure and high consideration
is referre d to as Team (9,9).
7.___________________________________________________In the ma nager ial
grid the le ade rship style o f low structure and _____________ con siderati on is
referred to as Im pove rishe d.
8.____________The depicting various leadership styles in four quadrants
was given b y Robert R Bla ke and J ane Mo uton.
9. _______ pro pound ed t he Leadership Contingency Model.
10._______________________________________________The Tr i-Dimens ional
Leader Effectiveness Model was given by _____________ _
11. In __ style of leadership th e leade r decentra lizes autho rity and arri ves a t
a decision from consulta tions and pa rticipation b y followers.
12.__An esse ntially autocra tic leader believes in Douglas McGr egor 's theory
_
13._______________________________LBDQ is a n abbr evi ation for _
14._____Manage rial Gr id impl ies that th e most d esir able leader behaviour i s
man agement (9,9).
15.________________________________________In t he Tr i-Dimensional
Lea der Effectiveness Model ___________________ is the third di mension .
Keys:
1: Leadership, 2 : Autocratic , 3: Situations, 4 : Leader, Followers, Situation, 5:
Trait, 6: High ,"!: Low, 8: Ma nagerial gr id, 9 : Fred E Fiedler, 10: William I
Redd in, 11: Democratic/Participative, 12 : X, 13 : Leader Be haviour
Description Question naire , 14: Team, 15: Environm ent
MARK THE FOLLOWING AS TRUE OR FALSE

1. Personal traits, characteristics of a person, his value sys tem, h is
personality ar e essentials in making him a successful leader .
2. Environmental fa ctors such as - organizat ional , economic , social forces pla y
an imp ortant role in a lead er's success .
3. Situational theory supports the argument that leaders are born not mad e.
4. The Scientific manag ement movement mainly emphasized on concern f or
relationsh ips.
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5. William I Reddin prop ounded the Leadership Contingency Model .

6. The managerial grid implies that the most de sirable leader behaviour i s
"Middle road" (5,5)
7. Ren sis Like rt's r esearch findings confirm the superiority of
democratic or participative style of lead ership over other styles .
8. William I Reddin was the first person to add effectiveness dimensio n to the
man agerial grid and other leadership style models .
9. An essentially authoritative leader believes in Douglas McGregor 's Theor y X.
10. In man ager ial gr id the leadership style of high structure and high
consideration
is referred to a s Team (9 ,9)
11. Succ essful lead ership i s synonymous with effective leadership .
12. LEAD i s an abbr eviation for Leader’ s Eff ectiveness and Adaptability
Description.
13. The fr amework called th e "Johari Window " was develop ed by Joseph Luft and
Harr y Ingham .
14. Man ager ial Grid depi cts leader behaviour on a single continuum .
15. Most evidence indicates that the leader behaviour mus t be
plotted on two separate axe s rather than on a single continuu m.
Keys:
True:- 2,7,8,9,10,12,13
HEALTH & HOSPITAL MANAGEMENT Collected By:
Krishna Jagrit
SECTION - C
Material Management
including Inventory Management
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Material Management including Inventory

Management
Material management is a scientific process by which an organisation is
supplied with the goods and services, which it needs to achieve its objectives
at optimum cost. Materials management is concerned with the planning,
organizing and controlling the flow of materials, from their initial purchase
through internal operations to the distribution or to the service points.
Hospitals require a variety of materials and supplies which are essential in

providing good patient care. These supplies have to be obtained at most
economical rates in right quantity and right quality at right time. Effective
management of these supplies is possible through the scientific system of
materials management.
The goal of a good hospital supply system is to ensure that there is

adequate stock of required items, so that an uninterrupted supply of all
essential items is maintained, taking due care that we do not overstock the
supplies which not only locks up the capital, but also gives room to pilferage
and obsolescence. We should also ensure that these items are properly
stored, controlled, made retrievable and distributed to the points of usage.
The materials in hospital can broadly be classified into three groups:
Consumables – drugs, medical gases, disposable needles and syringes,

reagents, kits, etc.
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Semi – durables – surgical instruments, linen, etc.
Durables – equipments, laboratory instruments, etc.
Further discussion on material management is divided into two parts:
Consumables / semi – durables
Equipment
PRINCIPLES OF MATERIAL MANAGEMENT
Principles
The prime objective of materials management is to utilize the available

resources most effectively and efficiently. To achieve this goal following
principles of management have to be practiced.
1. To determine the categories of items required, their quantity and

quality for smooth functioning of the hospital. These details can be
computerized.
2. To procure these items in the optimum quantity at lowest cost

consistent with specified quality at proper intervals to ensure
continuous supplies.
3. To store the items received properly to facilitate easy retrieval,

accounting and prevent deterioration.
4. To develop a good system of inventory control so that the inventory

(supplies) levels are kept as low as possible. The item should be on the
racks for short period to ensure high inventory turnover.
5. To develop an efficient system for proper distribution and accounting

in the hospital stores and point of usage.
6. To ensure that loopholes of leakage are efficiently plugged to check

pilferage and misuse.
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7. To ensure prompt payment to the suppliers which will build a good

purchase system necessary to maintain continuity of supplies. This
promotes favourable relations with the suppliers.
8. A written manual incorporating the policies and procedures to be

followed in the management of materials / supplies will be helpful in
eliminating confusion thereby, affording uniformity.
These general principles of materials management are applicable in the

management of any type of hospital stores like : Medical Stores , Surgical
stores , Miscellaneous Stores , Linen Stores etc., However , some of the
practices may differ marginally . The author has quoted extensively the
practices recommended to be followed in the management of medical
stores , just for convenience.
ADVANTAGES OF INTEGRATED MATERIALS MANAGEMENT
Materials management impinges on many of the functional areas of

organizational activities. Its effects are felt in almost all spheres of
organizational work.
Organizations which have adopted the integrated materials

management approach have the following advantages.
1. Better Accountability: Centralization of authority and responsibility

for all aspects of materials functions ensures specific accountability.
2. Better Coordination: When a central materials manager is
responsible for all functions, co – ordination of the various functions of
materials management is facilitated.
3. Better Performance: As all the inter – related functions are
integrated organizationally , an effective communication and enhanced
performance is a natural sequelae.
4. Adaptability to Electronic Data Processing (EDP) : All information
with regard to materials function is centralized. This facilitates
collection , collation and analysis of data leading to better decisions.
Advanced and efficient electronic data processing systems can be
economically introduced under an integrated set up.
5. Miscellaneous Advantage: Team spirit is inculcated under a central
materials manager resulting in coordination and cooperation. The
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opportunities of growth and development are better in an integrated

set up.
Techniques of Material Management
1. Material Planning and Programming
a. Material Planning always should be in terms of objectives viz., low

prices, high inventory turnover, low cost acquisition and possession,
continuity of supply, consistency of quality, low payable costs,
development of personnel records etc. The determination of
objectives is an important part of the overall planning process. The
plan should also indicate, how these basic objectives are to be
achieved. To achieve these objectives, the fundamental guidelines of
material planning are to be followed as:
- There should not be any production hold up of materials.

- Purchase are to be made in time
- Inventory holdings need to be kept at minimum in order to avoid
high carrying costs.
All these may require a proper purchase decision, purchase budgeting,

value analysis and maintaining inventory level and reorder point. There are
numerous varieties of drugs and surgical items required for running a
modern hospital . In larger or super – specialty hospitals the number is
greater. A rational classification based on their therapeutic action or usage
will proved the first control on hospital inventories. Items can be classified
rationally and coded serially by grouping similar items together.
b. Once the classification of the items is done it will be easy to undertake

standardization and simplification , there – by , reducing the variety of
items in each category . There are many items in the stores which may
have different trade names but their chemical properties and
therapeutic value will be the same. For example, once we classify the
drugs, we may have a lengthy list of analgesics like aspirin ,
paracetamol , brufen, diclofenac sodium , piroxicam or a combination
of two or more of these drugs . The question is whether we can afford
to stock this full range of analgesics? Most of the hospitals in our
country are short of funds. Reducing the variety of item in each
category will help us not only in achieving better economy but also will
facilitate good inventory control.
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2. Purchase process
This could be through State Rate Contract, Medical Store Depot, Tenders
System with negotiations or local purchase. While purchasing, four factors
have to be borne in mind; the essentiality, the quantity, the quality and the
cost in relation to the budget provision for every item. Buying in bulk is
always more economical. Local purchase and spot purchase should be
avoided as such purchases cost 15 to 20 percent more. The accepted method
of purchasing is by organising the Rate Contract method. The quantities of
various items required by the hospitals in the state , region or by an
organization for the ensuring year are consolidated. The expenditure of these
items during the previous year is taken into consideration. Tenders are called
for from the suppliers of these items by giving detailed specification of the
items , terms and conditions of the purchase etc. After analyzing the tenders,
negotiations are held to get the best price , quality , mode of supply and the
payments etc.
3. Receiving and Inspection
On placing the order for various supplies, it is necessary to organize a system

of door delivery so that the hospital can avoid the nuisance of demurrage,
deterioration and pilferage associated with consignments from Railways and
Road Transports. Every effort must be made to have a proper quality control
system to ensure that the hospital supplies received are safe for the patients.
Quality control of some items is organized by matching the supplies with the
sealed samples submitted with the quotations. Periodic drug analysis is
undertaken in the Drug Laboratory to check the offered specifications with
the demanded ones.
Payments for the purchases made should be prompt. We are aware that
many a time, there is inordinate delay in making payments causing hardship
to the suppliers. Prompt payments promote cordial relations with the
suppliers which will be helpful in procuring items in short supply other than
some handsome discounts.
4. Storage
Following guidelines will be helpful in organizing good storage and accounting

process:
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a. There should be sufficient space and enough shelves for storage with
fire safety precautions for storing the inflammables. The sera, vaccines
and other biological should be stored in refrigerators as required. The
stores area should be kept clean.
b. Items should be easily identifiable and retrievable for issue.
c. Storage should facilitate easy counting and physical verification so that
control is free of fuss. Each consignment should be preferably
segregated for easy identification by using color codes.
d. Items should not be allowed to deteriorate during storage. Expiry dates
should be constantly monitored by using standard chart. To minimize
human error , the principle of rotating the stocks should be observed to
prevent deterioration of materials . First – In and First – Out (FIFO)
principle should be followed by arranging the old supplies in the front
row of the rack and stocking the fresh supplies in the rear part.
Another method is to maintain the expiration date control chart as
shown in the figure below:
1998 1999 Remarks
Name of Drug A M J J A S O N D J F M A M J J A S
Inj. ATS
The store keeper should be trained to take necessary action for the utilization
of items as it reaches the first warning ‘O’ which appears 3 – 6 months before
the actual date of expiry, i.e. ‘X’.
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e. Loss due to pilferage can be checked by following simple measures like

stamping of labels with indelible ink, insisting on the return of empty
ampoules, vials, containers etc.
f. Safety requirements, particularly against fire should be met. Special
precautions should be taken in the control of narcotics.
5. Accounting
Stock verification and physical verification is necessary from time to time.

There are two methods of undertaking this:
a. Annual stock taking method: This is usually followed in government

organizations. Physical verification of all the items in all the
departments is done once in a year at a simultaneous time. This has
to be completed in minimum time as normal work has to be
suspended.
b. Perpetual inventory method: Verification is carried out by two
persons unconnected with the store. This is done almost on a daily
basis so that few items are checked everyday to ensure that all the
store items are checked at least 2-3 times in a year. Any discrepancy
between the ledger stocks and actual stocks is immediately
investigated.
Accounting of stores is another important aspect of store manager’s

duties. From time immemorial, we have been keeping may kinds of ledgers
for entry of receipts, issues, balances, and their values. It is much simple to
use the modern Kardex System. Bin cards as per material code numbers are
maintained in Kardex cabinet, so that they are readily accessible and brought
up-to-date. Flags of different colour codes can be mounted on the cards to
indicate the stock position to facilitate prompt recording. Computerization
has revolutionized the inventory control methods.
6. Issuing and Recording
A health centre may have several sections, such as a maternity ward, a

treatment room, a laboratory, a mobile clinic. The health worker in charge of
each section is responsible for the equipment in that section. Thus, a
maternity nurse may be responsible for weighing-scales, syringes and
vaccines, record cards, delivery kits and other apparatus, and a laboratory
worker for the microscope, test-tubes, glass slides and stains.
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After equipment has been ordered, received and recorded in the stock
book or ledger, it is issued for use when it is needed. Three paperwork
procedures are involved in issuing equipment:
- a ledger record ( writing the issue in the stock ledger)

- Issue of a voucher which must be signed.
- An inventory record of the section receiving and using the
equipment.
Inventory Management
Need & Necessity of Inventory Control
Inventory control is very essential in a developing country like India. India is a

country of scarce resources and it is the primary responsibility of each
organization whether it is a hospital, private enterprise or a Government
department to ensure optimum utilization of available resources to provide
good service or quality patient care. Due to inflation, hospitals are faced with
the budgets that do not balance prices that are not stable and costs that are
not controlled. In this atmosphere, the hospital management is faced with
choosing the alternative of either lowering the quality of care or adopting
ways and means to reduce the cost n inventories. It is estimated that
thousands of crores of rupees are being blocked in inventories. Hence there
arises the need for developing an efficient and effective inventory control
system.
“Inventory is the sum total and costs of all supplies official and non
official, where ever they may be stored and that have not yet been used.”
TYPES OF INVENTORY
Inventories may be classified as official and unofficial.
1. Official inventory is that which is brought into a storage space or unit,

counted and controlled until it is dispensed to a using department.
Examples of inventories of central stores are as follows.
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• Medical and surgical Items, dressing , linen , X-ray supplies, laboratory

supplies, housekeeping items, processed sterile supplies
• Pharmaceuticals items – fluids
• Dietary items like cereals, pulse etc.
2. Unofficial Inventory: It is those supplies that have been expensed and

dispensed from the central stores to the various departments and units
where they are store until used. Most hospitals never count or rarely
control this stock. Unofficial inventory exists in all supply consumer
departments such as: nursing units, laboratories, anesthesia, department,
surgery department, emergency rooms, radiology department,
maintenance department and administrative offices.
TECHNIQUES OF INVENTORY CONTROL
Inventory control is basically a scientific system which indicates as to

what to order, when to order, how much to order, how often to order so that
the purchasing costs and storing costs are kept as low as possible. The two
basic techniques of inventory control are ABC analysis and VED analysis.
ABC Analysis
It is based on cost criteria governed by Pareto’s Law where a small

number of items consume a big chunk of resources and vice-versa. The ABC
principle which is generally applicable to any type of store states that:
• Around 10 percent of the drugs / store material would cost 70% of the
resources. (Group A )
• 20% of the drugs / store material generally consume 20% of resources
(Group B ).
• Remaining 70% of the drugs / store materials would consume just
about 10% of the resources (Group C)
The calculations will not be so exact and the range may vary by about 5 per
cent.
Methodology for ABC Analysis
i. Work out the annual consumption cost of each item / drug.
ii. The list of drugs or items should be arranged in descending value of

their cost. The most expensive item is at the top followed by the next
less expensive and the cheapest item which has consumed least
amount will be at the bottom.
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iii. The cumulative cost of the items is worked out on this list. The
cumulative cost of the first item will represent its annual cost, whereas,
the cumulative cost of the second item will be its annual cost plus the
cumulative cost of the item above it. Similarly, that of the third item
will be its own annual cost and the cumulative cost of first and second
item. The cumulative cost of the last item will be the total annual
expenditure on medical store.
iv. The list is now ready for undertaking ABC analysis. Mark the figure
close to 70% of the total expenditure. All items upto this figure will be
A category items. This will be equivalent to only 10 – 15 % of the total
number of drugs. The interpretation about 10% of the items cost as
much as 70% of total budgetary expenditure.
v. The next figure to mark will be close to 90% of the total annual
expenditure. The items between the two figure i.e after the A category
items and upto the figure close to 90% will be B category. These will be
generally around 20% of all the items. The interpretation: about 20% of
the items consume 20% of the total expenditure.
vi. The remaining items will be C category which constitutes around

65% to 70% of the items. The interpretation: about 70% of the store
items cost as little as 10% of the total expenditure.
Following is a convenient example to understand the exercise better in

undertaking ABC analysis.
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Let us imagine that the medical store of a small hospital has 100 items on its
inventory and the total annual expenditure is Rs. 10,00,000. The items can
be arranged in the descending value of their annual cost in the following
manner:
S.No Name of the Item Annual Consumption Cumulative Cumulative

Category
In Rs. Total Rs.

Percentage
1. Inj. Ampicillin 91,000 91,000 9.1
2. Inj. Ciprofloxacin 89,000 1,80,000 18
3. Inj. Dextrose 5% 540ml 83,000 2,63,000 26.3
4. Inj. Normal saline 540ml 81,000 3,44,000 34.4
5. Inj. Cefatoxim 1 Gm 71,000 4,15,000 41.5 A

(10%)
6. Inj. Streptokinase 65,000 4,80,000 48
7. Tab.Ciproflaxacine 63,000 5,43,000 54.3
8. Inj. Haemaccel iv 59,000 6,02,000 60.2
9. Fluothane 51,000 6,53,000 65.3
10. Inj. Dexamethasone 2ml 47,000 7,00,000 70
11. --- --- --- ---
--- --- --- B (20%)
12. Inj. Urograffin --- 9,00,000 90
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C (70%)
13. Acriflavine 300 10,00,000 100
Another method of doing ABC analysis is to pick up approximately first

10% of the items from the list arranged in the descending order which
generally consume 70% of the expenditure. This is category A .The next 20%
of the items in the list account for 20% of the total expenditure. This is
category B. The remaining item (Category C) constitutes about 70% of the
items which consume only 10% of the total expenditure. As mentioned
earlier, the percentages will not be exactly identical and the variations may
be upto 5%.
APPLICATIONS OF ABC ANALYSIS
Following are the applied benefits of practice of ABC analysis.
S.No Activity Group A Group B Group C
1. Frequency of More frequent Less frequent Least frequent

purchase
2. Turnover / High Medium Low

consumption
3. Level of control Tight Moderate Routine
4. Estimates of Very rigid Rigid Moderate

