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Journal of the Academy of Hospital Administration

Operation Room Utilization at AIIMS, a Prospective Study

Author(s): Reena Kumar*, R.K. Sarma**

Vol. 15, No. 1 (2003-01 - 2003-06)

Keywords: Operation Theatre Utilization, elective resource hours, operating time.

Key Messages:

* There is marked difference in utilization of operation theatres between the perception of surgical consultants and reality.

* Non-availability of anaesthetic service after 14.30 hrs., improper utilisation of time between two surgeries and late starting of OTs are important areas needing attention of Hospital Administrator's to improve utilization.

* There is an imperative need to expand OT timings, especially in view of long waiting lists.

Abstract

Operation room utilisation analysis is essential to assess the existing workload as well as to optimise facility functioning and patient scheduling for surgical operations. It also aids in allocating reserve time for emergency operations, asepsis measures and procedures, and provides decision making information for augmentation or downsizing of the facility. The operation time utilisation varies in different healthcare settings. Optimum utilization of the OT time has always been a priority area for hospital administrator's.

A study was carried out at a tertiary care hospital with objective of assessment of utilisation of OTs and identification of bottlenecks, if any for optimum utilisation. The study revealed that the utilisation though satisfactory could be further maximised by increasing the operational timing of OT, functioning two shifts of 08 hours each and performing minor procedures in minor OTs of the OPD. The study identified the main bottlenecks as the non availability of the Operating Room Manual and non adherance to OT timings.

Introduction

The surgical suite typically consumes 9-10% of the hospital budget2. Surgical suites once needed only 20% utilization to produce a positive bottom line. However, economics of the OR environment have changed dramatically in the past 25 years. Technological advances like minimally invasive surgery which need costly equipment, payments based on diagnosis related groups, captivated payment and discounted fee-for service have all significantly reduced margins in the surgical business. It is therefore, not surprising that this area is earmarked by many hospitals as a place to reduce expenses. All of us who work in the OR must be cost efficient and must maximize productivity for long-term success. Achieving these goals requires reliable data to help various stakeholders, chief executive officer, chief financial officer, nurses, surgeons and anesthetists-all have to align what sometimes appear as disparate goals. We need to examine traditional OR management practices. Traditional utilization measurements that look only at the time patients are in the OR reward surgeons for occupying OR's but do not address cost efficiency or productivity. One measure of how well an OR functions is the "utilization".

OR utilization is defined by Donham and colleagues as the quotient of hours of OR time actually used during elective resource hours and the total number of elective resource hours available for use3 Optimum utilization of the OT time has always been a priority area for Hospital AdministratOR's. Baker had opined that accurate records, weekly analysis of recorded data, establishment of operating room rules and regulations and strict adherence to and enforcement of approved policies and procedures are essential ingredients for an efficient operating of an operating room. Thus it is clear that study of operating room records can provide means of assessment of the degree of utilization of operation theatres.

The present study was planned to analyze the OT utilization at the Main OT Complex at AIIMS.

Aims and Objectives:

The study had two objectives:

1. To examine the utilization of operation theatre in the Main Operation Theatre Complex of AIIMS in relation to work load.

2. To identify the bottle neck, if any, in proper and efficient utilization of Operation Theatre time and based on that, suggest remedial measures for improving the Operation Theatre Utilization.

Methodology

This study was carried out for a period of 3 months from August to October, 2001 at Main Operation Theatre Complex (MOTC) at AIIMS, New Delhi. The total bed complement of AIIMS hospital (excluding Neuro Science/CTVS/RPC/IRCH beds) is 866. The surgical beds utilizing Main OT is 271. No. of Operation Theatres in Main O.T. are 12, with surgical beds: Main OT ratio being 23.1. The toal no. of operations performed/year is 3,130.

In spite of a favourable OT: bed ratio, the waiting list of almost all the surgical disciplines is long thus resulting in dissatisfaction and resentment among patients as well as doctOR's and hence there is a need to make efforts to find a solution to this problem. The MOTC consists of 12 operation rooms of which OT 1 is for emergency cases and OT 12 for septic cases. Rests are twin operation rooms allocated to different surgical disciplines. A Pre Anaesthesia Room is attached to each O.R. where patient is wheeled in before surgery and I/V lines are set.

