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Journal of the Academy of Hospital Administration

Evaluation of the "Exit Proformas" in use at Special Wards of a Public Sector Tertiary Care Hospital

Author(s): Aarti Verma* R.K.Sarma**

Vol. 12, No. 1 (2000-01 - 2000-06)

Keywords : Evaluation, Exit proformas, Special wards, Hospital

Health care scenario is fast changing all over the world. Economic, political, social, environ-mental, and cultural factors influence the peoples need for health care and the delivery of health service. Emphasis is placed on providing quality services at the lowest possible cost, leading to a variety of alternatives to hospital care. This change in health care scene presents both opportunity and challenge for the health care professionals and the administrators.

Consumerism is also affecting the health care sector. It can help authorities to advance from considering individual members of their public (patients) as passive clients or recipients of service - who get what they are given for which they must be thankful-to thinking of them as customers with legitimate rights and preference as well as responsibilities. Carr Hill1 has discussed the applicability of the consumer council guidelines in health care sector, though the principle of consumer rights are not always easily applied in the health care context.

Principle of redress, consumer access, and principle of value for money is vitiated in a publically financed service of course, principles developed in an attempt to control the savagery of the market of things in the private sector are not ipso facto inapplicable to regulating relations of service in the public sector. Indeed, the fundamental issues are very similar1.

Presently, with the phase of globalization in India, upcoming corporate hospitals in tertiary care have further compounded still competition in the delivery of health care in terms of patients's perception and satisfaction vis-a-vis the value for money. Further, the latest concept in customer delight has added a new dimension to health care industry. Also the Supreme Court verdict of bringing Government hospitals under the purview of Consumer Protection Act has further necessitated to consider the patient as a consumer.

Even though the raison d'etre of the doctors is to serve the needs and wishes of the patient and work towards the good of the patient, an understanding of patients's concerns and interests is central.

Satisfaction with care has already been established as an important influence determining whether a person seeks medical advice, complies with treatment and maintains a continuing relationship with a practitioner2. It has been seen that even when patients report high levels of satisfaction, studies have shown how the volume of comment was a more sensitive indicator. Human satisfaction is a complex concept that is related to a number of factors including life style, past experiences, future expectations and the value of both individual and society. Because satisfaction is a derived concept, it is important to find out the sources of dissatisfaction. In addition to different preferences about the hotel aspects of care, technical expertise of doctors, communication of information and mutural trust and barriers of communication between doctors and patients need to be studied.

Thus, in the present day context, evaluation of hospital services from patient's point of view is becoming increasingly important component of health care delivery. A public sector tertiary care hospital in Delhi metropolis has an ongoing system of eliciting patient's opinions on hospital service in special wards with the help of exit proformas which were designed and implemented 20 years back. Information generated from these proformas is sent to middle and senior level management, but is used/analysed only when there are complaints or deviations from normal working. It has become more or less a ritual instead of being a tool for improving operational efficiency. Therefore the present study was undertaken with an aim to evaluate the adequacy of "exit proforma in use".

Materials and Methods

A retrospective study to evaluate the 'in use' exit proforma for patients opinion and suggestions was carried out in special wards of a public sector tertiary care hospital in the metropolitan city. Already existing "Questionnaire" collected over the period of one year, were analysed.

100 filled questionnaires were randomly selected as the sample for analysis and evaluation. However, the employees of the hospital falling in the sample were excluded and the next in sequence questionnaire was included instead.

Date was entered in the file created in Dbase. Double data entry was done and for validation both Dbase files were converted into Epi Info. Errors found were cross-checked with actual data. Quantitative and Qualitative analysis was done in Epi Info and SPSS package.

However this study has following limitations:

1. Some of the patients who did not fill the form/questionnaire may have been the patients with adverse opinion-their views could not be included. Patient's generally refrain from making negative remarks on papers, may be, because of fear of repercussions.

2. The proforma did not have any information on socio demographic profile and health status of the patient. Thus patient's opinions could not be co-related with the background characteristics of the patient.

3. The number of patients included in the sample was not large enough to allow generalization to be made, due to constraints of time and effort.

Observation and Discussion

There are 65 special beds where the patient has to pay for his treatment. These beds are distributed in 5 floors, each floor having 12 beds.

There are two types of paying ward rooms:

  1. 'A' class or delux room - 5 in number
  2. 'B' class rooms - 55 in number

These rooms are centrally air conditioned. Each room has attached toilet with hot and cold water supply and is furnished with a patient bed, a couch for attendant, table, chairs etc. 'A' class rooms have two beds, attached dressing room, toilet, a waiting room and a refrigerator. Each floor has a separate pantry, where the food (cooked in central kitchen) is warmed and chapatis, salads etc. are prepared fresh, and served in rooms. Water cooler is provided in each floor for drinking after near main entrance. Communication is through internal phone on each floor.