Requirement
5. Safety Stock Low Moderate High
6. Management Level Top Middle Lower
7. Monitoring Very strict Strict Moderate
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VED ANALYSIS
The limitation of ABC analysis is that it is based only on monetary

value and rate of consumption of the items. Sometimes, particularly in a
hospital an item of low monetary value and consumption (e.g. Injection,
Adrenaline, Anti – Snake Venom etc.) may be very vital or even life saving.
Their importance can not be overlooked simply because they do not appear
in category A of inventory. Therefore, another parameter of the materials is
their criticality. This could be in item of the therapeutic value of a drug or
intrinsic value of the material in achieving the objectives of the hospital
system. VED analysis is based on critical values and storage costs of the
items . Based on their criticality, the item could be classified into three
categories: Vital, Essential and Desirable.
1. Vital Items : There are several vita items in the inventory of a hospital
which could make the difference between life and death. There can be
serious functional dislocation of patient care when such item are not
available even for short period adversely affecting the image of the hospital.
Such items should always be stocked in sufficient quantity to ensure their
constant availability. This group of items should be controlled by top
management.
2. Essential Items : The shortage of such items can be tolerated for a short
period. If these items are not available for a few days or a week, functioning
of the hospital can be adversely affected ( drugs like antibiotics etc.) . These
items should preferably be controlled by top / middle level management.
3. Desirable Items : The shortage of these items will not adversely affect
the patient care or hospital functioning even if the shortage in prolonged
(Items like vitamins) . Desirable items should be controlled by middle / lower
level management.
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A combination of ABC and VED analysis can be gainfully employed to evolve

a meaningful control over the material supplies particularly in a hospital
system as shown in the chart.
ABC and VED Analysis
Category I includes all vital and expensive items. These require close
monitoring and strict control .
Category II covers items of essential category and they are less expensive.
Category III comprises the desirable and cheaper group of items .
Category I
V E D
A
AV AE
AD
BV
B
BE BD
Category II
CV
C CE
CD
Category III
SDE Analysis
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This is based on the availability of the items in the market. S items are
scarce, D items are difficult to procure and E items are easily available in the
market. Such an analysis may be handy when there is a lot of uncertainty or
vagaries in the availability / procurement of the items.
Other type of analysis which are not much significance to a materials

manager are :
HML analysis (based only on cost i.e., High, Medium, Low cost items) and FMS
analysis based only on rate of movement / consumption (Fast, Medium and
Slow moving items).
Advantage of ABC analysis
With the application of this technique the inventory manager exercises

selective control and focuses his attention only on a few items when he is
confronted with lakhs of stores items. In this way the inventory manager is
able to control inventories and show visible results in a short span of time.
Moreover, by controlling the ‘A’ items, and doing a proper inventory analysis
obsolete stocks are automatically pinpointed. Besides, it has been claimed
by many organizations that ABC analysis has helped in reducing the clerical
costs and resulted in better planning and improved inventory turnover.
However, the value of such an analysis to management would be more clear
by the following points.
(i) It provides a sound basis on which to allocate funds and time of personnel
with respect to the refinement of control over the individual inventory
items:
In this sense control may take several forms. It may by reflected in

minimizing inventory investment, its minimizing indirect costs associated
with inventory, in utilizing personnel, effectively, or in assuring effective
storage, handling, and delivering, of material to the place of operations as
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scheduled. The concept clearly permeates a number of departmental

operations viz. purchasing, production control, stores and accounting.
(ii) Management can use the information from such a study intuitively or
formally : some managers informally concentrate departmental efforts on
the A and some of the B items. Others develop formal policies and
procedures for handling A,B and C items. One company, for example, has
established the policy that all A items shall be reviewed and purchased
every two to four months, B items every four to six months, and C items
every six to twelve months. Details of formal policies such as this, of
course, are determined somewhat arbitrarily by management, based on
knowledge and judgment concerning the unique features of each
company’s operating situation. It should be emphasized, however, that
employment of ABC analysis greatly reduces the possibility of error in
such judgments by clearly pointing up the specific items on which
management can profitably concentrate its efforts.
(iii)Investment in inventory is reduced to the minimum possible level because

a responsible quantity of the items representing a significant of the
material costs is purchased.
(iv) Storage costs are reduced since unnecessary inventory is avoided.
(v) A strict control is exercised on the items which represent a high

percentage on the materials cost.
Limitations of ABC analysis
ABC analysis is subject to following limitations:
i. In order to be fully effective, ABC analysis should be carried out with

standardization and codification.
ii. As Grading of the items is done on the basis of importance of
performance of an item, i.e. by V.E.D which means vital, Essential and
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desirable, some items, though negligible in monetary value may be

vital for running the plant, and constant attention is called for.
iii. The results of ABC and XYZ analysis will be different, depending upon
the nature of obsolete items.
iv. The results of ABC analysis need be reviewed periodically and updated.
v. However, “in practice, a never ending problem is that of adequately
planning for handling the thousands of low-value items. Even with
good purchasing planning, because of the sheer number of C items,
low value nuisance purchases frequently require more time than
should be allotted to them. Consequently, they reduce the amount of
time available to purchasing personnel for value analysis, vender
investigation, and other creative work involving high-value A and B
items.
Hence it could be concluded that although ABC analysis represents a good

fundamental management tool, it does not, in its present form, permit
precise consideration of all relevant factors which should enter this
management decision. However ABC analysis is a powerful approach in the
direction of cost reduction as it helps items with a selective approach.
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INVENTORY CONTROL ANALYSIS
Steps to do A-B-C Analysis
For this refer to the li9st of hundred drug items given in the annexure. The
list of these drug items shown in the Annexure is taken from the actual drug
list of a medium size hospital. The steps do the A-B-C analysis from this list is
as follows:
Step 1
Identify all the drug items given in the list and check the estimated quantity
to be consumed during a year and also the unit cost of each of these items.
Then you are required to calculate the annual consumption cost of each item.
You can drive the annual consumption costs by multiplying the unit cost of
the item and estimated quantity to be consumed during a year.
Annual consumption Cost = Unit cost of the item X Total quantity

consumed
per annum
Step 2
Once you have calculated the annual consumption cost of each of the items,
arrange the same in the descending order list i.e. the costliest item (as per
the annual consumption cost) at the top followed up by next and so on and at
the bottom will be the least costliest item. Exactly in the similar way the drug
items are arranged in the list given in the annexure.
Step 3
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After arranging the drug item as per the descending order list, we have to
calculate the cumulative amount of each item. The cumulative cost of the
first item is the annual consumption cost itself. The cumulative cost of the
second item will be the cumulative cost of first item plus the annual
consumption cost of the second item. Similarly, the cumulative cost of the
second item plus the annual consumption cost of the third item. In this
manner you are required to calculate the cumulative cost of each item
separately and the figure is to be mentioned against that item as it is shown
in the drug list given in the annexure under the column cumulative amount.
Step 4
Once you have done the cumulative cost of each item separately, you will
find that the cumulative cost of last item is also the total expenditure
incurred in procuring all the drug item of the hospital for a year. Now as we
know that 70% of the total cost takes care of around 10-15% of the drug
items, which are shown in the descending, order list. Hence, if you calculate
the 70% of the final cumulative amount of Rs.2,54,51,234 as given in the
drug list, you will find the value of Rs.17815864. Now in the column of the
cumulative amount of the drug list, try to find where this value is lying. In
our drug list you will find that this value is lying between item No.12 and item
No.132, because the value calculated above is more than the cumulative
amount of item No.12 is less than the cumulative amount of item No.13.
Hence this is the dividing line which demarcates that all the items above this
line i.e. all the drug items upto items upto item No.12 of the re-arranged list
are Group ‘A’. Items as per A-B-C classification.
Step 5
Once you have identified the Group ‘A’ items next step is to identify the
Group ‘B’ items. For this we already know the 70% of the expenditure spent
on Group ‘A’ items. Also as per ABC analysis, 20% of the expenditure will be
on about 20-25% of the items. Hence for the calculation we add up 7-0% +
20% i.e. 90% and find out the value of 90% of Rs.25451234. If you calculate,
you will find a value of Rs.22906111. In our drug list you will find that this
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value is lying between item No.33 and item No.34, because the value
calculated above is more than the cumulative amount of item No.12 is less
than the cumulative amount of item No.13. Hence all the items from Sr. No.
13ato 33 of the drug list i.e 21 in no, are Group ‘B’ items as per A-B-C-
classification.
Step 6
Hence from the above A-B-C- analysis of the given drug list consisting of 100
drug items, you have seen:
Group ‘A’ 12% 70% of the total expenditure
Group ‘B’ 21% 20% of the total expenditure
Group ‘C’ 67% 10% of the total expenditure
This is how the A-B-C analysis is done for classifying the items of any drug
store into Group ‘A’, Group ‘B’ and Group ‘C’ items.
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Appendix
S. Name of the drug Unit Estimate Annual Cumulative A V

No cost d Consumptio amount
. (I) Quantity n Cost (I) X B E
consume (II) C D
d per
year (II)
1. Amoxycillin 1.15 3000000 3440017/- 3440017.00 A E

250mg
2. Coscopin Linc. 27.02 105000 2836618/- 6276635.00 A E

Plus
3. Rabipur 251.6 11000 2768019/- 9044654.00 A E

3
4. Rifampicin 3.10 599000 1852798/- 10897452.00 A E
450 mg
5. Cephalexin 1.48 750000 1112755/- 12010207.00 A E
250mg
6. Tonoferon 29.72 37400 1111730/- 13121937.00 A E
7. Pyrazinamide 1.46 750000 1096004/- 14217941.00 A E
500mg
8. Amoxycillin 2.50 3999960 996948/- 15214889.00 A E
250 + Clos. 250

mg
9. Profassi 5000 267.2 3000 801849/- 16016338.00 A E

9
10 Ethambutol 0.75 900000 670433/- 16687171.00 A E

.
400 mg
11 Gellusil 18.04 30000 541140/- 17228311.00 A D

.
MPS/ Catosy mg
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12 Zinc Oxide SLF 54.75 9000 492589/- 17720900.00 A D

. ADH Plaster 5m X
10cm
13 Ibuprefen 400 mg 0.29 1456000 418167/- 1813907.00 B E

. (Brufen)
14 Engerix-B 217.7 1880 409400/- 18548467.00 B E

. 7
15 Erythromycin 18.70 20000 373950/- 18922417.00 B E

. 100mg/ 5ml
16 Ladogal 100 mg 8.92 39970 356328/- 19278745.00 B D

. (Danazol)
17 Rifampicin 150 1.08 300000 323628/- 19602373.00 B E

. mg
18 Diclofenac Gel 6.12 49977 305749/- 19908122.00 B E

.
19 Chymoral Forte/ 1.94 150000 290452/- 20198574.00 B E

. Bidangen
20 Parnaparin 6400 277.2 1000 279235/- 20475809.00 B E

. 4
21 Normal Saline 9.102 28528 259784/- 20735603.00 B V

. 8528
22 DBI-TD 1.19 199965 237943/- 20973546.00 B E

. (Phenformin)
23 Fefol 1.07 222236 236883/- 21210429.00 B E

.
Spansules
24 Roxatidine 2.33 99960 232485/- 21442914.00 B E

.
25 Voveran 1.00 2212000 214920/- 21657834.00 B D

. (Diclofenic Sod)
26 Anti-D 300 mg 12.22 125 201024/- 21858858.00 B E

.
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27 Betnovate-C 15.09 12500 188557/- 22047415.00 B V

. 15mg
28 Carbamazepine 15.09 134400 155895/- 22203310.00 B E

. 400 mg
29 Providone 5% 50.63 27000 151989/- 22355299.00 B D

. (Betadine)
30 Salbutamol- 2mg/ 7.43 18500 137372/- 22492671.00 B E

. ml (Asthalin)
31 Disprin (Soluble 0.22 600000 131302/- 22623973.00 B E

. Asprin)
32 Cifran Eye Drops 40.75 30000 122251/- 22746224.00 B E

.
33 Metronidazole- 5 8.01 15000 120168/- 22866392.00 B E

. mg/ ml (Flagyl)
34 Beclate INH 50 79.19 1500 118775/- 22985167.00 C E

. MCG
35 Evion- 200 mg 0.78 140000 108535/- 23093702.00 C E

.
36 Bortropase 29.20 3570 104255/- 23197957.00 C V

.
37 Cetrizine- 10 mg 0.07 144500 102546/- 23300503.00 C E

.
38 Paracetamol 450 19.94 4998 99644/- 23400147.00 C V

. ml
39 Cotaryl 16.24 6000 97470/- 23497617.00 C E

.
40 Famotidine 40 mg 0.24 400000 96800/- 23594417.00 C E

.
41 Insulin Lente 60.25 1500 90387/- 23684804.00 C V

.
42 Metaprolol- 50 mg 0.52 156000 81247/- 23766051.00 C E

.
43 Fortum -250 mg. 88.70 850 75400/- 23841451.00 C E
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. 72064/-
44 Carbamazepine 1.44 50000 72064/- 23913515.00 C E

. Cont. Release 200
mg
45 Moisol Eye Drop 6.81 10000 68189/- 23981704.00 C E

.
46 Gentamycin Eye/ 3.28 20000 65556/- 24047260.00 C E

. Ear Drop – 5 ml
47 Bormhexin 4 mg/ 14.42 4500 64880/- 24112140.00 C E

. 5 ml
48 Occupres- 0.5% 15.75 4000 63000/- 2175140.00 C E

. (Glucomol Eye
Drop)
49 Dextrose – 10% 10.27 6000 61652/- 24236792.00 C V

.
50 Wintomylon 12.22 5000 61105/- 21297897.00 C E

. (Nalodixic Acid)
51 Trental 400 mg 1.95 30000 58596/- 24356493.00 C E

.
52 Voveran 1.22 45000 44140/- 24411633.00 C E

.
53 Diltiazam 30 mg 0.32 165000 53548/- 24465181.00 C E

.
54 Lupizyme 0.59 83400 49282/- 24514463.00 C E

.
55 Terazocin- 2 mg 4.84 10000 48466/- 24562929.00 C E

.
56 Dytide 0.96 50000 47926/- 24610855.00 C E

.
57 Nasivion Paed. 11.61 40000 46421/- 24657276.00 C E

. Nasal Drops
58 Fluthae/ 1127. 40 45119/- 24702395.00 C V

. Halothance BP 98
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59 Soframycine Eye 7.18 6000 43047/- 24745442.00 C D

. Drops
Exercise
Inventory Control
Exercise 1: List the drugs used in medicine ward and their cost. Analyze
these drugs into A (High cost), B (Medium cost) and (Low cost) categories.
Exercise 2: List using above list categorize the drugs into V (vital), E
(essential), and D (Desirable) groups.
Exercise 3: Visit the drug store of Medical College, by using the records
Categorized the list oaf drugs into F (fast moving) S (slow moving) and N (non
moving) groups.
CONDEMNATION AND DISPOSAL
The ultimate reality is that certain hospital equipment may either

become obsolete for go beyond economic repair over a period of time. It is
commonly seen that such irreparable equipment occupies the precious little
space in the respective department for hospital store. A part of the
equipment management therefore, is to condemn and dispose off such
equipment at regular intervals. The condemnation procedures are not
undertaken due to lack of authentic guidance on such procedures or
inadequate records in respect of the date of purchase, cost, source and costs
incurred on repairs. The top management may be unwilling for reluctant to
make decisions to condemn and dispose off the unserviceable equipment
just, because it is not such pressing problem.
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It is essential that proper procedure is laid down for condemnation and

disposal of unserviceable hospital equipment preferably in the shape of a
written mannual. Proper records of all expensive equipment should be
maintained related to the date of purchase, cost, manufacturer / supplier, life
expectancy, details of service contract, cost of repair etc. as shown in the
history sheet of the equipment. If this vital data is available we do not have
to compromise in following the minimum criteria for condemnation and
disposal of the equipment, when the equipment is:
1. Beyond economical repairs and non – functional

2. Obsolete and non- functional
3. Functional but obsolete and very expensive to run
4. Functional but hazardous to run
5. Functional but no longer required.
PROCEDURE FOR CONDEMNATION
1. A written manual on condemnation and disposal procedure should be

followed. The mannual should give details of steps to be followed in
condemnation of equipment. Competent authority and constitution of
condemnation committee should be clearly defined.
2. A nominee of the hospital director like RMO / Matron can condemn
items like disposable, rubber goods, linen, enamel- ware, furniture etc.
provided that the user department has sent in a written requisition
with list of items recommended for condemnation.
3. Condemnation Committee: Condemnation committee should be
constituted for assessing whether for not an equipment should be
condemned based on the recommendation of the user department.
The committee may consist of the designated medical officer in-
charge, concerned head of the department and head of maintenance
cell. In the case of expensive equipment suitable sanction is necessary
from competent authority like Director of Medical Services for health
Secretariat to constitute a special condemnation board. In all such
cases a certificate from the manufacturer that the equipment is
beyond repair / economical repair is mandatory.
After the equipment is condemned by following the prescribed procedure, the

condemned equipment should be disposed off as early as possible. The
methodology is:
1. If there is immediate need to replace the condemned equipment

“Trade-in” offer should be negotiated with the supplier to obtain
handsome concession on the purchase of the new equipment.
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2. If there is no urgent need for replacement, effort should be made to

elicit the need of this equipment by other departments for other
hospitals for transferring the equipment suitably.
3. Sealed tenders may be invited to get best price either from other
hospitals or scrap dealers.
4. If the number of items to be disposed off are too many and
inexpensive an open auction method may be followed by circulating
the auction notice well in advance.
Equipment Audit: This is recent concept, which promotes healthy practices

in the management of hospital equipment. Equipment audit is periodic
evaluation of the quality of equipment performance. Like the department,
hospital administration and the government. It ensures optimum utilization of
scarce resources and contributes to the quality of patient care. The perquisite
to undertake such as audit is good documentation, preferably in the shape of
equipment history sheet. The practices followed in the hospital are compared
with the norms, viz.:
- It affords evaluation of the utilization and performance of the hospital

equipment.
- It provides a satisfactory mechanism to assist in the process of
replacement, condemnation and disposal.
- It educates us in improving the method of procurement of the
equipment.
- It identifies the inadequacies in maintenance and repair system and
offers remedial measures.
- It helps in establishing actual costs to gain cost effectiveness
Equipment Record – The equipment record contains following:
1. Procurement
- Justification for the purchase of equipment.

- Suitability of the technical specifications whether comparable to the
best available in the market, state of art etc.
- Any deviation from the specification desired and its justification.
- Whether proper procedure has been followed in floating the tenders
and suitable negotiations held to get the best price, maximum
warranty, spares, consumables and service contract.
- Whether staff training has been ensured for efficient use of the
equipment.
2. Installation
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- Whether the required physical facilities, air- conditioning and other

special requirements have been provided?
- Whether enough care has been exercised to make the electrical
installations free of hazards and accidents (Proper grounding and
emergency switching off system etc.)?
- Whether all other installation instructions have been followed
scrupulously?
-
3. Performance
- Verification of “Up Time” as promised by the supplier.

- Whether the “Down Time” is within reasonable limits as guaranteed by
the supplier?
- Whether the consumption of water, electricity and other consumables
is as per the norms to ensure there is no wastage for undue repetition
of work?
4. Maintenance and Repair
1. Whether the staff of maintenance cell is adequately trained?