The scheduled elective theatre timings are 8.30 a.m. to 4.30 p.m. However the last case for operation under general anaesthesia is 2.30 p.m. At the end of operations performed under general anaesthesia, minor operations under local anesthesia continue to be performed till the list is completed. Major cases were defined by Owen as any surgical procedure done under general anesthesia, where as minor cases are those done under local anaesthesial. The proportion of work done by consultants and residents is variable and depends on the nature of scheduled cases. Each O.T. works 5 days a week through out the year except on public holidays.

Types of operations

Although all surgical units perform all kinds of general surgical procedures, there is discernible pattern in the case mix of the different units. This difference is dependent upon the training and inclination of the unit chief.

Conduct of the operations

Although the schedule for the day's work is made by surgeon's themselves, it is very common occurrence that the operations listed are either cancelled or postponed due to variety of reasons.

Flow Process of Activities of Operation Theatre

A biphasic approach was used in the study. In the first phase, the Medical Records Department and records of Main Operation Theatre were perused so as to obtain an overview of the workload of the Main O.T. and also the seasonal variations/fluctuations if any. The commonest problem of MOT staff, their timing and workload was studied. In second phase, observation regarding functioning of MOT, pattern of work as well as questionnaire for different categories of staff were devised. In last phase, the activities of the operating rooms were studied with a view to actually see the utilization, the workload and work content of personnel and to make recommendations if any.

Results

Although none of the residents felts that there is delay in start of Operation Theatre, yet majority of the consultants and 35% of the nurses felt that O.T.'s are starting late and commonest reason stated was delay in shifting of patients to O.T.'s from wards. Non availability of staff nurses/other staff or sterile supplies was an infrequent reason for delay in starting O.T.

Information sought on waiting list for surgeries showed that average waiting time for routine surgical procedures ranged from 6 months to 3 years for various benign disease and from few weeks to 3 months for malignant disease. In spite of long dates given, majority of dated patients do turn up on the appointed date except during festive season. Majority of residents and consultants felt that if additional inputs are given in minor O.T.'s (in the OPDs), main O.T. time can be utilized better. However, it would necessitate upgradation of the minor O.T.'s with respect to infrastructure, staffing and equipments.

Proposal regarding O.T.'s being run in two 8 hours shift elicited a favourable response, but they were apprehensive about their implementation, logistics, its impact on academic standards and the availability of the support services (ICU, labs, blood bank, CSSD/others) to handle the increased work load.

A total of 13,130 operative procedures were conducted in the Main OT during the year 2000-2001

Table 1

Sr. No. Year No. of Operating Rooms in MOT Operations performed in MOT Average Length of (ALS) Average Bed Occupancy Number of Nursing Staff
1. 1979-90 13 10,934 8.9 83% 71
2. 1996-97 13 12,438 6.2 83.6% 74
3. 1997-98 13 13,245 5.9 89.0% 73
4. 1998-99 13 12,457 6.4 83.3% 71
5. 1999-2000 13 12,801 5.7 83.6% 71
6. 2000-01 13 13,130 5.7 83.5% 73

Table 1 shows the increase in workload over the year, with average length of hospital stay decreased from 1989-90 to 2000-2001. It has reached a figure of 5-7 days (2000-2001) from 8-9 days (1989-90). Though the workload has tremendously increased, the operating room staff strength deployed is nearly the same

Table-2: Shows month wise utilization of Operation Theatre (July 2000-June 2001)

Months Major Operation Minor Operation Total Operation
July 2000 731 310 1041
August 2000 824 328 1152
September 2000 895 313 1208
October 2000 786 267 1053
November 2000 838 305 1143
December 2000 776 296 1072
January 2001 832 285 1117
February 2001 750 328 1078
March 2001 830 366 1196
April 2001 728 359 1,087
May 2001 746 317 1,063
June 2001 628 214 842
Total 9,364 3,688 13,052
Average cases/month 780 307 1,087

The Table 2 shows an average of 780 major cases/month and 307 minor cases/month which were performed. Thus an average of total 1,087 cases were performed/month at MOTC. Table 2 shows the monthly utilization of OT with two peaks of maximum utilization seen in August September, and March. It was observed that number of operations performed in MOTC decreased during the month of June, which is attributed to the fact that this month is the vacation time for the faculty of the AIIMS and only half the number of OTs are functional during the vacation.