Data collected from 100 questionnaire of randomly selected patients from special wards for the period of one year was analysed and following observations were made :

On an average, 133.3 admissions were made in spcial (paying) wards/month in the year understudy3.

It was observed that out of the total of 100 patients maximum i.e. 20% admissions were made under Deptt. of Urology in special (paying) wards whereas total admission in urology were 7.9% (in Gen. and Spl. wards)4. It is interesting to note that Borodoloi, 1983 in his study in private wards, in the same hospital had similar observations i.e. 24.98% admissions in private wards were of Urology department5.

18 patients were admitted under Deptt. of Surgery, 12 in Gynae and Obs., 10 under Gastroenterology, 9 under Orthopaedics, 5 under Nephrology, 4 under Endocrinology, 4 under ENT, 3 under GIS, 2 under Paediatric Surgery, 1 each from Dental, Rehabiliation, Haematology and Paediatrics.

It was observed that maximum demand of special (paying) wards was by Urology department in this study sample. Differences in demand of special wards in Medicine, Surgery, Gynae and Obs., Orthopaedics etc. was not significant. However, demand from discipline like Paediatrics, Dermatology, ENT etc. was negligible in special wards. This observation is also consistent with the Bordoloi study. In depth study to understand the reasons for this pattern of utilization of special ward beds is required.

Table 1 : Comparison of % admission in special wards with total admission in the hospital year 1995-96

  Special Wards Total
Gastroenterology 10% 2.8%
Urology 20% 7.9%
Paediatrics 1% 12.9%

Length of Stay

Average length of stay in special wards was found to be more than that in general wards.

In this study sample, average length of stay in special wards was found to be 13.4 days.

Observations Mean S.D. Min. Max.
100 13.4 11.5 3 67

According to census report, ALS of the hospital is 7.8 days. In the last decade the ALS of hospital has come down from 10.2 to 7.8 whereas there is very marginal decrease in ALS in special wards i.e. 14.09 to 13.4 days in special wards.

Average length of stay in different specialities varied from 9.0 - 24.8 days (Table-II).

Deptt. of Orthopaedics had maximum ALS of 24.88 days. Average length of patients in Medicine is = 15.3 days, Surgery ALS = 12.1 days, Nephrology ALS = 12.4 days, Urology ALS = 9.5 days, Gynae and Obs. ALS=9.08 days, Gastroenterology ALS = 19.1 days.

Paediatric Surgery, Endocrinology, ENT, Dental, GIS, Physical Med. and Rehabiliation, Haematology and Paediatrics were merged into one category - "other departments", as the number of patients from these departments in the study sample were small. Average length of stay in "other departments" was found to be 11.33 days.

On comparing the ALS of study sample with the records of yearly census bulletin of Medical Records for the year, it was observed that all the departments except Urology and Surgery had a longer average length of stay in special wards (Table-II). Chistie (1973) studied ALS of patients admitted in private wards of the public sector hospitals. He had also observed that the patient's average length of stay was higher in paying wards than the patients admitted in general wards. There is a definite need to investigate the reasons for longer stay in special wards/paying wards as compared to general wards6.

Table - II Comparison of ALS between study sample from special wards with the hospital census report

Department ALS in Study Sample
(Spl. Ward)
ALS of the Census Report of
Hospital (Spl. + General)
Surgery 12.11 11.2
Medicine 15.3 11.9
Obs. and Gynae 9.08 6.5
Urology 9.50 10.6
Gastroenterology 19.1 9.0
Orthopaedics 24.88 12.4
Nephrology 12.4 7.4
Others 11.38 7.7
(PS, Endo, ENT, Dental, GIS, Rehab. Haematology, Paediatrics)    


Though ALS was observed to be more in special ward patients in most of the disciplines, disparity was seen only of the patients admitted under urology.

Satisfaction with various aspects of Hospital Services in Special Wards

Patients views about various aspects of hospital services in special wards as elicited by the proforma were analysed. Overall, a very high level of satisfaction was observed with the various aspects of hospital services. All 100% patients were satisfied with the services of Consultants, Nurses and Physiotherapists (Table - III). Some dissatisfaction was observed with the Quality of Food (19.8%), supplies in private ward rooms (17%), Radiology Services (12%), Patient's were generally satisfied with "Comfort" and "Cleanliness of the room", "Nursing Orderlies", "Sweepers", "Laboratory Services" and "Radiology Services".