2. Whether they have the required tool kits and other facilities?
3. Whether there is standard practice preventive maintenance
propgramme?
4. Written manual on maintenance and repair, whether prescribed
procedure is being followed?
The audit of equipment undertaken by the Equipment Audit Committee which

consists of a nominee of the hospital director who is a senior officer
( chairman), user department (Secretary and Convenor), the Head of the
maintenance cell and one technical expert from outside. The portfolios may
be changed by rotation. The Equipment Audit Committee meets periodically
at least once in 6 months to undertake the equipment audit based on the
history sheet of the equipment. As good medical record is essential for
medical audit, good up-to-date record of the equipment in the shape of
equipment card for history sheet is indispensable for the equipment audit.
Some of the benefits of the equipment audit are:
- It affords evaluation of the utilization and performance of the

hospital equipment.
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- It educates us in improving the method of procurement of the

equipment.
- It identifies the inadequacies in maintenance and repair system
and offers remedial measures.
MANAGEMENT OF DRUGS AND VACCINES
Introduction/Purpose
Since there are no fixed targets imposed from the higher levels, you are
expected to estimate service needs of the RCH programme for community
members falling within the area of your sub – centre. Next to this, you would
have to demand or indent for drugs , vaccines and other materials that would
be required towards the provision of estimated services. Estimation followed
by indenting of right quantity of each drug , vaccine and other materials
which is absolutely essential to ensure continued availability of such items at
sub- centre level for providing services to assigned community members on
regular basis and also to avoid surpluses and wastages of the same. Once
the annual requirement of the items mentioned earlier, are estimated and
submitted to the controlling PHC, the mechanism of ensuring timely supply of
needed items and materials should be worked out based upon the prevalent
procedures and practices of each State ( either quarterly or monthly basis).
The demand made is to match with the sub – centre action plan. However ,
replenishment can be done earlier than scheduled supply date in the case of
exhausted stock or stock out situation. This module will help you to prepare
estimation of resources needed in right quantity , procure the same at right
time and store them properly before being put to use. Maintenance of other
equipments provided at sub – centre also needs your attention so as to
ensure their prolonged use. You must maintain a stock – register for all the
drugs , vaccines and materials received and used at sub- centre level.
Management of drugs and vaccines at sub – centre level includes:
a. Estimation of required quantity of the drugs and vaccines needed for

provision of services.
b. Procurement of drugs and vaccines in right quantity and at right time.
c. Proper storage and judicious use of drugs and vaccines.
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ESTIMATION OF VACCINE REQUIREMENT:
While calculating the requirement of vaccines you should consider the factors
mentioned below:
• Number of beneficiaries
• Number of doses of each vaccine
• Wastage and multiplication factor
• Number of sessions
The estimated requirement of various types of vaccines as worked out by you
can be further verified with the calculations arrived at by using demographic
data.
The correctness of estimates of vaccines worked out by you should be

discussed with your concerned Health Supervisor (female) and MO , PHC .
These estimates are to be finalised after the Health Supervisor (female )/ MO
is satisfied keeping in view the total requirement of area , past performance
and local situation.
For example: As per the model used earlier for Action Plan.
Vaccines:
Number of pregnant mothers =165
(2 doses of Tetanus Toxoid for each =330 (Approx.)
pregnant mother)
Infants alive at 1yr. Of age =139
OPV & DPT doses to be administered 139 X 4 = 556
(4 doses for each child)
OPV / DPT doses required – 556 X 1.33 =740(Approximate)
(Wastage and multiplication factor = 1.33)
BCG / Measles doses to be administered =139
(BCG / Measles doses required 139 X 2 ) =278
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(Wastage Multiplication factor = 2 )
(The vaccines are supplied in 10 or 20 dose vials or ampulses. To calculate

the number of vials required , number of doses are divided by 10 or 20 and
rounded off to the next 10 or 20 as per the number of doses per vial. The
quantities thus calculated would be for the whole year).
However , the requirement may increase , as all immunization sessions are

to be providing with vial of each vaccine.
The calculation for vaccine requirement will have to be done on the basis of
number of sessions planned for each month. With more number of sessions
additional vaccines would be required as for each session a new vial is
required to be used.
For children below 3 years of age,
Estimated to be 400 (8% of the total population)
Therefore , children between 1 to 3 years age group will be 400 – 139 = 261
(Children in this age group will require booster doses of DPT / OPV between
the age of 16 – 24 months , 2nd to 5th dose of Vit A (prophylactic) to all & 2
therapeutic doses to those with symptoms).
Requirement of Vit A concentrated solution
All children below 1 yr of age will require 2 dose of 1 lakh unit.
All children between 1 – 3 years of age will require 4 doses each of 2 lakh
unit.
Therefore , the total requirement of doses will be – 139 doses of 1 lakh units
and 844 doses of 2 lakh units.
Allow 20 per cent wastage and demand for 139 + 28 = 167
Doses of 1 lakh units , 844 + 169 = 1013 doses of 2 lakh unit.
Iron and Folic Acid Tablets
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For pregnant mothers:
Number of pregnant mothers registered – 165
100 Tablets for each mother – 16500 tablets
50 per cent of the mothers expected to be anaemic and would need double
the dose i.e 100 additional for each.
That is 165/2 X 100 = 8250
Hence , the total requirement of Ion and Folic Acid Tablets would be:
16500 / 8250 = 24, 750 tablets
(However , some of the anaemic women may be able to tolerate even 3

tablets a day. In that case extra tablets , if required , may be indented as and
when necessary from PHC.
Iron and Folic Acid (small) for children:
It is estimated that 40 per cent of children under 5 years of age will require
anaemia therapy i.e 100 tablets after deworming . Thus out of 650 children
about 260 children will need therapy of 100 tablets of Iron and Folic acid
(small ) for each. Accordingly , the total requirement of iron and folic acid will
be 26,000 tablets.
ORS Packets:
A child under 5 years of age suffers on an average 3 episodes of diarrhoea

every year. Thus , there will be 650 X 3 = 1950 episodes of diarrhoea every
year in a sub- centre area. Of these only 10 per cent of episodes are with
dehydration which would require three packets of ORS . Hence , the total
requirement of ORS packets would be 195 X 3 = 585 (i.e 195 episodes will
require ORS).
Mebendazole Tablets:
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Fifty percent of pregnant mothers ( in their 2nd and 3rd trimesters ) and all
children with anaemia (40% of the total under 5 years) would require
deworming with Mebendazole Tablets.
Therefore , 82 pregnant mothers and 260 children under 5 years of age

would require six tablets of Mebendazole in a year for a sub-centre area. Thus
, the total requirement of Mebendazole would be , 82 X 6 + 260 X 6 = 492 +
1560 = 2052 tablets.
Cotrimoxazole Tablets (Pediatrics):
The total episodes of Acute Respiratory Infection (ARI) at the rate of 3

episodes per child under 5 years in a year would be equal to diarrhoeal
episodes of 1950 cases as calculated above . It had been worked out that
only 10 per cent of the episodes of ARI are pneumonia requiring antibiotic
therapy. Thus, 195 episodes of pneumonia will on an average need 20 tablets
of cotrimoxazole (paediatric) each. Hence, the total annual requirement of
cotrimoxazole would be 195 X 20 = 3900 tablets. It would be desirable to
compare all these estimates with the estimates and actual use of last year
and verify whether the same has increased by 5 to 25 per cent or not.
Procurement:
Having prepared estimates, the next step is to fill the Action Plan Form along
with the form on ‘Inventory of Vaccines and Drugs’ and submit the same by
10 th of March each year ( Proforma available at the end of this unit).
Comparison between the assessment and actual quantity received and
requirement for current year would be visible in the form. There is also a
column in the form for listing surpluses or shortages of the last year. The
supply would be made from the concerned PHC. Usually , the drugs and
materials would be supplied on quarterly bases and replenished if needed
would be made even earlier. You must ensure that there is always stock for
one or two months at sub – centre. Larger quantity of stock would indicate
either over indenting or non – performance and/ or under utilisation of
services.
Vaccines are to be procured in a ‘ vaccine carrier’ on the day of immunization

session. The required action to procure additional drugs/ vaccines should be
taken well in time and a situation of stock being fully exhausted or stock out
must be avoided in all possible manner. List of the sub- centre kits are placed
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along with the forms to be filled for Action Plan and ‘Inventory for Drugs
&Vaccines (available at the end of this units).
STORAGE:
Vaccines:
Vaccines are not expected to be stored at the sub-centre level in any case.
Hence , these must be supplied on the day of use.
The precautions that needed to be observed to keep vaccines safe and

potent are as follows:
• Only required quantities for day’s consumption must be procured.

• The vaccine carrier must have frozen ice – packs.
• Immunization must be carried out in the shade and OPV and Measles
vaccines must be kept on an ice- pack or in a cup of ice during the
session.
• Only one vial of each vaccine should be taken out at a time.
• Unused and unpacked vials must be returned to PHC on the same day.
Other drugs:
• All drugs being supplied , in general , should be kept in a cool dry place
protected from direct sunlight , air and moisture.
• The drugs must be stored in a container with proper lables.
• The drugs supplied in strips and the ORS packets should be arranged
in a container or card board box in such a way that one with earlier
expiry date are in the front , so that these can be used first. The recent
supplies received should be placed behind. Thus , the principle of first –
in – first – out (FIFO) must be followed in true spirit.
• Do not use the drugs if they have changed colour or there is a change
in consistency.
Maintain a Stock Register:
Maintain Stock Register by making entries with dates of supplies received

and quantity procured form the PHC. The entries with regard to quantity used
daily must be made in stock register. At the end of each month ,check the
balance by way of physical verification.
Information to be filled in Stock register:
Sl.No Name of Date Previous Quantity Quantity Balance Remarks
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Drug balance received used in hand
Maintenance of Equipments at Sub –centre Level:
Vaccine Carriers
You can use ‘vaccine carriers’ for carrying small quantity of vaccines (i.e . 16-
20 vials) to sub – centre area and its villages. The vaccine carriers are made
of insulated material. The ice packs for lining the sides of carrier should be
fully frozen and the lid of carrier should be closed tightly. The vials of DPT ,
DT and TT vaccines should not be in direct contact with the frozen ice packs.
Before using or packing the vaccines in the vaccine carrier , the precautions
that need to be observed are as follows:
- Take out vaccine carriers and confirm that there are no cracks in its
body.
- Take out the required number of ice packs and wipe them dry.
- Place fully frozen ice packs in the carrier and wait for few minutes for
temperature to fall to less than 8 degree celsius.
- Put vaccine vials and ampules in a polythene bag and close it.
- Stack vaccines and diluent in the carrier.
- Place some packing material between DPT vaccines and the ice to
prevent them form touching the ice packs.
- Close the lid tightly.
How to keep vaccine carriers in good condition when not in use
Some of the tips to this effect are mentioned below:
- Clean and dry inner side of carrier after each use.

- Examine the carrier both from inside and outside after each use for
any crack.
- Keep the carrier away form direct sunlight and other sources of
sunlight , and other sources of sunlight , as this may cause the plastic
to crack.
- Do not sit or place anything heavy on vaccine carrier.
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- The carriers with four ice packs can keep the vaccines cold for 2 days
provided the ice packs used are fully frozen and the lid of carrier is
closed tightly.
Day Carriers:
Day carriers i.e. smaller vaccine carriers are also available in India. These
have two ice packs , one each at the top and bottom . They can carry only a
few vials ( 6 – 8 vials) at a time and can keep vaccines safe only for one
working day ( 6 – 8 hours) . If the duration of storing unused vaccines is likely
to be more than 6 hours , Day Carriers should not be used , as these would
prove to be ineffective for the purpose of maintenance of cold chain.
Blood Pressure Apparatus:
A sphygmomanometer has been provided to all sub – centres. You must

make use of it for checking B.P during antenatal check ups in antenatal
clinics. You may also carry this instrument during home visit for follow up of
suspected high risk cases.
The sphygmomanometer along with the stethoscope should be kept in the

cupboard free from dust and sunlight. While packing you should take care
that cuff is properly deflated and then folded and the rubber tube is not
kinked. While taking out always hold the dial to prevent it from falling. When
not used for a long time , the rubber tube and the cuff may start softening ,
particularly in summer and get leaked. You must check this frequently so as
to keep instrument worthy of use.
Weighing scale:
A weighing scale for adult and a spring balance for babies are provided to all
sub- centres As an In – charge of sub-centre you should ensure that these
equipments are maintained properly. The weighing scales must be kept in
the cupboard. You must periodically check the same for error by weighing a
known weight (Measures). Take adequate precautions to ensure that the
spring balance does not get rusted.
Key points
• Estimate the requirement of drugs and vaccines based on estimated

quantity of services to be provided / rendered.
• These estimates should be finalised in consultation with your
supervisors keeping in view the past performance , total area
requirement and local situation.
• Estimate the requirement of drugs and vaccines based on estimated
quantity of services to be provided / rendered.
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• These estimates should be finalised in consultation with your

supervisors keeping in view the past performance , total area
requirement and local situation.
• No vaccine should be stored at sub-centre level. These should be
procured on the same day of immunization clinic/ session in a vaccine
carrier.
• Store other drugs in container with proper label in cool and dry place.
• Do not use any drugs if there is change in colour or change in
consistency.
• Maintain a stock register for accounting of used and balance of
supplies received
.
Multiple Choice Questions
1. Pre-req uisite for modem material s management in hospita ls are :

(a) Meticulous p lanning (b) Acc urate demand
estimation (c) Appr opriat e staffin g
(d) All of the above
2. Tick the cor rect statement :
(a) Material is defined as e quipm ent, appa ratu s and suppli es, used by a n
organisati on or institut ion (b) Mat erial refers to co mmodities purchased
and stocked b y an institu tion for the purpose of c onsumptio n (c) M ate rial
refers to techni cal equipment o nly ( d) Mat erial s hould be used u nivers ally
to r efer to hospital supplies and equipment
3. "A model or general agreement of a rule established by authority,
consensus or cu stom with which to measure quantities, value, dimension
or quality" is known as :
(a) Sta ndard (b) Norm (c) Criter ion (d) Con sens us
4. Deg ree of adherance to pre-established no rm or criteria i s
known a s: (a) S tandard (b) Qua lity (c ) Cri terion (d) Norm
5. Inventor y carr ying cost is the :
(a) Co st associate d with kee ping the materials i n the store ( b) Cost of non-
availabilit y of an item (c) Cost of lost good wi ll (d) Co st incurred on
carryi ng an item
6. Inventory shrinkage cost :
(a) Cos t of fringe benefi ts (b) It represent s the cos t of pilferage (c) Loss of
intere st on money invested (d) Cos t on acco unt of sa laries Cost i ncurred i n
placing an ord er is known as:
(a) Inventor y carrying cost (b) Shortage co st (c) Inventory acquisi tion cos t (d)
Storag e cos t
8.
"ABC anal ysis" is the anal ysis of ite ms which is based on :
(a) C ritical ity of the ite ms in re lation to the fun ctioni ng of the hospital (b)
Cost criteria
(c) Avai labilit y of i tem ( d) Cos t per i tem per uni t
9. "VED anal ysis" is the ana lysis o f items based on:
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(a) Cr iticalit y of the i tems in rela tion to fun ctioni ng of the hospi tal (b)
Quan tity and r ate of co nsump tion of items (c) Co st criteria ( d) Availabil ity of
costl y items
10. Ana lysis b ased on "quan tity and rate of con sumpt ion o f items"is
known as : (a) HML a nalysis (b) FSN a nalysis (c) SDE a nalysis (d)
ABC a nalysis
11. DGS & D normall y offers th ree types of contractual se rvices e xcept :
(a) F ixed quan tity co ntrac t (b) R unning co ntract (c) Ra te contrac t (d) Ann ual
Mai ntenance Contract
12. Various catego ries o f indent s made b y different departments an d sent to
purchasing authorit y in the hospital are all except:
(a) A nnual i ndents (b) Suppl ementary i ndent s (c) Emerg ent indents (d)
Urgent in dents
13. Annual indents should be submitted by :
(a) IstJanuary eac h year (b) 1 st F ebruary e ach year (c) 1s t Marc h each year
(d) 1s t April each year
14. Out o f the total hospital b udget mater ials and supplies
account for: (a ) 0 - 20% (b) 20 - 30% (c) 2 5 - 40 % (d) 40 -
50%
15. Space requirement for storage of drugs in a major hospital with a bed
strength of 700 and above is:
(a) 4 - 5 sq.£t. area per bed (b) 7 - 8 s q.£t. area pe r
bed (c) 10 - 15 sq.ft. area p er bed
(d) 20 - 25 sq.£t. area per bed
16. All the newly recei ved stores from the fi rms after placement of order should
be kept separatel y till their inspection is carried out . It ma y not be feasible to
carry out 100 % check of the stores where suppl y is in bulk Qu antity of s tore
which should be checked b y random select ion is :
(a)5% (b)10 % (c)15% (d)20 %
17. "Repeat Supply Orders" can be placed by the Officer empowe red to effect the
purcha se at previousl y approved rates subject to following cond itions :
(a) The Officer empowered to place a repeat or der sat isfies himself that there
has been n o downwar d t rend of th e prices si nce the o riginal order and
placemen t of repeat or der is consid ered to be e ssen tial (b) Repeat orders
are plac ed within six mo nth s of t he date of placement of original order (c)
Supplies agai nst th e or iginal suppl y order ha ve been r eceived and th e
quantity does not exceed th e q uantity origi nally ordered (d) All of the
above stat emen ts are true
18. A S tanding Committee o f f ollow ing membe rs sho uld be con stituted for
carr ying out the i nspection of stores at hos pital le vel e xcept:
(a) Of ficer Incharge stores (b) Representa tive of th e Depar tment conc erned
(c) A sstt. Stores Officer a nd Store Keepe r con cerned (c ) Representative of the
firm
19. Certa in drugs requ ire storage at cold temperatur e but ar e not to b e frozen.
Temper ature required to be maintained at cold stora ge is :
(a) 2 °C -IO °C (b) 15 °C - 25°C ( c) - 18°C (d) - 2 °C -10°C
20. Blood components should ideally be stored at a
temperat -gre o f: ( a)2°C - 10°C (b) IO °C - 20°C ( c) - 4°C
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(d) - 20 °C
21. Vitamin preparations should ideall y be stored at:
(a) Cold temp erature 2° C to 10 ° C (b) Cool temperature 15 °C to 25 ° C (c)
Room t emperature (d) - 4 °C
22. The function s of Hospital Formul ary Com mittee a re follow ing except:
(a) R espon sible for the pr eparation of t he formu lary for th e hospital (b) To
exe rcise over a ll control on the con sumption of drugs a nd t o maintain
economy (c) It consider s the deletion of c ertain drugs which are not freq uently
used (d) Make s election of dru gs and injections which are to be used in the
hospital
23. The role of "Dru g Select ion Comm ittee" in a hospit al i s:
(a) Responsible fo r preparat ion of the fo rmulary for the hosp ital (b) To
con sider qu estion of speeding cons umption of certain d rugs whic h were o ut of
use bu t in stock (c ) Maintain qu ality of t he drugs (d) Is responsible for
selection of dru gs and i njections which are to be used in the ho spita l
24. Funct ion o f "Sur gical Stores Sele ction Committee" is :
(a) Make s election of the surgical g oods (b) Developing s pecifi cations for
surgical items to b e procured (c) T ender i nvitation for supp ly of s urgica l items
(d) Inspection of surgical supplies w hich have be en received at the store s
25. Role o f "General and L inen Store s Selection Comm ittee" i n a hosp ital is:
(a) Se lection of gene ral store i tems (b) S election of linen store s like textiles,
syntheti c fabri c and wool len articles and fur nishings (c) Selection of c leaning
mat erials like Vim, Soa p and det ergents (d) A ll of the above
26. Advan tages of Group Pur chasing a re fol lowing e xcept :
(a) Redu ction in co st of materia ls purch ased (b) Informa tion, sharing and
standardi sation (c) Reduc ed contr ol and d iversity within groups (d) La bour
reduction and enhancement of purcha sing opera tion
27. Advantages o f central ised purcha sing ar e follow ing e xcept :
(a) Ven dors offer better pric es and better serv ice a nd quantity discount s are
possible (b ) Duplication of effort a nd haphazar d purchasi ng prac tice are
minimi sed ( c) R espons ibili ty of the purc hasing func tion is wi th single
department h ead, there by facilit ating effe ctive ma nagement co ntrol ( d)
Vario us mem bers of the hosp ital ha ve the a uthorit y to pur chase and
purchaser u sual ly knows the needs of his depar tmen t and secures it.
28. One of the mo st important techn iques of mate rials management for
reducing co st is:
(a) ABC a nalysis (b ) Inventory control analysi s (c) Val ue analysis (d)
Group p urchasing
29. Value analysis is not a substitute for con ventional co st reduct ion. It
impro ves the effectiveness of work and if properly applied ,it ma y
contribute sav ings i n manufac turing co sts to the tune of :
(a) 2% (b) 5% (c) 10 - 25% (d) 50%
30. The basic technique of value analysis was first
formulated in 1947 by : (a) L.D. Miles (b) Harris ( c)
Farkins ( d) Ev ert Welch
31. Benefits of value analysis are following except:
(a) A reduction in cost of exis ting products (b ) The p reve ntion of
unnecessa ry cos ts in new products and sys tem (c) It improve s the
effectiveness of wo rk and achieves sa vings i n manuf acturing costs (d) It
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is a substitut e for con venti onal cos t reduction