In the prospective phase of the study, a questionnaire was designed to assess individual opinion of O.T. users ? Surgeons, Anaethetists and Nursing staff regarding resource, utilization pattern and workload. Analysis of this data gave the following findings:

Opinion regarding delay in start of OT and reasons for the delay gave the following responses (Table 3)

Table 3

Opinion regarding delay in start of OT and the reasons for the delay

OT functioning Consultant
(n=20)
Resident
(n=20)
Nurses
(n=20)
OT starts on time 3 (15%) 20 (100%) 7 (35%)
Delay is due to staff nurses 2 (10%) 0% Nil
Delay is due to other staff 12 (60%) 0% Nil
Delay is due to lack of sterile supplies 4 (20%) 0% Nil
Delay is in the readiness of other equipment 16 (80%) 0% Nil
Delay in shifting of patients 17 (85%) 0% Nil

Nil did not respond

Opinion sought regarding OT. Utilization showed that about 65% of the consultant and 60% of the residents considered that OTs are presently under utilized and significant time was wasted between two surgeries. It was thought that an interval of 10-15 minutes was an appropriate interval in between two surgeries.

The causes cited for not completing the OT list were varied. Surgeons felt that non-availability of Anesthetic services after 1,430 hours was a major reason, whereas anaesthetists felt that wrong or over scheduling of cases by surgeons was the prime cause. However, all the OT users agreed that non-availability of nursing orderlies for shifting the patients and sweepers for cleaning of Operation Room after completion of the surgery was the most annoying cause for delay between the cases and subsequent delay in completion of the list.

All the respondents agreed that no O.T. manual or guidelines exist in any department or the hospital and felt strongly the need for such a manual. Most of the respondents were not satisfied with the O.T.discipline in our hospital, which may be due to lack of defined guidelines. The suggestions made by the respondents for improving O.T. Utilization are as follows:-

  • First case should reach O.T. in time from the ward, to allow the O.T. to be started on time.
  • More trolleys are needed to shift the patients in and out of M.O.T. Complex.
  • The anaesthesia and other equipments must be made ready by the assisting staff so that the O.T. starts on time.
  • A proper work culture needs to be established in the OTs. Accountability should be fixed for any delay.
  • Need for availability of "Operating Room Manual" for ready referral was strongly felt. This manual should clearly mention the job description and responsibility of all the operating room personnel.
  • Discipline should be inculcated by organizing periodic in service training and workshops.

Operation Theatre Time Utilizations

Analysis of the data collected from various O.T.'s. with regard to O.T. utilization revealed that by and large all the O.T.s are adequately utilized as per the current working schedule. The overall O.T. Utilization % of M.O.T. Complex was 90.4%. The average O.T. case start time was 8.45 a.m., case end time was 3.55 p.m. and theatre closure time was 6.30 p.m. (Table 4)

Resource hours - total number of hours scheduled to be available for performance of procedures (i.e. the sum of all available block time and open time). Taking 5 days a week and 8 hours a day as theatre resource time, it was found that in O.T.-2, 3, 4, 5, 6, 9 and 10 resource hours were fully utilized. (7,12 to 7.47 hours). O.T.-7 was under utilized with utilization of 6.20 hours of resource time. O.T.-8, 8A and 11 were running beyond resource hours and are over utilized (utilization hours: 8.12 to 8.18 hours).

Room Clean up time - time from patient out of room to room clean-up finished and next case taken. The clean up time ranged from 5 minutes (when O.T. was not cleaned and next case was taken up immediately) as in O.T.-8A (ENT minor cases) and O.T.-11 (Ped. Surgery) to 26.6 minutes as in O.T.-2 where lengthy, HCV and HbsAg positive and complicated cases were usually taken up. O.T.-4,5 (General Surgery) and O.T.-7 (Urology) had clean up time of less than 10 minutes. The average clean up time of all OTs ranged between 10 to 15 minutes which is within the acceptable range Thus, it can be seen that not much time is wasted for cleaning the operation theatres.