Table - III Percentage of patients satisfied with various aspects of hospital services in special wards

  Percentage Satisfied
Admission Procedure 95.0%
Cleanliness of rooms 94.0%
Room Comfort 95.0%
Supplies 83.0%
Services of consultants 100.0%
Services of nursing staff 100.0%
Services of Dietician 95.8%
Services of Ward bearer 98.9%
Services of N. Orderlies 96.0%
Services of Sweepers 96.9%
Services of Physiotherapist 95.0%
Radiography services 88.0%
Lab Services 97.0%
Quality of food 80.2%

Generally, it was observed that patients' who were satisfied with the hospital services stayed longer than the dissatisfied patients (Table-IV), except in case of "supplies" and "nursing orderlies" where duration of stay did not affect the satisfaction level. Reverse was observed in case of "sweepers" and "quality of food". Patients dissatisfied with these services stayed for longer period in the hospital.

Table - IV Percentage of patients satisfied with various aspects of hospital services in special wards

Aspects of Hospital Services Mean duration of stay S.D. Min. Max.
Admission Procedure :
Satisfied 13.6 11.6 3 67
Dissatisfied 9.2 6.83 4 21
Cleanliness of Room :
Satisfied 13.6 11.7 3 67
Dissatisfied 7.3 2.25 4 11
Room Comfort :
Satisfied 13.27 11.2 3 67
Dissatisfied 8.2 5.06 4 17
Supplies :
Satisfied 13.1 11.7 3 67
Dissatisfied 14.2 10.4 4 37
Consultants :        
Satisfied 13.4 11.5 3 67
Dissatisfied 4 4 4 4
Nurses :        
Satisfied 13.3 11.5 3 67
Dissatisfied 4 4 4 4
Dietician :        
Satisfied 13.7 11.7 3 67
Dissatisfied 11.5 5.7 4 16
Nursing Orderlies :        
Satisfied 13.3 9.7 5 24
Dissatisfied 13.3 11.6 3 67
Sweepers :        
Satisfied 12.9 10.3 3 60
Dissatisfied 28.6 33.2 8 67
X-rays :        
Satisfied 14.1 12.0 3 67
Dissatisfied 10.9 8.8 3 33
Laboratory Services :        
Satisfied 13.6 11.7 3 67
Dissatisfied 11.3 10.4 3 23
Food :        
Satisfied 12.8 10.1 3 60
Dissatisfied 17.7 16.5 4 67

Despite the high satisfaction level expressed by the patients there were many suggestions given by the patients to improve the services in paying wards.

Out of the total of 100 patients, 49 patients did not make any suggestions. Most of these patients belonged to Gynae and Obs., Surgery, Urology, Orthopaedics.

12% patients had suggested improvements for quality of food. Patients admitted in Nephrology and Gynae and Obs. Departments had maximum suggestions for food quality. 11% patients made suggestions for improvement in Engineering maintenance department of hospital. Other suggestions like increase in nursing manpower, priority investigations for special ward patients, ISD/STD facilities, intimation of expenditure estimate before admission, increased no. of cash counters at Central Admission Office, more no. of visits by doctors etc. were recommended.

Surgical departments patients had minimum complaints. Studies elsewhere have also reported higher satisfaction of patients in surgical department.


There is a need to modify the present proforma to include the data on socio-demographic profile, perceptions of needs and how far consumers expect services to meet these needs, and also health status during hospitalization. Patient satisfaction survey should be administered routinely during the year. This will establish baseline data that will allow managers to focus on specific patient care issues. An effort should be made to generate information/feedback that begins with pre-admission activities and moves through the spectrum of patient care upto and including discharge planning.

Also in addition to structured closed ended questionnaire it will be useful to ask the patient to elaborate or give comments. More indepth studies are required to examine the bed utilisation pattern in special wards.


  1. Ray A Carr Hill, The measurement of patients satisfaction Journal of Public Health Medicine ; 14(3) : 236-49.
  2. Larson DE, Rootman I. Physician role performance and patient satisfaction. Social Science Medicine 1976; 10: 29-32.
  3. Yearly Hospital Reports.
  4. Bardoloi M. K. : Study of utilisation of private ward beds at All India Institute of Medical Sciences Hospital, MHA Thesis , August, 1983.
  5. Chestie K.M. : Study of Factors affecting the Average length of stay of patients in the private wards block at All India Institute of Medical Sciences, New Delhi, MHA Thesis, 1973.
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