32. Methods of value analysis are following except :
(a) By Brain storming se ssion s (b) Formation of value analys is
committ ee (c) Formation of value analysis team ( d) Nego tiation s
33. There are three basic methods by which a buyer may formulate the
right pr ice. The y are all except :
(a) Publi c Price l ists (b) Co mpetitive bidding (c) Nego tiation (d) Value
anal ysis
34. Certain rules to be followed by hospitals during negot iation w ith.
suppli er or fi rm representative are all except :
(a) Never purch ase at list price ask for quantit y prices and t ry to ge t
that p rice for an y amo unt purchased. (b) Always ask for pric e prot ection
on nego tiat~d pr ices . Begin with two years and wor k downwards (c)
Never tr y quoting pri ces a t which th e suppli er will sell rather than
having the supplier quote price a t which ho spital must buy ( d) Never
feel sor ry fo r th e suppli er or the sa les represe ntative
35. The essentials of right purchasing are:
(a) Right quantit y and qu ality (b) Right price and ri ght source of suppl y
(c) Right delivery time (d) All th e above
36.
"Two Bin System" for inventory control is a part of :
(a) Cyc lic ordering sytem (b) Fixe d order quantit y sy tem (c) None (d)
Both a & b
37. Which of the following is not a part of inventory analysis:
(a) Ove r all anal ysis (b) C ategory analysis (c) Individu al item anal ysis (d)
Value analysis
38. One of the two fundamental systems of codification is "Kodak System" .
Which i s not true about Kodak system:
(a) Con sists of 10 di gits of num erical code
(b) Thi s sys tem is base d on so urces of supply
(c) A ll materials are divided int o 100 b asic classific ations a nd eac h class is
divided i nto fur ther 10 sub class es
d) Th e material s a re fu rther divided accor ding to t heir n ature, use,
10.
9. characteristics, class e tc
39. Advantages of codif ication are fo llowing except:
(a) Re duction in numb er of items and avo iding d uplica tion (b) Sys tematic
grouping of s imil ar i tems and avo ids co nfusion (c) Serves as star ting po int
of simp lication and s tandardisation and easy recog nition of a n it em in store
(d) Over laping o f groups so me time s does occ ur
40. In JJBrisch System " of codification which is not true :
(a) Thi s sys tem consists of seve n digits and i s appli ed in thr ee pha ses ( b)
Materials to be cod ified are grouped to gether so as to f orm a m ajor g roup
(c) Materials are f urther d ivided accord ing to their natur e, use,
characteristics, class e tc (d) As per requirements, digits ca nnot be increase d
or decrease d
41. In stores management , the anal ysis which helps in arrangement of stock in
the stores and in deciding the distribution and handling method is known:
(a) SDE a nalysis (b) HML analysis (c) FSN analysis ( d) XYZ analysis
42. In order to avoid expiry and deterioration of drugs instores ,the following
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simple techn ique for distribution of drugs can be adopted :

(a) Fixed shelf sys tem (b) Fi rst in First out (c) C ardex sys tem (d) FSN
analysis
43., Drug Distribution System, in which a master card is carried with all types of
supplies from the central store s to all user wards and departments on fixed
days and delivers a predetermined fi xed 'quota of stores without any prior
indent is known as :
(a) Ca rdex sys tem ( b) Fixed shelf system (c) Two bin system (d) Perpetual
inventory sys tem
44. For keeping a control over consumption of items at the departmental level ,
the following type of anal ysis can be done :
(a) HML anal ysis (b) FSN analysis (c) A BC analysis (d) XYZ analysis
45. Use of drugs fo r research and investigations in human beings are
labelled as : (a) Investigational dru gs ( b) Nar cotics (c) Placebo (d)
Research drugs
46.Inventory Control is a part of :
(a) Ge neral Managemen t (b) Personnel Manage ment (c) Ma teria ls
Manageme nt
(d) Fi nancial M anage ment
47. The time taken for placing an order to the receipt of the mater ial is termed
as :
(a) Internal Lea d Time (b) Ex ternal Lead Tim e (c ) Ordering Time ( d)
Acq uisition T ime
48. Unofficial Inventor y is :
(a) Inventory held ove r and a bove the off icial inventory ( b) Items stocke d by
departme nts without acco unt abilit y (c) Items which are s tored in various
units/ departments until u sed. (d) None of the above
Keys:
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Vehicle Management in Health Organization
Introduction:
The geographical distribution of different health care units in the

country indicates that primary health centres in a district are situated at a
distance of 30 to 50 km apart and the area of operation of a primary health
centre is about 500 sq.km. This being the case, the provision of transport
infrastructure plays a vital role in rendering the services promptly and
effectively.
A critical appraisal of some of the health services shows that it is only

through transport infrastructure facility that the doctors and other health
personnel can render their professional services to the target group
effectively and in a meaningful manner. For instance the programmes, like
• National Malaria Eradication Programme and National Filaria Control

Programme
• MCH Control Programme
• National Tuberculosis Control Programme
• Universal Immunisation Programme
• Prevention and Control of Communicable Diseases
• Diarroheal Diseases Control Programme
• Education and Environmental Sanitation
Can be made to reach the door steps of the rural masses and
monitored by District and PHC medical officers and health personnel through
their better mobility. This highlights the importance and the role of transport
infrastructure facility in fulfilling the avowed objectives of various health and
family welfare programme and primary health care services.
However, in the districts, the transport wings are normally manned by

service engineers and they report to DHO’s in all matters relating to vehicles
operation and maintenance. The organisational structure of the transport
department plays a crucial role in determining the effectiveness of the
management and its capacity to realise speedily its objectives.
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It is felt that existing structure is in time with the requirements and it

serves effectively the needs of the department. However the reallocation of
jobs to various personnel / functionaries, taking into account the necessity to
maintain up-to-date data base on the functioning of the transport
department, should be done as and when desired.
District vehicles are classified into two categories : family welfare

vehicles and general vehicles.
The general vehicle is supplied by the State Directorate of Health, and

is under the administrative control of the Directorate. It may be used to
support any district health programme activity.
The family welfare vehicle is supplied by the Central Government. It

may be used to support only the family welfare programme and family
welfare activities.
Maintenance of Transport
Proper maintenance of fleet is very crucial in the functioning of the transport

system. High standards of fleet maintenance is essential to achieve efficient
utilization of vehicles, their road worthiness and reduction in the operating
costs. Otherwise various problems may arise in the system. This can result in
high operating costs, poor road worthiness and sometimes even breakdown
and accidents.
The degree of vehicle maintenance required, depends upon a number

of factors. Important among them are:
- Vehicle design
- Operating conditions
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- Terrain
- Driving skills
- Maintenance policy, etc.
A proper maintenance policy is the best way of achieving high

maintenance standards. It should specify the format to be adopted and
assign responsibility. The format should include a maintenance schedule
whereby vehicles undergo regular check-ups and normal maintenance at
selected intervals. The general maintenance strategy followed in any
organisation could be broadly divided into two categories:
i. Preventive maintenance
ii. Breakdown maintenance
Under preventive maintenance strategy, the vehicle is subjected to

various checks at periodical intervals to keep the vehicle in good running
condition. It includes check up of:
- Engine of the vehicle

- Tyres
- Tuning of the engine light etc.
- Life of the Battery
- Overall condition of the vehicle
- Mileage and Average of the vehicle given on the road/ km.
It ensures better road worthiness and consequently less problems

during operation. However, it involves larger infrastructural facilities, more
number of maintenance personnel and higher financial resources. This is best
suited where the area of operation of the entire fleet is limited to a city /
region.
In the case of Breakdown maintenance strategy, even though the

driver, but a periodical maintenance of various items undertake normal
routine checks have not been attended to. The vehicles will be sent to garage
for repairs whenever breakdown takes place.
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The transport wing of the Department of Health and Family Welfare in

States are fully aware of all these problems and attempt to provide as far as
possible uninterrupted transport service to the doctors, and other medical
personnel. However in Karnataka a central workshop at State capital and
Mobile Maintenance Units at every district head quarters are being
maintained.
Mobile Maintenance Units (MMU)
Though there are MMUs to facilitate transport maintenance in the

district but it has its own problems associated with their working. The best
unit of measurement of maintenance is the cost of repairs and maintenance
per vehicle. It is also to be noted that the MMUs are not fully equipped to
undertake all the repairs and maintenance requirements of the fleet. As such,
some of the repairs and maintenance problems are attended through private
workshops. In such cases, the above parameter, the cost of repairs per
vehicle, may not yield sufficient information about the functioning of MMU. It
is felt that another parameter, “the number of times the vehicle had
undergone repairs” may throw some light about the condition of the vehicle
and indirectly represent the quality of maintenance. This parameter, “the
number of times the vehicle had undergone repairs” was also further split to
give information regarding the percentage of times the repairs were
undertaken at MMU. This information is obtained to focus attention on two
important issues:
- the available facilities at MMU for repairs and their adequacy to

undertake all the minor repair work and maintain the vehicle in good
condition.
- The number of times the repairs were undertaken at the private
garages and the amount of money that was paid to the private
workshops in spite of maintaining the MMUs.
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Log Book: Log book is a kind of a summary report which has to be filled in month
wise:
LOG BOOK SUMMARY REPORT FOR THE MONTH OF…
Place: Make: Type:
VEHICLE No. SECTOR
1. Date of Servicing:
2. Servicing done by:
3. Kms. Remaining at the beginning of the month:
4. Kms. Remaining at the end of the month:
5. Total Kms. Covers during the month:
6. Balance of petrol / diesel of last month:
7. Petrol / Diesel purchased during the month:
8. Petrol / Diesel consumed during the month:
9. Petrol / Diesel balance at the end of the month:
10.Engine oil purchased during the month:
11.Gear oil and grease purchased during the month:
12.Average Kms. Per litre if Petrol / Diesel:
13.No. of days worked during the month:
14.Whether the Registration is renewed and tax token obtained:
15.Whether driver’s license is valid:
16.Name of the Driver:
17.Name of the Officer and Signature:
Vehicle Breakdown report:
1. Vehicle No:
2. Kms. Reading:
3. Description of breakdown how it happened:
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4. Have the defect rectified and by whom details of spares, labour etc.:
5. Date of breakdown.
Signature and Designation:
Time Management
A study carried out by World Health Organization revealed that the time utilization by
doctors in Primary Health Centres for patient care is only 21 per cent. It is even less in
case of preventive health care as most of the time is wasted in traveling. Besides, the
medical personnel in rural areas, either absent themselves or come late and go early,
thus devoting very less time to productive work. For example:
Many studies have found that nurses devote only 33 per cent of their time on
nursing activities while rest of the time is used for non-nursing duties.
Multipurpose workers devote only 30 per cent of their time for health activities.
PHC doctors devote only 25 per cent time for patient care.
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Doctors at district level waste 60 per cent of their time in traveling and
unwanted meetings.
The statement that “ Time is money” sums up the significance of time

management. Though most people in Government, Public Enterprises and Private
Sector understand the implications of time management, but in actual practice, we
find that time is wasted and its importance is undermined. Most of the executives and
workers in administration complain that they are too busy, but still they while away a
lot of their time in unnecessary activities. All other resources can be increased
whenever required, but not time, as it is inelastic and therefore, we must make the
best use of time. Just to illustrate the importance of time, many studies conducted
revealed that persons in administration hardly devote 30 to 40 per cent of their time
for the activities they have been primarily engaged for. It means that if proper use is
made of time, we can provide services with the existing infrastructure two to three
times more and thus the process of development can be accelerated.
Thus, if all the employees make the best use of time, we can accelerate the
process of development and help the people of the country suffering from abject
poverty, ill-health, illiteracy, unemployment, in leading a good standard of life. In
developed countries, the most precious resource is time and that is why they are
developed, but in developing countries, time is unconsciously and consciously wasted
in useless activities, resulting in under development or backwardness.
Nation must be committed to utilize even a fraction of second for accelerating

the tempo of development to usher in socio-economic democracy, as enshrined in
the preamble of the Indian constitution. How to go about it? How to ensure
optimization of time? How to make the best use of time? The answers to these
questions are very simple, i.e., time management at all levels.
If our country can manage time, we can achieve in a year the work of a decade and
thus can move fast towards modernization and development and can say with pride
that India occupies a prominent place, as in the past, in the community of Nations.
The aim of time management is not turn workers into machines, who work
without interruptions or breaks, nor is it to develop rigid routines. Rather, the aim is to
organize and arrange the use of time so that time pressures and overcrowded
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schedules and wastage are reduced, and that staff can have adequate rest periods
without lowering work output.
If forced to work under continuous pressure, people devise means of escape,

such as by taking few days off for illness or slowing down their pace and becoming
inefficient. These ways of relieving pressure can be observed among staff in an
average overcrowded department. It has been repeatedly shown in industry that
regular breaks increase work efficiency and work output.
TIME MANAGEMENT TECHNIQUES
It is very difficult to enlist all the techniques of time-management as these are many
and range from simple common sense approach to sophisticated techniques of
PERT/CPM, OR, Method Study, Work measurement, etc. We discuss here some
important techniques:
1. Assessment of Time Use for Activities that are not Related to Work
In this technique, in columns across a sheet of paper, write down all the activities that
are not related to work and that might take place during the course of a working day
(e.g. relaxing in staff room or canteen, personal telephone calls, going out t shop,
reading a newspaper, tea or coffee breaks, arriving late, leaving early, interruptions by
other staff).
Give copies of the papers to staff members who have volunteered to take part
in this exercise. Ask them to record the number of minutes spent on each activity not
related to work over a period of one or more days.
Collect the records and add up the minutes spent on non-working activities
each day by each staff member.
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Request all staff members, who have agreed to record their non-work activities,
to meet together to discuss the results or some team of outside experts may be
deputed to collect this data.
Give the group the totals from above without revealing the identity of the staff
members who provided the data.
Discuss the following questions with the groups:
Is the amount of time spent in non-working activities reasonable, too much, or not
enough?
Would it be better to have recognized time breaks (e.g., 30 minutes for tea,
shopping, reading the newspaper, or chatting) rather than having many unofficial
breaks?
Would recognized or official breaks, be introduced at different times so that the

work did not stop?
2. Assessment of Time use for Activities that can be done at Lower Levels
Most of the senior persons n the organization perform the work which can be done at
lower levels or that does not require the competence of the level where it is being
done. If such work is delegated to the lower level, the time spent by the busy people
at the higher level can be saved. This would also be economical since the salary scales
are higher at upper levels. To understand this with the help of a Case Study from
Thailand, reported in Public Health Development and Administration by Dr. K.
Klinoubol (New Delhi, Deep, 1989,pp. 336-44). This study was conducted under the
guidance of the author.
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Acceptance of female sterilization in Thailand has increased considerably, but

because of the shortage of doctors, especially in rural areas, long delays occurring
before surgery are common. Women are discharged from hospital within 24 to 48
hours of delivery and although many wish to have post-partum sterilization, they often
find it inconvenient to return to hospital for tubal ligation. Besides, it is very costly.
The Thai Ministry of Public Health decided to introduce the performance of post-
partum tubal ligation by trained nurse-midwives, since this could alleviate the
shortage of doctors and so reduce waiting time and free doctors for more skilled tasks.
This reduces costs as well.
3. Time Proportion Study to Give Weightage to Priority Areas
The Health executives should plan their work according to the priority, so that more
attention can be paid to such work. Here the Health executives may analyse the
activities done during the day and the time devoted on each activity: The writer has
done this exercise on many executives. The analysis of the results of such exercise
suggest that the executives spend more time on activities that are less significant and
spend less time on activities – that are very important. It means that the executives
never devote time in proportion to the importance of the activity, resulting in many
wrong decisions, affecting the performance of the organization. For example, the
tertiary health care institutions are created to do research, which can help in policy-
making and planning in different areas. However, it is seen that they are engaged in
routine activities of patient care. An opening of a department of a subject like Public
Administration, Sociology, etc. in a University and a College is done with different
objectives: that is why staffing at two levels is entirely different. The University
Department is supposed to engage itself in Research, Consultancy and teaching, while
a college department is mostly meant for teaching. A careful analysis of practices
would indicate that both are engaged merely in teaching and that is why we generally
hear that the Universities have become white elephant for the State exchequer.
Administrative Reforms Commission examined the problem of administration and
observed that in most cases, the top administration only okays the proposal initiated
at lower levels. This means that the high level administration finds no time to think of
real issues meant for them, like Organizational Development, Management of Change,
Conflict Management etc.
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Because of the non-existence of referral system, patients rush directly to

tertiary and secondary health care institutions, resulting in high cost and making
specialists attend to the work that could be done at lower levels.
Hence, there is a need of developing time schedule so that important activities

are not missed and due weightage may be given to them.
4. Time-Proportion Study on Meetings
In today’s administration, top-level executives/experts attend a number of meetings,

which are not well planned and well focused, resulting in the wastage of time and
executives/ experts. Whenever one goes to the District Health office or State health
directorate, one will find that most of the key people are busy in one meeting or the
other. The analysis of the agenda and outcome of the meetings would indicate that
there is too much wastage of time and that is why the key officials find no time to
listen to the grievances of the people and develop a climate of understanding.
The technical staff of the SEARO has to spend a lot of time in attending meetings of
other regional agencies for liaison purposes. Besides, they have to prepare a large
number of documents to exchange information with other regional organizations.
These activities have been increasing over the years, largely because the increasing
number of organizations tend to complicate the process of co-ordination. This was also
pointed out by the UN Secretary-General who wrote:
“I detect a sense of concern in many quarters at the growth in the number of

bodies and programmes which have been established primarily for co-ordination
purposes or in which co-ordination activities play an important and increasing role, in
the time and the documentation required to service them, and in the complexities and
even the duplications which they involve.
It is strange that even in hospitals, most of the time of the key experts is spent
on meeting like Sub-Committees and it is very difficult to meet them and discuss
important issues. They key experts get no time for important discussions, as they are
exhausted in meetings dealing with matters of relatively lesser importance. It is,
therefore suggested that the time on these meetings may be reduced to be utilized on
areas of greater significance.
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5. Time Study to Solve the Problems and Not Symptoms
Most executives don’t find time to deal with a case thoroughly from all angles, but
rather deal with the symptoms. In this way, the issue lingers on and continues in this
way for long, resulting in wastage of time and resources, not only of the management,
but also of the beneficiaries as well as creating bitterness between the two. It has
been seen that the cases which could be dealt with in a week’s time continue for
years.
An analysis of decided cases by various courts in the country would show that
the key officials in the administration initiate action, against the employees on
disciplinary grounds without due applications of mind. This results in the wastage of
resources and time of the administration in attending court cases. All these litigations
can be avoided if the key personnel attend to these maters in a thorough manner. Key
officials, by attending to real problems, can save a lot of time in the long-run and
make the administration efficient and responsible.
6. Well Planned Time Table for Field Visits
Many of the key personnel at state and district health offices have to control a wide-
network of offices. A part of this job can be carried out through telephone, or by
getting periodic reports from the field offices. But, there is a need of personal
discussion among the headquarter and the field staff, which involves the use of time
for traveling and discussion. The officials plan their visit in such a way that they waste
most of the time in traveling and less in discussion. It is suggested that field/
headquarter visits must be well planned, so that the discussion can be pertinent and
all the issues discussed in detail, to avoid meetings off and on. The headquarter
personnel must carry with them a well prepared schedule to guide them in the field,
while the field people must also come prepared with all the information to clarify the
vague points.
7. Fixing of Time Schedule to Devote Time to Work
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In most of the offices, the time for the visitors, is fixed, so that they may not be
thronging the offices throughout the day and waste the time of the personnel. At the
Scheduled time, people visit the offices but do not come back satisfied. It is suggested
that the Personal Assistants, before sending any person to visit the officials, must
listen to him to keep their file ready, so that action can be taken immediately and the
person concerned may not visit again and again. A lot of time, as already mentioned,
of the officials is wasted when the dame people for the same work, visit the offices
again and again. A brief training to staff and especially the Personal Assistants can
help in quick disposal of public cases and thus avoiding their recurrent visits.
8. Providing Regular Time for Rest and Recreation to Avoid Fatigue
Executives are human beings and thus cannot work beyond their capacity. It is,
therefore, suggested that they may observe regular rest periods to feel fresh.
However, these rest periods may not be done at will but must be already notified to
avoid difficulty to the staff and the people, until and unless there are compelling
reasons for it.
9. Brevity
Besides, the executives must learn to be brief and to the point and discourage
relatives/ friends to visit them in offices. Telephonic discussions must also be brief.
Conclusion
Time management would not only be beneficial to the health experts and executives
but would also provide more opportunities to the people to share their ideas and
views and thus we would be able to lay the solid foundations of People’s Participation,
Development and Modernization.
The development and modernization of developing countries can be accelerated

by an efficient Public Health Administration. It has been observed that Personnel in
Administration are not utilizing their time for the assigned job. They are wasting a lot
of time in unnecessary trivial activities which are non-productive. We must manage
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our time purposefully to build Modern India, otherwise we would remain an under-
developed country as time and tide waits for none.
Health Services can be increased 3-4 times with existing personnel, provided
these personnel devote their time to their duties efficiently. The failure of the Primary
health care in India is the failure of health personnel who never took interest in it and
devoted full time for the essential activities.
It is high time for the Union and State Governments to get the time utilization
study conducted for different categories of personnel, so that remedial action can be
taken for optimization of health services.
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SECTION – D
BUDGETING & ACCOUNTING
BUDGET
Budget generally refers to a list of all planned expenses and revenues. It is a

plan for saving and spending.[1] A budget is an important concept in
microeconomics, which uses a budget line to illustrate the trade-offs between
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two or more goods. In other terms, a budget is an organizational plan stated in

monetary terms.
In summary, the purpose of budgeting is to:
1. Provide a forecast of revenues and expenditures i.e. construct a model of

how our business might perform financially speaking if certain strategies,
events and plans are carried out.
2. Enable the actual financial operation of the business to be measured
against the forecast.
Source:  ^ Sullivan, arthur; Steven M. Sheffrin (2003). Economics: Principles in

action. Upper Saddle River, New Jersey 07458: Pearson Prentice Hall. pp. 502. ISBN 0-
13-063085-3. http://www.pearsonschool.com/index.cfm?
locator=PSZ3R9&PMDbSiteId=2781&PMDbSolutionId=6724&PMDbCategoryId=&PMDb
ProgramId=12881&level=4.
Break Even Analysis
Structure
1.0 Objective
1.1 Introduction
1.2 Importance of Break Even Analysis
1.3 Calculation of Break Even Point
1.3.1 Formula Technique
1.3.2 Break Even Point in Table Form
1.4 Chart Approach to Calculate Break Even Point
1.5 Let Us Sum Up
1.0 Objectives
After going through this unit, the students should be able to:
i. Discuss the broad concepts and application of break even analysis;

ii. Apply the break even analysis with a view to determine the level of sales
needed to be achieved to avoid losses;
iii. Determine sales level required to earn a target profit;
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iv. Determine sale price needed to avoid losses; and

v. Determine further BEP with the changed conditions to avoid loss.
1.1. Introduction
After going through the study materials one must have learnt about the
importance of Cost Volume Profit (CVP) analysis. Also one must have learnt about
break even analysis which is the most widely known form of CVP analysis. In this unit
firstly the basic concept and theory will be revised and then work on practical
exercises. This will enable to prepare and present break even analysis in various
formats. The purpose of this unit is essentially to help to prepare the actual
application of the theory in practical form.
1.2 Importance of Break Even Analysis