Due to unrealistic scheduling and shortage of OT time it has been seen that nearly 26% of total cases posted in all the OTs are cancelled. Inaccurate prediction of the duration of surgical operations resulted in over utilization, under utilization and frustration for those involved in caring for patients coming to the OR. It was observed that each surgical service has a different use pattern for OR resources. Some surgical services work largely in allocated scheduled time and use very little out of scheduled time. Other surgical services regularly push in to after hours time starts, still others are in consistent in their pattern of utilization. It is:

Table 4: OT utilization pattern during the study period (in hours)

O.T. NO. 1and12 2 3 4 5 6 7 8 8A 9 10 11
Avg.Case Start time 0836 0846 0831 0832 0858 0838 0905 0839 0843 0830 0836 0854
Avg. case End time 1530 1510 1558 1544 1635 1510 1436 1605 1617 1554 1536 1627
O.T.Close Time 1735 1736 1729 1749 1829 1726 1732 1920 1930 1736 1725 1735

Avg. case Start time-wheeling in of Ist case.

Avg. case End time - wheeling out of last case.
OT Close time - closing of operation theatre after cleaning. Time at which the room should be empty and the assigned personnel free to be discharged.

The average resource hour was 0749 hours The clean up time ranged from 5 minutes to 26.6 minutes as in Table 5.

Tabel 5: Resource hours and clean up time in relation to different OTs.

O.T. NO. 1 and 12 2 3 4 5 6 7 8 8A 9 10 11
Resource Hours 0721 0734 0747 0712 0745 0735 0620 0812 0807 0737 0703 0818
Cleanup Time in mts. 21 26.6 13.3 4.2 7.9 12.9 8.9 16.7 11.2 11.25 11.4 27

The average number of major, minor and total cases done per day per O.T. in M.O.T. Complex were 3.0, 1.2 and 4.0 respectively (Table-6). Average major cases done is 26.9 as against 38.95 posted in all 12 OT's.

Table 6: Number of major, minor and total cases done per day per OT/day

O.T. NO. 1 and 12 2 3 4 5 6 7 8 8A 9 10 11
Major/day 1 1.5 2.3 2.1 2.3 2.7 3.7 2.8 0 2.4 3.6 2.5
Minor/day 0 .5 0.05 .25 .75 .4 1.7 1.4 8.5 0 0 0.5
Total/day 1 2 2.3 2.3 3.0 3.1 5.4 4.2 8.5 2.4 3.6 2.5

Major case - cases done under general anesthesia; Minor case - cases done without general anesthesia.

Table 7: Average number of major and minor cases posted and done/OT.

O.T. NO. 1 and 12 2 3 4 5 6 7 8 8A 9 10 11 Total
Major cases posted 1.25 2.5 3.3 3.5 4 4.4 5.3 4.1 0 3.8 3.8 3 38.95
Major cases done 1 1.5 2.3 2.1 2.3 2.7 3.7 2.8 0 2.4 3.6 2.5 26.9
Minor cases posted 0 .5 .5 .25 1.08 .4 2 1.6 10.6 0 0 .5 16.43
Minor cases done 0 .5 0.5 .25 .75 .4 1.7 1.4 8.5 0 0 .5 13.5
  • Major cases posted = 38.95
  • Major cases done =26.9
  • Minor cases posted = 16.43
  • Minor cases done = 13.5
  • % of major cases cancelled = 32%
  • % of total cases cancelled = 26%
  • % of minor cases cancelled = 17.8%

Average minor case done is 13.5 as against posted in all 12,078 is 16.43 32% of major cases and 17.8% of minor cases are cancelled.

important to treat service use over several time starts. Analyzing date in this manner may permit evaluation of how well services or surgeons use allocated time. This provides further information on which services or surgeons need more allocation of time and

Working pattern of MOTC/day

Average case start time 0845 Average major cases/day  3 cases/day
Average case end time 1555 Average minor cases 1.2 cases/day
Average OT close time 1773 Total cases 4.2 cases/day
Average resource hours 0740 Average OT utilization % 90.4%

which should have reduction in allocated time. The after hours evaluation gives an indication of how staffing should be allocated for evening and night shifts. Knowing which services is a heavy user in after hours may help set staffing pattern to concentrate appropriately to meet the demand.

However, keeping in view the increased workload there is need to devise methods to improve the O.T. utilization. This can be done by;

  • Increasing the O.T. time to 5.00 p.m.
  • Running O.T. in two shifts of 8.00 hours.
  • Performing all the minor procedures in minor O.T.'s attached to the OPD.

This would aid in completing the O.T. list every day and thereby reducing the waiting list.