The Break Even Analysis is basically concerned with the Cost Volume Profit
relationship. Break Even Analysis focus attention on the variable cost by separating
them from fixed costs, which management has little control over it. Break Even
Analysis describes graphically the relationship between the costs, volume and profits;
it is used to determine the profitability of a given course of action of equipment.
An important indicator of an organization’s performance is the profit. An

analysis of the effects of various factors on profit is an essential step in financial
planning and decision making.
A break even analysis is a specific technique of studying and presenting the

interrelationship between costs, volumes and profits. It is an efficient and effective
method of financial reporting the planning.
To start of any financial activity for profit, mainly when a new facility in a
hospital is in the stage of planning consideration; it becomes logical and essential to
analyze with facts and figures to whether the venture would be profitable in near
future.
However, before the actual profit, one would come to a point of level of
operation where there is no profit or loss i.e. the costs and revenues of the activity
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have become even and further efforts would take the organization on the profit side.
This is a point of equilibrium and is commonly known break even point.
Thus the break even point is that point of sales volume for a given project of
activity at which there is no profit and no loss i.e. total revenue is equal to total cost.
For the purpose of further studies it is essential to know about the fixed costs, variable
costs, total costs and contribution. Let these terms be understood first.
Fixed Costs
These are the costs that cannot be avoided and are essential for the business.
These remain fixed irrespective of the changes in the volume i.e. the number of units
of goods produced. For example, the cost the base unit/ equipment, rent of hospital
facilities etc. These costs will remain the same whether patient traffic is zero or
1,00,000 patients. The other examples are:
a) Depreciation
b) Insurance
c) Bills and taxes
d) General administrative expenses like salaries, and maintenance of office
e) Repairs and maintenance (AMC)
Variable Costs
These are the costs (expenses) which vary in direct proportion to the changes in
volume of production. The examples are:
a) Cost of consumables; say x-ray film the quantity of which will go on

increasing in direct proportionate the x-ray images made.
b) Direct labour cost
c) Direct activity cost say electric power, which will go on being consumed in
direct proportion to the number of units of goods or number of units of
service provided say with every x-ray image made.
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d) Commission payable on unit basis.
Variable costs will go on increasing in direct proportion to the production

activity.
Revenue Cost
These are the costs which are actually recovered from the customers. Usually
the revenue cost will also try to have profit inbuilt in it hence the revenue cost should
be more than the variable cost. Though various market factors including
demand/supply of the services in the market plays a crucial role in determining the
exact revenue cost.
Contribution
This difference between selling price per unit and variable cost per unit is called
contribution per unit or simply unit contribution. The sum total of all unit contribution
is called “Total Contribution”. In break even point the total contribution is equal to the
fixed cost. Thus at break even point, the fixed cost has been overcome by the
contribution and any further activity would have additional contribution to generate
profit. In a break even analysis we would determine this point break even point (BEP).
1.3 Calculation of the Break Even Point
There are two approaches to determine the break even point. These are (a) the
formula approach and (b) the chart approach as described in succeeding paragraphs.
1.3.1 Formula Techniques

In this approach, the break even point (BEP) can be calculated in two ways:
1. The first technique

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Unit selling price – unit variable cost = unit contribution
Unit contribution x units sold = total contribution
At break even point (BEP), total contribution will be equal to total fixed cost.
2. Other technique to calculate the break even point (BEP)
Fixed costs divided by selling price per unit minus variable cost per unit = Break Even
Point (BEP)
Hence Break Even Point (BEP) can be calculated by the following two approaches:
BEP (units) = (Total Fixed Costs) / (Unit Contribution)…. Technique (1)
= (Total Fixed Costs)/ (Selling price) – (Variable costs per unit)
….. technique (2)
The above equations will give the units required to be produced and sold so
that the break even point is achieved. The following example will illustrate the point:-
Example 1
A hospital is offering Laparoscopic Cholicystectomy at a package deal with a selling

price Rs.30000/- per operation and the variable cost per operation comes out to be
Rs.20000/-. The annual fixed cost is Rs. 50,00,000/- How many Laparoscopic operation
the hospital must do to come at BEP.
Solution
Total fixed cost = 50,00,000
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Unit selling price = 30000
Unit variable cost = 20000
Unit contribution = unit selling price-unit variable=30000 – 20000 = 10000
Therefore BEP (units) = 50,00,000/10000 = 500 numbers of Laparoscopic operation as

per technique (2).
Thus a minimum number of 500 operations must be done so that the Hospital
achieves breaks even point.
Example 2
An X-ray centre has priced its X-ray test and report for Rs. 200/- each. The variable
cost is Rs. 100/- per test. The annual fixed cost is Rs. 2, 00,000/-. Find out the number
of X-ray tests to be performed per year at break even.
Solution
Total Fixed cost = 2, 00,000
Unit selling price = 200
Unit variable cost = 100
Therefore BEP (units) = 200000/ (200-100) =2000 as per technique (2)
Thus a minimum of 2000 X-ray tests must be carried out so that the X-ray centre
breaks even.
Thus, break even analysis in an institution leads to a point where there is no

profit or loss i.e. where revenue and expenditure match. In public sector hospitals this
sort of analysis is usually not done as there is no such pressing requirement. In private
hospitals this has to be made. Otherwise the hospitals will not know whether that the
hospital is making a profit or going in loss.
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1.3.2.Break Even Point in Table Form

Costing of the services and departmental accounting are the bases on which we
can build a break even analysis structure. Cost centre will be the fulcrum to make the
analysis. Let us make the hospital laboratory as the cost centre. Cost centre
represents allied group of activities, in this case the laboratory. With reference to the
number of investigations done in the laboratory we know the income. Since
departmental accounting is maintained, we know the revenue and expenditure of the
laboratory.
To find out whether laboratory is financially viable, we work out the fixed costs
and variable costs of the cost centre and divide the total by the number of
investigations done during a specific period. We now know the cost of an investigation
i.e. the cost unit. We also know the selling price of each unit which we have fixed. We
now have a rough idea where we are in our finances.
Now to work out the exact point from where we are going to make a profit, Let
us look into the data given in the table No. .
Table 1: Data of the Laboratory regarding its Fixed Cost, Variable Cost &
Revenue Cost
No. of units Fixed cost Variable Total cost Revenue

cost cost
Rs. Rs.
Rs. Rs.
1000 32,000 2,000 34,000 10,000
2000 32,000 4,000 36,000 20,000
3000 32,000 6,000 38,000 30,000
4000 32,000 8,000 40,000 40,000
5000 32,000 10,000 42,000 50,000
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We have to find out where our income and expenditure meet. The following
equation will give the clue: i.e. when total cost (i.e Fixed cost + Variable cost) = Total
revenue cost it is the indication that Break Even Point has reached.
Hence from the above table it is at 4000 number of units where the total cost is
equal to total revenue cost. So, when we reach investigating 4000 units (tests) we
arrive at the break even point.
To work out the practical situation we may do the following equation:
We know we have already worked out fixed costs and variable costs of the
laboratory in question. We work out in detail the same for a particular section of the
laboratory viz. urine and stool.
Let us assume the figures (as from the above table) are:
• Fixed costs Rs.32,000,

• Variable costs per unit Rs.2/- and
• Selling price Rs.10/-.
Break even point = 32,000 divided by 10 minus 2 = 4000 units.
Hence, at the stage when we reach investigating 4000 units (tests) we arrive at
the break even point. After this point we will start making profit, and the volume of the
profit will go up with the volume of tests done.
To make this exercise stick in our minds let us present it in a chart form.
Simulate the figures of investigation units, the total cost and revenue (income from
laboratory tests). It will take the following form:
1.4 Chart Approach to Calculate Break Even Point

To calculate the Break Even Point (BPE) by a graphical presentation is far more
quickly and easily understood by the senior manager as it takes less time to analyse.
A break even chart is thus a convenient tool of BEP analysis. The chart basically
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consists of drawing a two dimensional chart showing costs and revenues on Y-axis
(vertical) and volumes on the X-axis (horizontal); we will plot the above data in the
chart by drawing the following as under:
a) Service Volume Lines: Service volumes are plotted on X-axis. Service volumes
may be expressed in rupees or units. Convenient equal distances are marked
along X-axis to show sales volume at different activity level i.e. 0,8,16,24,32,40
thousand in rupees, and 1,2,3,4,5,6 thousand in numbers.
b) Cost and Revenue Lines: The fixed, variable costs and revenues from
services provided are plotted on the Y-axis, which correspond to the activity level.
These can be plotted in Rupees.
c) Fixed Cost Line: As the fixed cost does not change in value it becomes a
horizontal line parallel to the X-axis at the fixed cost point. In an alternative from
this can be drawn marking fixed cost on both sides of the variable cost line and
joining the same. The fixed cost is Rs. 32,000.
d) Variable Cost Line: This line can be drawn starting from the origin i.e. point
(0.0) rising upto the total variable cost marked on the right hand side
corresponding to the sales in Rs./units.
e) Revenue Cost Line: As the name suggests this line shows sales revenue on
the Y-axis plotted against the volume (i.e. over and above the fixed cost) at the X-
axis. In our case the line will start from the origin of fixed cost at Y-axis.
f)Profit: The difference between the ‘sales revenues’ and the ‘total cost’ is profit.
It would be seen the sales and the total cost lines intersect. At the point of
intersection the value total cost is equal to sales revenue thereby meaning that the
profit at this point is zero. This is thus the Break Even (BE) Point. The BE point can
be scaled and easily seen in terms of rupees or units.
The chart has accordingly been drawn below:
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56
Cost and Revenue (in thousand rupees)
48
Revenue Cost
Profit
Variable Cost
40
B.E.P
Loss
Fixed cost
32
24
0 1 2 3 4 5
UNITS OF SERVICES (in thousands)

16
It would be further be noted from this chart that before the BE point the total cost line
is8 above the sales revenue line meaning thereby that the cost is more than the
revenue hence there is loss upto this point. However beyond this the sales revenue
line is above this point hence there is profit beyond this point. The area below and on
the left of the break even point is the “loss area’ while the area above and to the right
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there is “profit area”. At BE point the contribution is equal to the fixed cost plus all the
variable cost.
Advantages of the Break Even Chart
1. It serves as a useful tool of planning and control.

2. It is useful tool to study the feasibility of acquiring the equipment.
3. It’s practical implications are profit estimation at the different levels of activity, ascertaining
turnover for desired profit.
BE chart is not free from limitations; it ignores the price and technology changes and
efficiency.
1.5 Let Us Sum Up

Break even analysis is a simple tool for financial analysis so as to make a right
decision in business proposals when more than one alternative is available. The break
even analysis is most commonly used to do the cost volume profit analysis. It
indicates the level of sales at which the total revenues are equal to the total costs. For
the purpose of this analysis the various costs are divided in two parts i.e. fixed costs
and the variable costs. The fixed costs are the costs that cannot be avoided and are
essential for the business. These remain fixed irrespective of the changes in the
volume i.e. the numbers of units of goods produced such as rent, insurance etc.
Variable costs are expenses, which etc. For every unit of goods produced the
sale/activity generates revenue and the difference of the price minus variable cost is
called unit contribution.
The break even analysis can be done either by formula technique or can be
effectively presented in chart form for easy understanding. A BE chart essentially
consists of (a) revenue cost, (b) fixed costs (c) variable costs. The chart also shows
BEP (no profit, no loss point), loss area, profit area, contribution, and margin of safety.
Thus a chart becomes volumes and profits. It is an efficient and effective method of
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financial reporting and planning and easily understood by the senior executives when
compared to accounting data.
ZERO-BASED BUDGET
Zero-based budgeting is a technique of planning and decision-making which

reverses the working process of traditional budgeting. In traditional
incremental budgeting, departmental managers justify only increases over the
previous year budget and what has been already spent is automatically
sanctioned. No reference is made to the previous level of expenditure. By
contrast, in zero-based budgeting, every department function is reviewed
comprehensively and all expenditures must be approved, rather than only
increases.[1] Zero-based budgeting requires the budget request be justified in
complete detail by each division manager starting from the zero-base. The
zero-base is indifferent to whether the total budget is increasing or decreasing.
The term "zero-based budgeting" is sometimes used in personal finance to

describe the practice of budgeting every dollar of income received, and then
adjusting some part of the budget downward for every other part that needs to
be adjusted upward. It is more technically correct to refer to this practice as
"zero-sum budgeting".
Zero based budgeting also refers to the identification of a task or tasks and
then funding resources to complete the task independent of current
resourcing.
Advantages of zero-based budgeting

1. Efficient allocation of resources, as it is based on needs and benefits.
2. Drives managers to find cost effective ways to improve operations.
3. Detects inflated budgets.
4. Useful for service departments where the output is difficult to identify.
5. Increases staff motivation by providing greater initiative and
responsibility in decision-making.
6. Increases communication and coordination within the organization.
7. Identifies and eliminates wasteful and obsolete operations.
8. Identifies opportunities for outsourcing.
9. Forces cost centers to identify their mission and their relationship to
overall goals.
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Disadvantages of zero-based budgeting

1. Difficult to define decision units and decision packages, as it is time-
consuming and exhaustive.
2. Forced to justify every detail related to expenditure. The R&D
department is threatened whereas the production department benefits.
3. Necessary to train managers. Zero-based budgeting must be clearly
understood by managers at various levels to be successfully
implemented. Difficult to administer and communicate the budgeting
because more managers are involved in the process.
4. In a large organization, the volume of forms may be so large that no one
person could read it all. Compressing the information down to a usable
size might remove critically important details.
5. Honesty of the managers must be reliable and uniform. Any manager
that exaggerates skews the results.
Incremental budgeting
Incremental Budgeting uses a budget prepared using a previous period’s
budget or actual performance as a base, with incremental amounts added for
the new budget period. The allocation of resources is based upon allocations
from the previous period. This approach is not recommended as it fails to take
into account changing circumstances. Moreover, it encourages “spending up to
the budget” to ensure a reasonable allocation in the next period. It leads to a
“spend it or lose it” mentality.
Advantages of incremental budgeting
1. The budget is stable and change is gradual.

2. Managers can operate their departments on a consistent basis.
3. The system is relatively simple to operate and easy to understand.
4. Conflicts are avoided when departments appear to be treated similarly.
5. Co-ordination between budgets is easier to achieve.
6. The impact of change can be seen quickly.
Disadvantages of incremental budgeting
1. Assumes activities and methods of working will continue in the same

[2]
way.
2. No incentive for developing new ideas.
3. No incentive to reduce costs.
4. Encourages spending up to the budget so that the budget is maintained
next year.
5. The budget may become out-of-date and no longer relate to the level of
activity or type of work being carried out.
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6. The priority for resources may have changed since the budgets were
originally set.
7. There may be budgetary slack built into the budget, which is never
reviewed. Managers might have overestimated their requirements in the
past in order to obtain a budget which is easier to work within, and which
will allow them to achieve favourable results.
A zero-based budget means you start with the absolute essential expenses and
then add-back expenses from there until you run out of money. This is an
extremely effective, yet rigorous, exercise for most doctors and medical
professionals; and can be used personally or at the office.
Source
1. : ^ Zero Based Budgeting..Learn How To Justify Your Business Forecasts

2. ^ Incremental budgeting
Preparing Your Budget

Budgeting in OR
Factors on which budget depends
a) Design of the study
b) Subject being investigated
c) Size of intervention
d) Duration
Budget
1. Use Work Plan as a starting point
2. Specify for each activity in the work plan, what resources are required
3. Determine for each resource needed the unit cost and the total cost
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4. UNIT COST (eg. Per diem or cost of petrol per km),

5. the MULTIPLYING FACTOR (no.of days),
6. And TOTAL COST should be clearly indicated for all budget categories.
Component of the Budget

Program Cost
1. Intervention Cost
(Example 1) -IEC --[often vary by size of target group)
a) Consultant
b) Printing
c) Delivery
d) Concurrent monitoring and supervision
(Example 2) Emergency Contraception
a) IEC
b) Training
c) Supply
d) Assistance in case of contraindication
2. Non-intervention Cost
3.
Non-Program Cost
1. Baseline/Endline survey
Manpower
– Field investigators
– Supervisors
– Principal Investigators
– Secretarial and Accounting
2. Instrumental Development
– TAC meeting cost
– Field testing
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– Instrument
3. Transportation
4. Correspondence and Communication
5. Stationery
6. Data entry and processing
– Salary of data entry operator
7. Report writing and Printing
8. Dissemination
– Higher level
– Local level
– Seminar/publication/press-briefings
– Miscellaneous
FORMAT OF BUDGET
Categor Unit Cost Multiplying Factor Total
y cost
Personn Daily Wage/ Per diem No. Of Staff Days (No. Of Staff X No. Total
el Of Days
Transpo By Road: Cost Per No. Of Kms. (No. Of Vehicles X No. Of Total
rt Km. Days X No. Of Km Per Day
By Air/Rail Round Trips Fare
Supplies Cost Per Item Number Total
Example of budget
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Advice on Budget Preparation

 Do not underestimate the time for completion of tasks
 Include contingency fund
 Allow flexibility – transfer between line budget
 Build in allowances for inflation- in case budget is for a period longer than a
year
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EXERCISE :
Activity 1:
Exercise – Comparison of budget and expenditure, Health Centre – A
Input Budget (in RS.) Expenditure in Cost profile(expenditure as
(Rs.) % of budget)
Capital
Vehicles 1,80,000 2,00,000
Equipment 1,00,000 1,07,000
Buildings, space 1,20,000 1,10,000
Training, non-recurrent 0 0
Social mobilization, 0 0
non-recurrent
Subtotal, capital
Recurrent
Personnel 6,00,000 5,79,000
Supplies 2,00,000 24,600
Vehicles, operation & 1,00,000 1,23,000
Maintenance
Buildings, operation 27,000 24,000
& maintenance
Training recurrent 0 0
Social mobilization, 0 0
recurrent
Other operating inputs 90,000 87,500
Subtotal, recurrent
Total 14,17,000 14,76,500
Complete the last column in the table.

• Did the district’s total expenditure keep within the budget (say, within 3-5% of it)?
___ Yes ___ No
• Which inputs were overspent and which were under-spent?
• What percentage of total expenditure was on capital?
• What are the recurrent cost implications of this capital expenditure?
• For which inputs was expenditure greatest?
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Unit 2
Accounting
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Accounting: means recording of the financial transactions that take place in a proper
manner, classifying them periodically under pre-determined budget heads and at the
end of a given period aiding and collecting the information on how much has been
received or spent under specific heads.
Single Entry System: It is the simple way of maintaining accounts without any hard
and fast rules and does not reflect the financial health in terms of balances and dues.
Double Entry System: In Double Entry System every transaction has two accounting
entries, one on debit side and other on credit side and, therefore, at any given time
the financial status of the organization can be ascertained.
Financial Statement: The primary financial statement includes balance sheet,

income statement and receipts and payments statement. The financial statement is
prepared on the cash basis of accounting and the accounting standard issued by ICAI.
Cash Book: The cash book shows the cash receipt and cash disbursement and is the
primary book of entry after a voucher is prepared for a particular transaction.
Drawing and Disbursing Officer: is an officer who is responsible for maintenance of

all financial accounts and registers head wise / sub-head wise.
Trial Balance: Trial Balance for a particular period is prepared to assess the overall
financial status of an organization in terms of assets, receipts, cash in hand and
liabilities. It is prepared on the basis of Cash Book.
Journal: is an accounting record in which information from the source documents first
enters the accounting system.
National Health Accounts: is a system through which the expenditure flows in the
health sector (public and private) in a given time period in a manner that is relevant to
policy makers in understanding how this sector operates.
1.1 Accounting
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Accounting is recording the financial transactions that take place in a proper manner,
classifying them periodically under predetermined Heads and at the end of any given period aiding
and collecting the information on how much has been received or spent under specific Heads.
1.1.1 Financial v/s Management Accounting
Financial accounting includes maintenance of accounts to enable the management to prepare
the financial statements showing the results of operations and the financial state of affairs to
exercise control on the assets and liabilities of the organization. Management Accounting enables
the management to discharge its functions properly in respect of forecasting and budgeting and
control over the costs, revenues and decisions, both routine and strategic.
1.1.2 Systems of Accounting

Single Entry System sounds simple as it has no hard and fast rules. In this system of
accounting, only personal accounts are maintained. This is essential because, without personal
accounts, it would be difficult to know the balance and the dues. In this system, no trial balance
can be prepared and hence arithmetical accuracy of books cannot be proved. The
In the Double Entry System, every transaction has two accounting entries, one on debit side
and the other on credit side of an account. A debit balance is money owing to the firm; or the firm
owns some property (cash, goods, furniture, etc.); or the firm has lost money or incurred some
expense – A credit balance shows that: money is owing to some person or the firm has earned an
income.
1.2 The Accounting Process

The accounting process is a set of activities that begins with recording a transaction and
ends with the closing of the books. Because this process is repeated in every reporting period, it is
referred to as the accounting cycle. To record a transaction, the following steps need to be followed:
Step 1: Identify the transaction or other recognizable event that has a financial impact on the entity.
Step 2: Generate the transaction’s source document such as a purchase invoice, cash receipt etc.
Step 3: Determine the dual effect of the transaction in terms of quantifying the transaction,
identifying the accounts that are affected by the transaction.
1.2.1 Period of Accounts
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The annual accounts are maintained for the transactions which have taken
place during a financial year. In government and private sectors generally the financial
year runs from 1st April to 31st March.
An actual cash transaction taking place after 31st March should not, however,
be treated as pertaining to the previous financial year even though the accounts for
that year may be open for the purposes mentioned earlier. However, in non-
governmental establishments the accounts are closed as on last day of the financial
year.
1.2.2 Cash Basis of Accounts

Generally, the transactions in government accounts shall represent the actual
cash receipts and disbursements during a financial year.
The cash receipts and disbursements that is recorded in the accounts of the
year in which they are ‘actually realized in cash’. This is what is known as ‘Cash Basis
of Accounts’.
1.3 Main Divisions and Heads of Accounts

There are two main divisions - Revenue Accounts and Capital Accounts. Each of these
divisions will have two parts Receipt Heads and Expenditure Heads. Capital expenditure is an
expenditure incurred with an object of increasing assets of a permanent or long lasting nature like
construction of buildings; purchase of an equipment etc. Revenue expenditure on the other hand
refers to the expenditures incurred for performing the activities of the organization - like expenses
connected with running the PHC, running the district hospital etc.
1.4 Accounting Process by the Government

The broad outlines of the system of government accounting are:
i. All receipts shall be paid into a treasury or bank and the initial accounts shall be maintained
at the Treasury.
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ii. Disbursements on the basis of vouchers duly passed by the Drawing and Disbursing
Officers shall be made either at the treasury or at the bank. All initial accounts shall be kept
by the treasury.
iii. At the beginning of each month, the treasuries will submit monthly accounts supported by
the requisite schedules, vouchers etc. to the concerned Accountant General, in respect of the
transactions that took place in the treasury during the previous month.
iv. These monthly accounts are then consolidated into accounts of receipts and disbursements
for the State by major heads and sub heads.
Financial Statements
The primary financial statements include:
 Balance sheet: A Statement of financial position at a given point of time. A balance sheet
focuses on the assets, liabilities, and equity of an organization, reflecting the fundamental
principle of accounting (assets-(liabilities+ equity) =0).
 Income Statement: An income statement reports on revenue and expenses resulting from
the organization’s operations during a specified period.
 Receipts and Payments Statement: Statement that summarizes the sources and uses of
cash for a given time period.
1.5 Introduction to National Health Accounts

National Health Accounts describe the expenditure flows in the Health sector
(public and private) in a given time period in a manner that is relevant to policy
makers in understanding how this sector operates. It details out in an integrated way
who pays, how much and for what, separating who from what. In basic form it shows
and links both public and private sources and uses of funds and can be represented in
a matrix format.
1.6 Activity
Activity 1: Prepare a trail balance from the following financial statement of Dr. K.B. Singh’s clinic
(as on 31st December 2008)
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Particulars Amount (Rs.)

Dr. Singh’s capital account 76,69,000
Stock as on 1st January 1994 46,80,000
Services 3,89,60,000
Returns inwards 8,60,000
Purchases 3,21,70,000
Returns outwards 5,80,000
Carriage inwards 19,60, 000
Rent and taxes 4,70,000
Salaries and wages 9,30,000
Sundry debtors 24,00,000
Sundry creditors 14,80,000
Bank loan @ 10% 20,00,000
Bank interest 1,10,000
Printing and stationery 14,40,000
Bank balance 8,00,000
Discount earned 4,44,000
Furniture and fitting 5,00,000
Discount allowed 1,80,000
General expenses 11,45,000
Insurance 1,30,000
Postage and telegram 2,33,000
Cash balance 38,000
Traveling expenses 87,000
Drawings 30,00,000
Total 5,11,33,000
Activity 2: Journalize the following transactions in the books of Dr. Ramanathan for the year 2008
a. Dr.Ramanathan commenced his nursing home with cash Rs. 10,00,000, Machinery
Rs. 10,00,000, Buildings Rs. 30,00,000 and Furniture Rs. 15,00,000.
b. Installed and paid for Neon Sign Board at a cost of Rs. 1,00,000
c. Dr.Ramanathan borrowed Rs. 25,00,000 from his friend and the same were
deposited by him in bank to open an account.
d. He purchased medicines and other equipments for Rs. 7,00,000 for cash.
e. He purchased drugs & medicines worth Rs. 10,00,000 from Ms. Rao
Pharmaceuticals on cash @ 2% Cash Discount.
f. Supplied drugs & medicines to worth Rs. 15,00,000 against cash after allowing 5%
Discount.
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g. Paid Rs. 1,99,500 to M/S Rajesh & Co for purchases of hospital equipment after
allowing 5% Cash Discount on the invoice.
h. Sent a cheque of Rs. 1,00,000 to Chief Minister’s Fund as Dr.Ramanathan’s personal
contribution.
i. Placed an order for equipments for worth Rs. 2,000 with M/s Archana Traders.
j. Air conditioners worth Rs. 4,50,000 brought in the clinic for use.
What are your experiences while journalizing? What is the role played by the rules of accounting
while journalizing transactions?
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SECTION – E
MEDICAL RECORDS
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RECORDS MANAGEMENT IN HOSPITALS

Records Management is a programme that involves the functions of creating,
administering, retaining, submitting and destroying records. Herbert Hoover
has rightly mentioned the advantages of proper records keeping when he says:
II A business decision is only as good as the facts on which it is based." Records
are the memory of the internal and external transactions of an organization. By
external transaction we mean the correspondence between the organization
and its clients - beneficiaries as well as supporters. By internal transaction is
meant the dealings on external transactions by persons in the organizations at
all levels.
RECORDS:
Records are usually written information kept in daily diary, notebooks, registers
cards etc. Records consist of information on work done, health status of the
community members, in general and also of individuals in particular. Records
are also essential for administrative matters such s maintenance of accounts of
supplies received and items used in rendering services in sub-centre area.
Records should be: - accurate
-accessible
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-available when needed and contain information that is useful for

assessment and making decision regarding future action.
Hence, records of different services provided need to be maintained at sub-

centre. Though there is wide variation from State to State regarding the registers
expected to be maintained at sub-centre, the registers listed below are essential for
effective implementation of the RCH programme at the most peripheral level.
Thus, the records management is concerned with the retaining, submitting and
destroying of records. The proper maintenance of these records in right quantity and
quality is the essence of records management. The success of this record keeping
would be reflected in the timely availability of all the records. In the conte4xt of
Medical Records, Dr. McGibony had said, II A cronicle of the pageantry of medical and
scientific progress is found in the hospital records. There may be found the running
story, disconnected it is true, of the drama, the comedy, the mystery, the miracles of
medicines and hospital of the Twentieth Century. "
The medical record is a clinical, scientific, administrative and legal document

relating to patient care in which is recorded sufficient data, written in sequence of
events to justify the diagnosis and warrant the treatment and end results.
DEMONSTRATION ON VARIOUS TYPES OF RECORDS NEEDED TO BE

MAINTAINED AT SUB CENTRE
1. Village records:
The register is maintained to store the information regarding an overall picture of each
village covered under the sub-centre area. This should include information on items
listed below:
• Number of households ( a household is defined as

consisting of those family members having a common kitchen)
• The population of each village
• The population distribution according to age and
sex
• Number of Anganwari centers with the name and
address of AWWs.
• Number of private practitioners (Allopathic,
Ayurvedic, Homeopathic, RMP etc.)
• Dais in each village (Name & Address)
• Schools - location
• Panchayat Bhawan - Name & Address of Sarpanch
• M.S.S./Mahila Mandal members
• Voluntary organization, if any
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• Number if deep hand-pumps installed.
2. Household Survey Register

The information regarding each and every household are collected during household
survey. After the initial survey, it should be revised after three years. The details of
information, need to be collected and entered in this survey register have been listed
in Unit-I.
3. Eligible couple registers

Identify the number of couples where the wife's age is between 15-45 years from
household survey register and enter in this register with, address. The family status
with parity and age of the youngest child should be mentioned. The couple if using
any contraceptive also need to be recorded along with the details of contraceptive
methods being used.
4. Maternal and child health register and contraception register

The details of items of information that need to be recorded in these registers ae
discussed in maternal care and child care modules
5. Register for recording Contraceptives:

a. Condom distribution
b. Oral pills register
c. CU'T'IIVD register
d. Sterilization - Male/Female
6. Sub-centre clinic register
This register is maintained for keeping records of patients attending the subcentre
clinics. The attendance in antenatal, immunization, family planning clinics should not
be recorded in this register
The following columns are essential for this register:
S.No. Date Name & Address Complaints Medicines Remarks
gIven
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7. Death register
You should enter all deaths occurring in the area covered by your sub-centre. The
items of information to be recorded include:
• Date of death
• Name & address
• Age
• Sex
• Cause of death
8. Stock Registers
Records of particulars related to all items provided and utilized at sub-centre should
be maintained. The details of sock register is given in Unit-III.
9. Register for recording consultative process
You have to conduct the meetings with village working team constituted for
each village and with other members of group of that village as has been
discussed in Unit- I and Unit II. You should record the details of each meeting in
this register. The following information needs to be entered.
Month / Year Date & time of Venue/Place Members Items
holding the attended discussed
meeting
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10. Referral register
The details of all referred cases should be entered in this register. This will also help
you to undertake follow UD of the referrals made
Date Name & Age Sex Complaints Reasons Referred Follow
Address for to up
referral actions
taken
1 2 3 4 5 6 7 8
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11. Daily Diary
Each health worker (male and female) is expected to maintain a daily known as "Daily
diary" in which you will record the daily activities performed in the field as well as at
the clinic with regard to; immunization, antenatal check up and follow up, distribution
of contraceptives, follow up of IUD and OP cases, identification of PID RTI/STI cases,
birth and deaths reported, malaria cases etc. The meetings conducted with the village
working team and with the group of village representatives should also be mentioned
in this diary.
This daily diary will enable you to up-date all the registers to be maintained and
will also be helpful in preparation of monthly report. While visiting houses, you cannot
carry all the registers but you can always keep the daily diary easily which can be
used for reference.
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SUMMARY CHART OF BASIC SUGGESTED IMMUNIZATIONS
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Cheklists
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Pharmacy - General specifications
S.N Pharmacy - General specifications Main Note

Elements(s)
1 * Each Pharmacy must have a minimum area of 30 Area > = 30 SQM
Square meter to ensure sufficient size to allow for
thesafe and proper storage of medicines and for the
safe and proper Compounding and/or preparation
ofPrescription Drug Orders.**
2 * The recommended ceiling height of the facility is > = Ceiling Height > =
2.7 meter. The ceiling must provide 2.7 m
acceptableinsulation to medications from humidity and
heat .
3 The floor shall not be below the public road level Floor Floor Level
Level
4 * The facility shall not be connected to ,or have access No Connection
to any other activity toother Activities
5 Exterior Walls of the facility shall be made of Brickwork Walls Painted
and painted with proper quality paint with no
sharpedges
6 Floor shall be made of easily washable material Floor Material
7 Each facility must be well ventilated and sufficiently Ventilation ,
lighted and maintained in a clean and orderly Lightning , AC
condition.Proper air conditioning must be available to
keep the temperature inside the Pharmacy at 20c° - 23
c° orless. A non-Mercuric thermometer must be kept to
monitor the temperature.
8 Each facility shall have access to a sink with hot and Sink
cold running water .The sink must be kept in a
cleancondition.
9 Storage area shall be maintained at temperature Storage Area
which will ensure the integrity of Drugs prior to temperature
theirDispensing as stipulated by the USP/BNF and/or
the Manufacturer’s or distributor’s Labeling unless
otherwise indicated by HA-AD .
10 First aid kit must be available in the facility and shall First aid kit
include all necessary updated items
11 The facility must be readily accessible to clients in Tel , Facsimile ,
person, by telephone, and by facsimile Computer ,
machine.Computer with internet access for the Internet
purposes of email, and information research must also
be available.
12 The Dispensary must be accessible to authorized Dispensary
personnel only accessibility
13 Each Pharmacy shall maintain an area designated for Counseling Area
the provision of Patient Counseling services. This
areashall be designed to provide an accepted degree
of privacy , and afford confidential communication.
14 Each Facility shall maintain one up-to-date copy of Laws , regulations
Federal drug laws relating to the Practice of availability
Pharmacyand the legal distribution of Drugs ( Law #
4 / 1983 ) and any related rules or regulations
governing the
practice of pharmacy issued by MOH or HA-AD
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15 Each Pharmacy shall maintain one current reference in Pharmacy

:Pharmacology;Drug interactions; Patient Counseling References
Guide Text ;Extemporaneous Preparation
Text;Therapeutics; Over The Counter Drugs
Reference ; and Compendium of Pharmaceutical
products
17 Medicines , Pharmaceutical products and Nutritional Shelves , cabinet ,
items must be stored on a suitable shelves or Wooden Pallets
cabinet.Wooden pallets must be used to separate
boxes of medicines from the floor
18 Controlled Drugs Group (A) ,CDA and / or (B) , CDB Controlled Drugs
must be stored out of reach of the public in a
lockedcabinet/ room .Register Book for each group
must be maintained and ready for inspection
19 The facility must have a refrigerator that is: Refrigerator
clean and in good working order;
dedicated to the storage ofpharmaceuticals and
related products;
capable of maintaining the temperature defined by
themanufacturer of product stored in the refrigerator;
ihave a built-in / separate thermometer to monitor and
register the temperature.
20 The facility must have a waste container of plastic, waste container
metal or similar material.
21 If a Pharmacy is willing to compound medicines Compounding and
according to a prescription ,the following minimum list dispensing
of equipments
compounding and dispensing equipments must be
kept :
1- Prescription Balance having sensitivity reciprocal 10
mg (torsion model) and a set of metric weights, or an
electronic balance.
2- Metric graduates of the following sizes: 10 mL and
100 mL
3- Glass mortar and pestle, 250 mL
4- Spatulas: 3 stainless steel: small, medium and large
5- Ointment slab or pad
6- Counting tray
22 Copy of pharmacy license, pharmacist(s) license(s), Licenses in the file
intern license(s), preceptor license(s) and proof of
renewal shall be kept in a suitable box file
23 Copy of Pharmacy license and Pharmacist(s) license(s) Licenses posted
shall be posted in a observable area .
24 Each facility shall post a signboard displaying it is title Signboard
in Arabic and English
25 All out-dated medications (both prescription and OTC) Expired Items
and other expired items must be quarantined in
aspecial box labeled "Expired Items , Not for Sale"
.This Items must be destroyed in accordance to
relatedrules and regulations.
*Requirements 1,2,3,4 are a MUST for the preliminary inspection

**The Facility must be empty at the time of the preliminary inspection
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S.N Drug Store General Specifications Main Note

Elements(s)
1 * Each Drug store (Storage area without offices ) shall have a Area > = 30 SQM
minimum area of 30 Square meter to ensure sufficient size to allow
for the safe and proper storage of medicines.
2 The recommended ceiling height of the facility is > = 2.7 meter. The Ceiling Height > =
ceiling must provideacceptable insulation to medications from 2.7 m
humidity and heat .
3 The Floor shall not be below the public road level Floor Level
4 The facility shall not be connected to , or have access to any other No Connection to
activity other Activities
5 Exterior Walls of the facility shall be made of Brickwork and painted Walls Painted
with proper quality paintwith no sharp edges
6 Floor shall be made of easily washable material Floor Material
7 Each facility must be well ventilated and sufficiently lighted and Ventilation ,
maintained in a clean andorderly condition .Proper air conditioning Lightning , AC
must be available to keep the temperature inside theStore at 20c° -
23 c° or less. A non-Mercuric therm ometer must be kept to monitor
thetemperature.
8 Each facility shall have access to a sink with hot and cold running Sink
water .The sink must be keptin a clean condition. The sink might be
located outside the facility
9 Storage area shall be maintained at temperature which will ensure Storage Area
the integrity of Drugs prior totheir distribution as stipulated by the temperature
USP/BNF and/or the Manufacturer’s or distributor’sLabeling unless
otherwise indicated by HA-AD .
10 First aid kit must be available in the facility and shall include all First aid kit
necessary updated items
11 The facility must be readily accessible to clients in person, by Tel , Facsimile ,

telephone, and by facsimilemachine. Computer with internet access Computer ,
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for the purposes of email, and information researchmust also be Internet

available.
12 Each Facility shall maintain one up-to-date copy of Federal drug Laws , regulations
laws relating to the Practice ofPharmacy and the legal distribution availability
of Drugs ( Law # 4 / 1983 ) and any related rules orregulations
governing the practice of pharmacy issued by MOH or HA-AD
13 Medicines , Pharmaceutical products and Nutritional items must be Shelves , cabinet ,
stored on a suitable shelvesor cabinet. Wooden pallets must be Wooden Pallets
used to separate boxes of medicines from the floor
14 Controlled Drugs Group (A) ,CDA and / or (B) , CDB must be stored Controlled Drugs
out of reach of the public ina locked cabinet/ room .Register Book
for each group must be maintained and ready forinspection
15 The facility must have a refrigerator that is: Refrigerator
i. clean and in good working order;
ii. dedicated to the storage of pharmaceuticals and related
products;
iii. capable of maintaining the temperature defined by the
manufacturer of product stored in therefrigerator;
iv. have a built-in / separate thermometer to monitor and register
the temperature.
16 The facility must have a waste container of plastic, metal or similar waste container
material.
17 Copy of Store license , pharmacist(s) license(s), intern license(s), Licenses in the file
preceptor license(s) andproof of renewal shall be kept in a suitable
box file
18 Copy of Store license and Pharmacist(s) license(s) shall be posted Licenses posted
in a observable area .
19 Each facility shall post a signboard displaying it is title in Arabic and Signboard
English
All out-dated medications (both prescription and OTC) and other Expired Items
expired items must bequarantined in a special Segregation Area
labeled "Expired Items , Not for Sale" .This Itemsmust be destroyed
in accordance to related rules and regulations.
*Requirements 1,2,3,4 are a MUST for the preliminary inspection

**The Facility must be empty at the time of the preliminary inspection
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SECTION – E
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MEDICAL AUDIT & QUALIT

ASSURANCE
1.0 Introduction
Hospitals are the key institutions in providing relief against sickness and
disease. They have become an integral part of the comprehensive health services in
India, both curative and preventive. Significant progress has been made in improving
their efficiency and operations.
Effectiveness of a health institution - hospitals or nursing homes, depends on its

goals and objectives, its strategic location, soundness of its operations, and efficiency
of its management systems. The administrator's effectiveness depends upon the
efficiency with which he is able to achieve the goals and objectives. Some of the major
factors determining the effectiveness of a health institution include patient care
management and patient satisfaction.
Hospital Management Society is a simple yet effective management structure.