Discussion

Due to rising health care costs, funding agencies are continuously striving to curtail costs incurred in the O.T.'s. while at the same time maintaining high standards of care. The developments have made "most effective and efficient utilization" of the available operating time an absolute necessity in every hospital4 Out of 866 beds of AIIMS Main Hospital, Surgical disciplines (excluding Orghopaedics) utilized 271 beds. With 12 OTs available at MOTC, the surgical beds to OT ratio is 23:1. This ratio corresponds to that recommended in literature (by COPP, 1964).5 A total number of 13,130 operations were performed in 2000-01 in MOTC as compared to 10,934 in 1989-90. During this period the average bed occupancy, number of surgical beds and number of operating rooms have remained more or less the same. However, average length of hospital stay has decreased from 8.9 days to 5.7 days thus enabling more number of operations to be performed. The shortened hospital stay has been made possible by introduction of laparoscopic surgery. The other factOR's which may be contributing to the reduction of the length of stay are introduction of newer antibiotics, improved OT methods, improved hospital infection control techniques and other measures like managerial review of medical records.

Cancellations

Inefficient scheduling of operation theatre time often results in delay or cancellation of surgical procedures. This increases the cost of patient care in the hospital and also results in monetary loss to the patient as he/she is away from work. Cancellation also results in psychological trauma to patients, as they have to undergo the preoperative mental and clinical preparation again.

Lacqua and Evans prospectively reviewed 1,068 elective cases that resulted in 184 (17%) cancellations6.They concluded that cancellation of cases could be decreased by improved preoperative patient evaluation, improved communication between the physician and the patient and a modified schedule design.

Brewer evaluated the utilization of operation theatres in an academic 2,000 bed hospital and found a cancellation rate of 8%7. K. Vinukondaiah, et al in their study found, a total of 310 (14.9%) cases cancelled during one year period lack of operating time was the single most important factor for cancellations of cases. This was mainly because surgeons took longer than the estimated duration of srugery8.

Dexter opined that improving efficiency of the OR can be achieved by making every OR large enough and flexible enough to accommodate all types of surgical procedures. Large OR's that are able to handle all surgical services add substantial flexibility to the scheduling of cases9.

Another way to increase efficiency is to have variable-length shift to handle he nonstandardized routine of a typical OR suite. "Longest cases first" results in the highest utilization rate, lowest amount of overtime, and largest number of delayed cases being transferred to another room to be done in the most timely fashion.

In our study, due to unrealistic scheduling and due to shortage of OT time, nearly 26% of the total cases posted in all the OTs were cancelled. The single most important cause for the cancellation was found to be "time factor" due to restriction of general anaesthesia time. In a report of National Audit office, the cancellation rate for surgical lists was found to be about 23%5. As this hospital is a teaching hospital and operations were done by surgeons with different levels of experience, the time take for a procedure varied, making it difficult to predict the duration of surgery.

Late Start

Late starts and unutilized time between cases is an area where improvement is possible. This is especially true of starting on time. Although none of the residents felt so, majority of the consultants and 35% of nurses felt that OTs are starting late and the commonest reason stated was delay in shifting of patients to OTs from wards. Delay in readiness of other equipment was also an important reason mentioned. Attention of this problem would increase the utilization of available operating time. Non availability of staff nurse/other staff or sterile supplies was an infrequent reason for delay in starting OT. Undue delay between cases did not account for any wastage of operating time. Healthcare Benchmarks reported average turnover times of 21 minutes for main OR's and 15 minutes for ambulatory OR's6.

Waiting list for surgery

Information sought on waiting list for surgeries showed that average waiting time for routine surgical procedures ranged from 6 months to 3 years for various benign disease and from few weeks to 3 months for malignant disease. In spite of long dates given, majority of dated patients do turn up on the appointed date except during festive season. Majority of residents and consultants felt that if additional inputs are given in minor O.T.'s (in the OPD's), main O.T. time can be utilized better. However, it would necessitate upgradation of the minor O.T.'s. with respect to infrastructure, staffing and equipments.

Proposal regarding running OT's in two 8 hours shift

Proposal regarding O.T.'s being run in two 8 hours shift elicited a favourable response, but they were apprehensive about their implementation, logistics, its impact on academic standards and the availability of the support services (ICU, labs, blood bank, CSSD/others) to handle the increased work

Operating Time

The operating time at this hospital vis-a-vis other centers in India and abroad is restricted. Also, the number of public holidays decreases the period of availability of the operating room. The cut off anesthesia time is 2.30 p.m. The causes cited for not completing "OT list" were varied. Surgeons felt that non availability of anesthetic services after 1,430 hours was major reason, whereas anesthetist felt that wrong or over scheduling of cases by the surgeons was the prime cause. However, all the OT users agreed that non availability of nursing orderlies for shifting the patients and sweepers for cleaning of OR after completion of the surgery was most annoying cause for delay between cases and subsequent delay in completion of list.