This committee, which would be a registered society, acts as a group of trustees for
the hospitals to manage the affairs of the hospital. It consists of members from local
Panchayati Raj Institutions (PRIs), NGOs, local elected representatives and officials
from government sector who are responsible for proper functioning and management
of the hospital / Community Health Centre/FRUs. HMS is free to prescribe, generate
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and use the funds with it as per its best judgement for smooth functioning and
maintaining the quality of services.
1.1 Case Study: Visit to Your District Hospital and Name the Member
of HMS
HMS would be a registered society set up in all District Hospitals/Sub-district
Hospitals/CHCs/FRUs. It may consist of the following members:
• -------------------------------------------------------------------------------------------------
--
• -------------------------------------------------------------------------------------------------
--
• -------------------------------------------------------------------------------------------------
--
• -------------------------------------------------------------------------------------------------
--
• -------------------------------------------------------------------------------------------------
--
• -------------------------------------------------------------------------------------------------
--
• -------------------------------------------------------------------------------------------------
--
The HMS will not function as a Government agency, but as an NGO as far as functioning is
concerned. It may utilize all Government assets and services to impose user charges and shall be
free to determine the quantum of charges on the basis of local circumstances. It may also raise
funds additionally through donations, loans from financial institutions, grants from government as
well as other donor agencies. Moreover, funds received by the HMS will not be deposited in the
State exchequer but will be available to be spent by the Executive Committee constituted by the
HMS. Private organizations offering high tech services like pathology, MRI, CAT SCAN,
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Sonography etc. could be permitted to set up their units within the hospital premises in return for
providing their services at a rate fixed by the HMS.
Activity: If you are the member of this above mentioned society, review the status in
the District hospital as per the following headings:
• Review of the OPD and IPD service performance of the hospital in the last quarter
and service delivery targets for the next quarter.
• Review of the outreach work performed during the last quarter and outreach work
schedule for the next quarter.
• Review of efforts in mobilizing resources from the community, trade/industry and
local branches of professional associations like IMA and FOGSI etc.
Activity: What are the various types of hospitals in your districts? Describe the main
functions of the district hospitals and discuss the common problems in hospital
management.
Activity: Discuss how the hospitals play a vital role in providing primary health care
Quality management in health sector is important for improving health status of

the population, enhancing quality and access, increasing macroeconomic and
microeconomic efficiency, strengthening cost and clinical effectiveness and improving
quality of care and consumer satisfaction.
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Quality has two dimensions which are quality control and meeting customer
requirements. TQM is a management philosophy and methodology for guiding the
continuous improvement of products, processes and services with the objective of
realizing, optimum customer value and satisfaction. To improve the process of
delivering care and thereby increase the customer satisfaction with the quality of care,
improve the functional health of patients, and reduce the cost of providing care.
Operationalizing TQM is a systemic process that begins with top level management.
Performance standards are powerful managerial tools for control. They serve as
levels of desired performance against which actual performance can be measured and
evaluated. Standards that can be achieved by workers are fair and reasonable.
Performance levels that are not realistic will not serve to motivate worker
achievement or provide management with a useful tool. The performance standards
must be realistic, behaviorally based, observable and quantifiable.
Activity: Briefly discuss how to start quality Management in your District Hospital?
Activity: How in your district hospital infected cases in the ward/O.T. are handled?
Activity: How a system of surveillance in a hospital can help in the control of:
a. Infection in hospital
b. Communicable diseases in the community?
Activity: What are the different types of designs of emergency area? Which is most suitable for
your district hospital? Discuss the various administrative and managerial problems raise in the
emergency department.
1.2 Implementing Total Quality Management

Operationalizing TQM is a systemic process that begins with top level management.
Implementation requires two to five years and varies depending on the size and culture of the
institution. Senior management must accept the idea that it takes more than strategic vision and
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talent to succeed. Successful hospitals execute their plans and consistently do well by striving to do
better. Therefore the first step toward implementing TQM is the belief and commitment by senior
management that it is the road to long term success.
1.3 Case Study

The five pillars of TQM include the product, process, organisation, commitment and
leadership. These five pillars form the basis for quality assessment and continuous improvements in
the product, process, organisation, commitment and leadership in the competitive business
environment.
Visit to your District hospital and find a process to improve, organize team that knows the
process, clarify current knowledge of the process, use of qualitative measurements and select the
process improvement by planning, doing, checking and acting to hold and to continue quality
improvement.
1.4 Hospital Performance Standards

As a result of the technological developments, demand for highly specialized staff, changing
facility requirements and increased consumer demands, the health care world over is becoming
progressively complex and expensive. This phenomenon has put great emphasis on looking more
carefully at the community needs for services and setting priorities based on those needs, managing
them more carefully and continually evaluating how we are doing. These activities eventually lead
us to the need for development of realistic, effective performance standards against which to
measure the performance. Recognition by many countries including India about the need for
national level performance standards for the hospitals is gaining momentum.
Activity: How would you go about selecting Performance Indicators for the evaluation of a District
hospital and Define Hospital Performance Standards and what are the essential requirements in
their formation?
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If you are Medical superintendent of district hospital, how will you discuss usage of Hospital
Performance Standards in reference to Quality Management in your District hospitals based on
following quality indicators and mention necessary steps for the improvement?
1. Hospital mortality
2. Adverse events
3. Disciplinary action against doctors
2. Sanctions from peer review
3. Malpractice suits
4. Doctors performance treating specific diseases
5. Number of services available
6. External evaluations
7. Specialization of doctors, and
2. Patients assessment of their care
The need of psychological, social, nutritional and other patient assessment is

determined by patient need and by policy. Diagnostic testing necessary for determining the patient’s
health care need is performed. All indicated assessments and diagnostic testing are completed
within 24 hours of entry. The care of each patient is planned collaboratively and is based on the
integration of results of the assessments and testing. Each patient is reassessed periodically to
determine response to care and the need for continuing care.
If poor out comes are obtained, it is necessary to go back to structure and process to
help determine what went wrong and where. Thus a combination of structure, process and outcome
standards will be the best alternative to monitoring quality of care and service within the health care
facilities.
Activity: How will you monitor the access to care and continuity of care to judge the outcome of
the service(s) provided by your District hospital based on the following indicator:
1. Does the patient have access to the types of care and settings required for preventive,
curative and rehabilitative services?
2. Does the patients are referred or transferred based on their needs and the organisation’s
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capacity to provide the care required meeting their identified needs?

3. Do the patients and families receive information about the organisation, available services
and proposed care at the time of entry?
Audit
Audit has been defined differently by authors and agencies, In the simplest way
the audit is the official examination and verification of accounts or dealings, it has
been further defined as an examination or review that establishes the extent to
which a condition, process or performance, conforms to predetermined standards
or criteria,
Assessment or review of any aspect of health care to determine its quality, The
audits may be carried out on the provision of care, compliance, community
response, completeness of records, etc.
Medical Audit
Evaluation of medical services in retrospect through analysis of medical records.
The systematic critical analysis of the quality of medical care, including the
procedures used for diagnosis and treatment, to help to provide reassurance that
the best quality of service is being achieve, having regard to the available
resources.
Background
The history of medical audit dates back to the Florence nightingale, during the
Crimean war (1853-1855) she carried out the quality assurance checks in
hospitals of Scutari, where the war affected civilians and wounded soldiers were
being treated, ,
Ernest Codman (1869-1940) was a pioneer in the monitormg surgical outcomes,
He carried out many such procedures of monitoring health care during his lifetime.
However, the medical audit was slow to catch on, In the la.5t few decades, it has
become a regular exercise for the hospitals in developed countries. In USA and
Canada, Joint commission on accreditation of hospitals (JCAH) has been
established. Each hospital to have an ongoing medical audit for satisfactory level
of health care. This is also becoming a common practice in India, where you might
be reading in newspapers that a particular hospitals has been accredited by joint
monitoring commission. It is the time when medical tourism is catching on,
medical audit is soon to become a regular practice in India.
Types of Audit
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The types of audit may depend upon the objective with which audit is being
carried out. It has been variously classified.
1. On the basis of what is being assessed:
• Structure audit:
Quality of care assessment through study of structure.
• Process audit:Evaluates what provider does for patient and whether it
conforms to the standards.
• Outcom e audit:What happened to patient in terms of palliation, cure,
rehabilitation or death.
2. On the basis of auditing agency:
External audit:When audit is carried out by the agencies outside the institution.
Internal audit:Sometimes, for bringing the necessary changes, the hospital or
organization may go for internal audit. Usually these audits precede the external
audits.
conceptual framework quality assurance/medical audit

STRUCTURE - Organizational objectives
- Organizational structure
Physical facilities - Personnel
- Budget
- Materials
- Drugs and supplies.
PROCESSS - Procedures
- Flow of activities
- Effective utilization of human and material resources.
OUTCOME - Cured
- Improved
- Referred
- Consumer satisfaction
- Cost.
Audit Cycle
The audit is an orderly process and follows a few a steps to complete the process. A
typical audit process has following steps:
1. Identify the problem or issue: The first step in audit cycle is to identify the areas
where problems have been encountered. This is followed by identification of potential
where scope for improvement exists. These are usually high cost, and high risk areas.
2. Define standards and criteria:
A criterion is "a measurable outcome of care, aspect of practice or capacity".
A standard is "the threshold of the expected compliance for each criterion".
For example, gross death rate, anesthesia death rate, postoperative death rate,
hospital infection rate, recurrence rate, caesarean section rate.
3. Agreement on standards: These criteria should be agreed upon by entire medical
staff before hand. So, if a particular practice is upto the mark in the criteria. It is fine or
it need improvement.
4. Observe current practice: These current practices can be directly observed and
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the supportive documentary data may be collected from medical records department.
5. Compare performance with criteria and standards: If standards are met; that is
what we desire for. If these are not than look for the possible reason, whether these
are acceptable or not. If not acceptable; suggest changes for improvement.
6. Implement change
7. Re-audit: After sometime to check whether echanges have been implemented or
nof. The impact of the changes implemented.
Uses of audit in health care

1. Educational value for participants: The participants learn the correct practices
from the auditor during the audit cycle.
2. Improvement/change: The ultimate aim of the process is the improvement in
health services.
3. Reassure consumers: An accreditation from an reputed agencies on the quality
of health services of a hospital reassures the patients.
4. Cost effectiveness: The audit process increases the efficiency and cut the patient
cost. The health services become more cost effective.
Methods for Medical Audit

A. Case Study to Conduct Medical Audit
The study was conducted in two phases.
a. Retrospective Study (Audit Group), and

b. Prospective Study (Re-audit Group).
B. Statistical Method
The following are some of the data used:
c. Average length of stay

d. Bed occupancy rate
e. Bed turnover rate
f. Gross and net death rates
g. Infection rate, and complication rate
h. Consultation rate
i. Percentage of disagreement between initial and final diagnosis etc.
C. Mortality Review a.k.a. audit of death cases in the hospital

D. Indirect Method - comprises evaluation of appraisal factors involved in hospital
administration.
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E. On-spot Medical Audit - medical audit team goes to a particular ward and carries out
audit when patient is still in ward and treating medical team is available.
Example: based on one of the pioneering post-graduate M.D. thesis work titled "Medical Audit and
Patient Care in a Hospital". It was carried out in a large teaching hospital in Delhi in the year 1976-77.
Done by Dr Aggarwal
Appendix
Criteria for
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The Retrospective Study of Typhoid Fever
Basic Data
MRD No. Date of Admission Physician
Name Date of Discharge Discharged Alive - Yes/No
Age Length of Stay For Deaths
Sex Result Autopsy OR No Autopsy
I. Indication for Admission Yes No Nil/Not Applicable
┌─────┐ ┌─────┐ ┌──────┐
1. Presence of Proved └─────┘ └─────┘ └──────┘
Fever
2. At the Time of Admission Diagnosis was,
Established ┌─────┐ ┌─────┐ ┌─────┐
└─────┘ └─────┘ └─────┘
Suspected ┌─────┐ ┌─────┐ ┌─────┐
└─────┘ └─────┘ └─────┘
II. Diagnosis Agreement Yes No Nil/N.A.
1. Provisional with ┌─────┐ ┌─────┐ ┌─────┐
Final └─────┘ └─────┘ └─────┘

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2. Final with ┌─────┐ ┌─────┐ ┌─────┐
Bacteriological └─────┘ └─────┘ └─────┘
3. Any Associated ┌─────┐ ┌─────┐ ┌─────┐
Diagnosis └─────┘ └─────┘ └─────┘
If yes, specify -
III. Services Recommended for Yes No Nil/N.A.
Optimal Care
a. History, specific reference was made to,
1. Type of Temperature ┌────┐Continuous
at Onset └────┘
┌────┐Remittent
└────┘
┌────┐Intermittent
└────┘
2. Association with ┌────┐ ┌────┐ ┌────┐
Rigours and Chills └────┘ └────┘ └────┘
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3. Toxaemia ┌────┐ ┌────┐ ┌────┐
└────┘ └────┘ └────┘
4. Appearance of Rose ┌────┐ ┌────┐ ┌────┐
Spots └────┘ └────┘ └────┘
5. Cough & Epistaxis ┌────┐ ┌────┐ ┌────┐
└────┘ └────┘ └────┘
6. Bowel State ┌────┐ ┌────┐ ┌────┐
└────┘ └────┘ └────┘
7. H/O Previous ┌────┐ ┌────┐ ┌────┐
Episodes (Relapse) └────┘ └────┘ └────┘
8. A Typical Symptoms, ┌────┐Vomiting ┌────┐ ┌────┐
└────┘ └────┘ └────┘
┌────┐Others
└────┘
9. H/D Inoculation with TAB ┌────┐ ┌────┐ ┌────┐
└────┘ └────┘ └────┘
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10. Behavioural Pattern ┌────┐ Normal ┌────┐ ┌────┐
└────┘ └────┘ └────┘
┌────┐Abnormal ┌────┐ ┌─────┐
└────┘ └────┘ └─────┘
b. Physical Examinations YES NO NIL/N.A.
1. General Condition ┌────┐ ┌────┐ ┌────┐
└────┘ └────┘ └────┘
2. Comparison of Pulse ┌────┐ Bradycardia ┌────┐

└────┘ └────┘
┌────┐
Rate with Temp. ┌────┐ Tachycardia └────┘

└────┘
3. Per Abdominal ┌────┐Enlargement ┌────┐ ┌────┐
Examination └────┘of Spleen └────┘ └────┘
┌────┐Abdominal
└────┘Distension
┌────┐Tender Rt
└────┘Iliaec fossa
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4. Chest Auscultation ┌────┐ ┌────┐ ┌────┐
└────┘ └────┘ └────┘
5. Character of Stools ┌────┐Constipated ┌────┐ ┌────┐
└────┘ └────┘ └────┘
┌────┐ Pea Soup (loose)
└────┘
6. Mental State ┌────┐ Alert ┌────┐ ┌────┐
└────┘ └────┘ └────┘
┌────┐Delerious
└────┘
┌────┐Unconscious
└────┘
7. Symptoms of P.C.F. ┌────┐ ┌────┐ ┌────┐
└────┘ └────┘ └────┘
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8. Appearance of tongue ┌────┐ ┌────┐ ┌────┐
└────┘ └────┘ └────┘
9. Malaena ┌────┐ ┌────┐ ┌────┐
└────┘ └────┘ └────┘
c. Progress Notes ┌────┐Adequate ┌────┐ ┌────┐
└────┘ └────┘ └────┘
┌────┐Indequate
└────┘
d. Consultation with other ┌────┐ ┌────┐ ┌────┐
Clinicians └────┘ └────┘ └────┘
Consultation Notes Recorded ┌────┐ ┌────┐ ┌────┐
└────┘ └────┘ └────┘
Compliance to Consultations ┌────┐ ┌────┐ ┌────┐
└────┘ └────┘ └────┘
e. Nursing Services ┌────┐ P.T.R.Charts ┌────┐┌────┐
└────┘ └────┘└────┘
┌────┐ Intake/Output Charts
└────┘
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┌────┐Barrier Nursing
└────┘Technique
Specify if nursing services inadequate.
f. Laboratory tests, Done Not Done Day of
Investigation
1. Blood Culture ┌────┐ ┌────┐ ┌────┐
└────┘ └────┘ └────┘
2. Complete Blood ┌────┐ ┌────┐ ┌────┐
Picture └────┘ └────┘ └────┘
3. Urine Analysis ┌────┐ ┌────┐ ┌────┐
└────┘ └────┘ └────┘
4. Widal Reaction ┌────┐ Shows fourfold ┌────┐ ┌────┐
└────┘ rise of titre └────┘ └────┘
┌────┐Positive in 1/400
└────┘titre
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┌────┐Not repeated/Negative
└────┘
5. Peripheral Blood Smear ┌────┐ ┌────┐ ┌────┐
└────┘ └────┘ └────┘
6. X-ray Chest ┌────┐ ┌────┐ ┌────┐
└────┘ └────┘ └────┘
7. Stool Culture ┌────┐ ┌────┐ ┌────┐
└────┘ └────┘ └────┘
8. Policy up Laboratory ┌────┐ ┌────┐ ┌────┐
Studies └────┘ └────┘ └────┘
g. Complications Yes No Nil/N.A.
1. Were there any ┌────┐Malena ┌────┐ ┌────┐
Complications? └────┘ └────┘ └────┘
┌────┐Dnoophalophy
└────┘
┌────┐Perforation
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└────┘
2. Any super-added ┌────┐ ┌────┐ ┌────┐
Infection? └────┘ └────┘ └────┘
3. Were Cortico Steriodes ┌────┐ ┌────┐ ┌────┐
Indicated? └────┘ └────┘ └────┘
If yes, specify -
h. Mortality ┌────┐ ┌────┐ ┌────┐
└────┘ └────┘ └────┘
If died, specify the cause
i. Discharge Criteria Yes No
1. Afebrile for four days ┌────┐ ┌────┐
└────┘ └────┘
2. Free of all Symptoms ┌────┐ ┌────┐
and Complications └────┘ └────┘
3. Ambulant ┌────┐ ┌────┐
└────┘ └────┘
4. Carrier free Status ┌────┐ Widal vi ┌────┐
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Established └────┘ └────┘
┌────┐Stool culture
└────┘(repeated on 4-8 times)
5. Were health authorities ┌────┐ ┌────┐ ┌────┐
informed at the time of └────┘ └────┘ └────┘
discharging carriers?
6. Copy of discharge slip ┌────┐ ┌────┐ ┌────┐
attached to the records └────┘ └────┘ └────┘
j. Treatment ┌────┐ Chloramphenicol ┌────┐B complex
(Antibiotics) └────┘ └────┘
┌────┐Ampicillin ┌────┐ Cortico
└────┘ └────┘Steroides
┌────┐Furoxone ┌────┐Septran
└────┘ └────┘(Trimethoprim
and methoxazole)
Dose and Duration ┌────┐ Adequate
└────┘
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┌────┐Inadequate
└────┘
IV. Evaluation
Admission was (check one) ┌────┐Appropriate ┌────┐Inappro-
└────┘ └────┘priate
For appropriate Admission only:
Length of Stay ┌────┐Appropriate ┌────┐Inappropriate
└────┘ └────┘
┌────┐If,understay ┌────┐If, overstay ┌────┐
└────┘ └────┘ └────┘
┌────┐How many days ┌────┐How many days
└────┘ └────┘
Hospital Services were (check two)
┌────┐Adequate Inadequate ┌────┐
└────┘ └────┘
Specify
Other comments:
MULTIPLE CHOICE QUESTION

1. Medical Audit is :
(a) Prelude to taki ng pun itive a ction (b) Es sen tial fo r legal action against doctors
(c) Educational m eas ure (d) Statu ary r equis ite fo r 500 a nd abo ve bedded h ospi tals
2. The outcome criter ia which ma y be utilised fo r med ical aud it are all
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except :
(a) D eath rate (b) Infec tion rate ( c) Readmi ssion rate (d) Al l are c orrect
3. The structural criteria whi ch may be util ised for Medical Audit i s/are:
(a) Job d escript ion of employed p erso nnel (b) Capac ity utilisa tion of equip ment
(c) Inventory analysis procedures ( d) Pa tient satisfa ction
4. The process criteria which may be util isd for med ical aud it in cludes
all e xcept: (a) Nu rsing a udit ( b) Death review (c) X- ray rev iew (d) Infection
rate
5. A hospita l efficiency and effectiveness can be measu red b y all of t he
indica tors ex cept: (a) S tructura l criteria ( b) Pro cess criteria (c) Outcome criteria (d)
Architect's bri ef
6. Bed complement includes t he fol lowing exc ept:
(a) Beds in wa rds (b) Incubator s (c) Cots 'for newborn (d ) Bass inets for pr emature babies
7. The formula used for ca lculating ALS include a ll except:
(a) C ummula tive n umber of bed days of al l discharged p atients including th ose dying
in hospi tal dur ing one year divi ded by the n umber of di scharged and d ead p atients.
(b) Total numb er of bed day s in th e year divided by the number of admis sion in th e
same year . (c) To tal numb er of bed da ys in the year divid ed by the numb er of
discharges and d eaths in th e sa me yea r.
(d) Total number of bed da ys i n the y ear divid ed bysum of admi ssions and d ischarges
in the sa me year .'
8.________________________________________________________________A post
operative death is defined as percentage of death occur ing with in days of
operation in relation to to tal operations dur ing that period:
(a) 1 d ay ( b) 2 da ys (c) 5 days (d) 10 d ays
9. Neonatal death rate is defined as percentage of deaths of neonate in relat ion
to:
(a) Total viabl e newborn s discharged includi ng deaths (b ) Total viable newborns
discharge d excludin g death s (c) Tot al viable and non- viabl e newbo rns (d) Depends on
the exis ting neonatal facilities i n th e hospital
10. The average dail y census in a hospital is calculated
at: (a) 0600 hrs (b) 1200 h rs. (c) 1800 hr s (d) 2 359 hrs.
11. While calculating bed complement of a hospital which of the following is
considered a s hospital bed:
(a) Bassi net in nur sery for sick babies (b) Ob servation bed in Ca sualty Department (c)
Beds in r ecove ry room (d ) Bed s in pr e-an aesthe sia room
12. Bed utilisa tion indices are all, except:
(a) A LS (b) B ed turn ove r rate ( c) Post oper ative death r ate (d) Turn ove r interva l
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MARK THE FOLLOWING AS TRUE OR FALSE administration

of a naes thesia
1. Medical A udit is define d as the eva luati on of me dical care i n is co nsidered
retros pect thr ough analysis of c linical recor ds. . for calculation
2. In calculation of the admission r ate readmi ssions of the sa me of death rat e.
perso n for a different pat hologica l condi tion are co unt ed
separate ly
3. In calculation of the Average Le ngth of S tay (ALS) the bed
days of the patients in th e year previous to the one u nder
considera tion are ta ken into accoun t but the be d days of
patients who are s till in the hospital at th e en d of th e year a re
disrega rded
4. Turnover i nterval expresses an average time a bed rema ins
empt y between ad missio n of o ne patient and disc har ge of the
previ ous one.
5. Norma l hea lthy new born b abies s hould n ot be co unt ed as
inpatient ad missio ns but b abies requiri ng spec ial ca re
should b e included in the admissions.
6. Death of a n admitt ed p atient, transfer of patient t o another
institut ion or re lease of pa tient agai nst medical advise are
also co nsidere d as d ischarges.
7. Dea th in the ' cas ualty depa rtment, OP D or in an ambulance )
before the ac tual a dmissio n are not coun ted as hosp ital deaths.
8. Average dai ly ce nsus i nclude new born b abies:
9. Net dea th rate is dea th occurr ing af ter 24 hours of admission .
10. A revive d cardiac a rres t case eve n if he dies af ter 5 days of
Hint: only 8,9,10 are false.
125
11.
12.
FILL IN THE BLANKS

1) Hospital admission rate is calculated by the formula _____.
2) Bed occupancy ratio is calculated by the formula________ .
3) Bed population index is calculated by the formula________ .
4) The average length of stay is calculated by the formula
________.
5) The bed occupancy rate is calculated by the formula ________ .
6) Turnover interval is calculated by ________ .
7) The death rate is given by the formula ________ .
8) The anaesthetic death rate is given by the formula________ .
9) The normal anaesthetic death rate is one in________ .
10) An anaesthesia death is defined as death occuring within __
hours of administration of anaesthesia due to causes related to
anaesthesia.
Hint:
1 Annual
admissions x 1000
Population
2 Average daily number of beds occupied x 1000
Mean population for the same year
3 Number of beds available x 1000
Mean population
4 Total number of bed days
Total number of admissions
5 Average number of beds occupied
Number of beds provided
6 Bed complement x 365 - Hospitalization days
Discharges + Deaths
7 Total number of deaths x 100
Total discharges including deaths
8 Number of Anaesthesia related deaths x 100
Total number of patients who
received anaesthesia 9 5000
1024
MATCH THE FOLLOWING
1. Net d eath rat e a. 4-5 %

2. Caessarian Sec tion rate b. 15-20
3. Autopsy ra te %
c. 0.25 %
4. Rate of normal tiss ue removal d. 0.02 %
5. Neonatal death rate e. 10-12
6. Materna l dea th rate % %
f. 2-4
7. Anaes thetic dea th ra te g. 1-2 %
Hints:
1f 2 a 3b 4 e 5 g 6c
7d
Quality Assurance
1. conformance to requ irements. Assessment of the level of existing performance a ids in :

(a) Quality Co ntrol ( b) Qua lity Ass urance (c) TQM ( d) All are co rrect
2. Quality is the degree of excellence and standards. Activity bridging the gap between
observed and expected quality is:
(a) Q uality co ntrol (b) Quality As surance (c) Medical Audit (d) CQI
3. Which of the following is likel y to yield the best outcome :
(a) Q uality Ass urance (b) Quality Control (c) Medical Audit (d) CQI
4. The follow ing are the structural criter ia of professio~al quality indicators in hospitals
except: (a) Examin ation (b) t echnology (c ) Manp ower a llocation (d) Proto cols fo r admission
5. The following are the process and outcome c riteria for assessing quality of care in a
hospital e xcept :
(a) Patien t satisfaction· (b) Ad mission poli cy (c) Prot ocols of admi ssion and di scharge (d)
Tec hnology
6. All are classified as patient care 'processes in a hospital except:
(a) Medical audit (b) N ursing audit (c) Death re view (d) P atient satisfact ion
7. The key properties of health care that constitute quality care:
(a) Effectiveness (b) Effic iency(c) Opt imality, acceptabilit y and equity (d) All are correct
8. Which ISO is applicable to health serv ices:
(a) 9001 (b) 9002 (c) 9003 ( d) 9004
9. Quality circles have been u tilised to e nhan ce morale of emplo yees, redu ce co sts and to
provide quality medical ca re to pa tients. A qualit y circle normall y consists of :
(a) 1- 5 m ember s (b) 8 -10 m embers (c ) 25 - 50 members (d) 100-500 mem bers
10. Quality Circle m emb ers are gene rally:
(a) Doing similar work (b) B elong to the Fi nance Deptt. (c) Are from di fferent organisatio ns
(d) Belong to same workers union
11. The proce ss of exa mining the qu ality and adequac y of the factors and facilitie s
contributing to war ds patie nt care is:
(a) Process evalua tion ( b) Outcome evaluation (c) S tructu ral evaluation (d) Medica l Audit
12. Deg ree of adherance to pre-established norm or criteria is termed as :
(a) Standard (b) Efficienc y (c) Effec tiveness ( d) Quality
13. A process used to d etermine t he number to be inspected from a produ ct to calculate
prob ability t hat th e organisationa l quality stand ards are be ing met is termed as :
(a) Quali ty contr ol (b) Materia ls re quirements planning (c) Ma terials re quirements contro l
(d) Statistical qual ity control
14. Cos t dev oted to prevent non qualit y is called :
(a) Price of non-conformance (b) Price of conforman ce (c) Price of awar eness (d) Price of
ignorance
15. Cost produced by non -quality i s called:
(a) Pric e of o bsolescence (b) Price o f careless ness (c) Price of confo rmance
(d) Priceof n on-con forman ce
16. All are tr ue about Con tinuou s Qual ity Improvement (CQI) except:
(a) It is achie ved b y understan ding, mee ting, and exceedin g th e needs of the custome rs
(b) Involves sys tematic man ageria l approa ch in an organi sation based on co ntinuous
impr ovement in op erati on, proc ess es and func tions (c) It is of ten used interchangeabl y
with total quality management (d) JCAHO had advocate d th at quality assuran ce and quality
control con cepts are feasible in health care sec tor ra ther than CQI
MATCH THE FOLLOWING
A. Match the f ollowing crite ria with their r espective pr ocesses:

1. Proc ess a. Selection of techn ology
2. Structur e b. Medical Audit
3. Outcom e c. Patient satisf action
B. Ma tch the foll owing terms with the ir respective ra tios :
4. Effecti veness a. Ratio of actual o r
expected
impro vements in h ealth t o the cost of care respon sible for these improv ements .
5. Efficiency b. Degree to which the c are
proposed
or r eceive d h as a chieve d t he greate st improv ement in he alth now po ssibl e.
6. Opti mality c. Rat io of th e effect s of care
on health or of th e finan cial b enefits of th ese eff ects to the cost of car e.
C. Match the following with the i 15. ISO9003
proc esses :
7. Bottom d own approa ch
8. Bottom up appro ach Quality Circles a. Qualit y in H ealth S ervices

b. Quality Circles
9. Joint Comm issio n on Accre ditation c. Zero defects pro gramme .
of Health C are O rgani zat ion(JCAHCO ) d. TQM
10. ISO 900 4
D. Match the following ISO with theira. Mod el f or qualit y ass urance i n
produ ction and in stall ation
characteristics : b. Mode l for qualit y assurance in
design/ developm ent
11. ISO 84 02 c. Guidelin es for auditin g q uality
assuran ce
12. ISO 9000 d. Qu ality sys tem voc abula ry
e. Qu ality sys tem - guidelines for
13. ISO 9001 sel ecti on and us e of standards on
qualit y sy stems
14. ISO 9002
E. Match the following ISO wit h the ir corresponding ISI:
16. ISO 9000 a. ISI4004
17. ISO 9001 b. ISI400 3
18. ISO 9002 c. ISI 4002
19. ISO 900 3 d. ISI4001
20. ISO 9004 e. ISI 4000
Hints:
A 1 :b,2:a,3: c,
B 4: b,5·: a, 6:c,
C 7: c, 8:b,9:d,10:a ,
E. 11 :d,1 2:e,13:a,14:b ,15:c
F. 16 :e,17: d,18 :c, 19:b,20 :a
Management strategies to manage SC, PHC, CHC and DH

Institutionalizing Hospital Management Society/ (Rogi Kalyan Samiti)
With growing population and advancement in the medical technology and

increasing expectation of people for quality health care, it has now become
Rationale: imperative to establish a system to render desired services. In the rural areas
the secondary level care is provided through CHCs with specialist services of
physicians, pediatricians, O & G Specialists & surgeons being made available.
However, these services have not been fully achieved due to paucity of
resources, lack of accountability and non-involvement of community.
Upgradation of CHCs to Indian Public Health Standards is a major strategic
intervention under NRHM, the purpose of which is to provide sustainable quality
care with accountability and people’s participation along with total transparency.
However, there is a general apprehension that this may not be possible unless
a system is evolved for ensuring a level of permanency and sustainability. This
requires development of a proper management structure which is called as
‘Rogi Kalyan Samiti’( Health Management Society) as in other states which has
high feasibility and is being replicated in Orissa.
Rogi Kalyan Samiti is a simple, yet effective management structure, which is a

registered society, acting as a group of trustees for CHC/ hospitals/ to manage
the affairs of the hospitals. It consists of members from local P.R.I., NGOs, local
elected representatives and officials from Government Sector, who are
responsible for proper functioning and management of hospitals/ CHCs/ FRUs.
The RKS is free to prescribe, generate and use the funds placed with it, as per
its best judgment for smooth functioning and maintaining the quality of services.
In the State 90% of the institutions have been registered and fund utilization has
started. Many new innovations are taking place in health institutions through
these funds.
Sensitization of RKS members is also key to the smooth functioning of the RKS.
In this regard a sensitization of RKS is currently being undertaken through a
cascade model. District divided into five zones and key members have been
sensitized, who in turn shall orient & sensitize the RKS functionaries. Fund
requirement for the above is also being projected.
• Ensure compliance to minimal standard for facility and hospital care and
protocols of treatment as issued by the Government.
Objectives: • Ensure accountability of the public health providers to the community.
• Introduce transparency with regard to management of funds.
• Upgrade and modernize the health services provided by the hospital
and any associated outreach services.
• Supervise the implementation of National Health Programmes at the
Hospital and other institutions that may be placed under its
administrative jurisdiction.
• Organize outreach services/ health camps at facilities under the
jurisdiction of the hospital
• Display a Citizens’ Charter in the Health facility.
• Generate resources locally through donations, user fees and other
means
• Establish affiliations with private institutions to upgrade services
• Undertake construction and expansion in the hospital building
• Ensure optimal use of hospital land as per govt. guidelines
• Improve participation of the society in the running of the hospitals
• Ensure proper training for doctors and staff
• Ensure subsidized food, medicines and drinking water and cleanliness
to the patients and their attendants.
• Ensure proper use, timely maintenance and repair of hospital building
equipment and machinery.
• A number of RKS have developed an action plan and have also initiated
expenditure. To provide greater ownership and enhance responsibility
of the RKS the appointment and management of contractual paramedic
in the district is being provided to the RKS.
• Development of local specific Bye law & memorandum of Association.
• Constitution and organizing a meeting for members.
Strategy: • Registration of the RKS under Society Registration Act 1860.
• Opening of Bank Account.
• Orientation & Sensitization of RKS members.
• Development of institution specific annual Action plan

• Identifying the problems faced by the patients in CHC/ PHC.
• Acquiring equipment, furniture, ambulance (through purchase, donation,
Activities: rental, or any other means, including loans, from banks) for the hospital
• Expanding the hospital building, in consultation with and subject to any
Guidelines that may be laid down by the State Government.
• Making arrangements for the maintenance of hospital building (including
residential buildings), vehicles and equipment available with the
hospital.
• Improving boarding/ lodging arrangements for the patients and their
attendants
• Entering into partnership arrangement with the private sector (including
individuals) for the improvement of support services such as cleaning
services, laundry services, diagnostic facilities and ambulatory services.
• Developing/ leasing out vacant land in the premises of the hospital for
commercial purposes with a view to improve financial position of the
Society.
• Encouraging community participation in the maintenance and upkeep of
the hospitals
• Promoting measures for resources conservation through adoption of
wards by institutions and adopting sustainable and environmental
friendly measures for the day-to-day management of the hospitals e.g.
scientific hospitals waste disposal system, solar refrigeration systems,
water harvesting and water re-charging systems.

Health & Hospital Management

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HEALTH & HOSPITAL MANAGEMENT Collected By: Krishna

HEALTH & HOSPITAL MANAGEMENT

HUMAN RESOURCE MANAGEMENT

Motivation • Power point presentation

Inventory Management • Power point presentation

BUDGETING & ACCOUNTING

Accounting • Study of Ledger and Cash Book entry.

QUALITY ASSURANCE & MEDICAL AUDIT

SECTION - B HUMAN RESOURCE

SECTION - D BUDGETING &

SECTION - E MEDICAL RECORD

SECTION - F QUALITY ASSURANCE &

1-Introduction and Definition of Management

Management may be understood as an art (& science) on following counts:

1. The knowledge of management like other arts has practical application. It is

of using principles of management normally became more efficient. They develop

Management as a science bears the following characteristics:

1. Management is a systematic body of knowledge

So the management principles are universally applicable to all types of

Development of Management Thoughts

1. Classical or Traditional Management Approach

2. Behavioural or Neo- Classical Approach

3. Modern Approach to Management

Classical Organization Theory

Its two major purposes were to

(2) identify the basic functions of managing organizations.

The Behavioural Approach

The behavioural approach to management developed partly because practicing

The Human Relations Approach

The Systems Approach

The systems approach to management is essentially a way of thinking about

organizational parts; no single part of an organization exists and operates in isolation

The Four Parts of Open System Organization

Inputs Transformatio Outputs

and skills and technology

Information transforms inputs

Environmental Feedback serves as a Response to Products/ Services

Importantly, today most organizations must operate as open systems to

The Contingency Approach

The systems approach to management advocates that managers recognize that

The contingency approach attempts to bridge the extreme points on this

Very General Very Specific

Contingency Purely Situational

So, the multivariable analysis in contingency approach has proved that

What is Scientific Management?

(1) identifying the proposition;

2-Management Function &Techniques

If objectives of a Health programme in a state District or PHC are to be achieved,

Another way of classifying management function is in terms of (a) planning, (b)

According to Gulliksen a more traditional classification of management function is

The modern classification such as planning, implementing and controlling and

The management functions indicated below: -

Coordination: The manager has to inter-relate the various activities contributing to

Certainly a person who does above management functions is a manager.

1) To achieve an effective utilisation of human resources for the achievement

MANAGEMENT IN HEALTH CARE INSTITUTIONS

So, the relevance of management in health care institutions are as follows:

Planning Primary Health Service Programme