The available time per day was only 6 to 7 hours, which is unduly short. This is related to the shortage of anaesthesia and operation room staff as well as scheduling of postgraduate teaching programme in the afternoon. The actual operation time during the period was mean of 740 hours./day amounting to 90.4% of the total available operating time. In a report a study of Vinukondaiah et al showed a mean of 10 hours 31 minutes of operating time/day, amounting to 91.5% of the total available operating time8.

In a report by Narian et al, the total operating time found to be 82.5% of the total available time10 According to the National Audit Office study, only 50% to 60% of the total time was utilizeed in performing surgery11. Our figure are better than this average.

A measure of productivity of OT would be an analysis of the level of utilization in relation to a consistent period of activity. The manner in which OT functions is usually deducted by the customs established in individual hospital OT. Therefore, utilization analysis would need to be tailored accordingly (O' Donneal, 1976).

Policy on Anaesthesia

As a policy, general anaesthesia was also administered on the main operating table. Considering that induction of and recovery from anaesthesia are as important as the surgery itself, the time utilized for this should not be considered as wasted. However, this time could have been gained for performing operations if the induction/recovery from anaesthesia had been performed in the anaesthesia room. This should be weighed against the need for two qualified anesthetists to alternate between cases and proper monitoring equipment being available in the anaesthesia induction/recovery room.

Conclusion

Thus it can be summarized that even with certain existing lacunae and constraints, the OT utilization of MOTC is optimum as per the literature. However, in spite of optimum utilization MOTC, there exists long waiting lists in every surgical discipline leading to dissatisfaction and discontentment among patients as well as doctOR's. Even with the existing bed strength and number of OTs, one way of solving this problem is running the OTs in two shifts or increasing the OT time. This would mean extra manpower, supplies and costs. Restructuring the reorganization of O.T. personnel should be done so that adequate number of staff are available in each shift. It also needs to be ensured that this step would not in any way downgrade the academic standards in the undergraduate and postgraduate teaching which is of prime importance. This system can be tried on experimental basis for a short period to test its feasibility. National Health Services Management Board has pointed out that full utilization of operation theaters would involve the recruitment of considerable numbers of staff, the provision of substantial numbers of extra beds as well as a substantial amount of extra funding12.

References

  1. OR Manager May 1996, 12:9-10.
  2. MaCaulay, HMC and Davies LL. Hospital planning and Administration. WHO 1966.
  3. Donham RT, Mazzei WJ, Jones RL. Procedural times glossary. Am Anesthesiol 1996:23 (suppl):5.
  4. Breslawski S and Hamilton D: Operating room scheduling. Choosing the best system, AORN J 53 (5): 1229-1237, 1991.
  5. Committee on Plan Projects (COPP, 1964).
  6. Kaiser share ambulatory surgery benchmarks. Health Care Benchmarks 1998;Jan:5-6.
  7. Lacqua MJ, Evans JT. Cancelled elective surgery - An evaluation. Am Surg 1994;60:809-11.
  8. K. Vinukkondaiah, N. Ananthakrishanan, et al. Audit of operation theatre utilization in gernal surgery NMJI 2000.13:3-118-121.
  9. Dexter F, Macario A, Traub RD. Which Algorithm for scheduling Add-on Elective Cases maximizes Operating Room Utilization- Anesthesiology 1999 91(15): 1491-500.
  10. Narain P, TackleyR, Lee M, Clyne CAC. A computer audit of the use of theatre time by a surgical team. Surgical Audit 1998.13:3-118-121.
  11. National Audit Office. Use of operating theatres in the National Health Service. London: HMSO, 1987 (Report 143).
  12. National Centre for Health Statistics. Health, United States, 1999 with health and aging chartbook (DHSS Publication No. PHS99-1232). Hyattsville, MD: National Centre for Health Statistics, 1999.

* Senior Resident, Deptt. of Hospital Administration, AIIMS, New Delhi
** Prof. and Head, Deptt. of Hospital Administration, AIIMS, New Delhi

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