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Indian Journal of Community Medicine

Streamlining Working of a Hospital Immunization Clinic - A PiIot Study

Author(s): S. Goel, S. R. Lenka, Shailainder, A. Singh

Vol. 31, No. 4 (2006-10 - 2006-12)

S. Goel(1), S. R. Lenka(1), Shailainder(2), A. Singh(1)


Amongst the interventions for child survival tried across the world, the childhood immunization has been claimed to be the most appropriate and effective technology. Immunization is in fact one of the ‘best buys’ in public health. Significant progress has been made in increasing the coverage levels of various vaccines in India1. However, the satisfactory qualitative improvement is yet to be obtained.

The resident doctors of our department posted at a 50-bedded hospital in north India observed that, the immunization clinic invited a lot of rush on weekly immunization days. The scene in the immunization room was usually chaotic and noisy. It was often overcrowded with attendants and beneficiaries. No queuing system existed. Client provider interaction was observed to be grossly unsatisfactory with hardly any time for IEC activity by the health worker. So, it was felt that an attempt should be made to streamline the immunization services at the immunization clinic of the hospital by adopting simple operational strategies. The prime objective of the present study was to observe the impact of these basic interventions on the quality of service of the immunization clinic

Material and Methods

This was a short term operational research (Before/After) pilot study conducted at Immunization Clinic in a 50 bedded Hospital of North India and its adjoining community over a period of 15 days i.e. between 9.9.04 and 23.9.04. The observations made on Sept. 9, 2004 (which was the weekly routine immunization day at clinic) were analyzed and discussed in a health worker (HW)/Junior Resident (JR)/Senior Resident (SR)/Faculty meeting. Based on this, strategies to improve the functioning of immunization services were formulated. These were implemented from the subsequent immunization services. Consent of Senior Medical Officer (SMO) Incharge, female health worker and clients was taken. All data was kept confidential. Study was conducted without hindering routine immunization services.

Collection of Data

The following methodology was adopted for data collection:

  1. Observation of quality of immunization services at health facility using observation checklist.
  2. Exit Interviews of few randomly selected attendants a self-developed satisfaction scale questionnaire.
  3. A house-to-house survey to enlist infants in Ward 7 and 8 of the study area (the area adopted by our department for home based health care delivery). They interviewed their parents regarding the quality of immunization services availed in recent past at the immunization clinic.
  4. Female HW providing the immunization services was also interviewed before and after the intervention.


Structural changes

The furniture of immunization room was reorganized for maximizing the utilization of the available space. Initially, the two tables were placed in series, joined together with both health workers sharing these for registration, recording and vaccine administration. All the clients used to enter the room without restriction and crowd near the tables for receiving the immunization services. We segregated those tables and set them apart perpendicularly to each other with adequate gap in between. One table was put at the entrance manned by one health worker, who apart from restricting the entry of crowd did the registration and made relevant entries in the cards/registers. The other table was placed inside the room near cold chain equipments (ILRs and Deep freezers). This table was used for vaccine administration only. In addition, a bench was placed inside the room away from tables along the facing wall. This was meant to be used by the attendants waiting for their turn.

Functional/process changes

Queuing of attendants was duly enforced. Entry of people inside the immunization room was restricted to a maximum of five beneficiaries at a time. Flow of clients was also regularized. First, they were asked to report at registration table. After the entries were complete, they moved on to the immunization table. Based on the observations pertaining to health worker’s function, skill-based training was also provided to her. Windows of immunization room were opened for cross ventilation. An additional round of floor mopping was also introduced in mid session to ensure cleanliness.


A total of 55 and 53 children between ages of 0-5 years were immunized on Sept. 9th and 16th respectively between 9.00 AM to 1 PM. This was similar to the range of 42-55 during previous five immunization days at same clinic.

The items pertaining to quality of immunization services that showed significant changes after intervention are shown in Table I.

Table I – Results obtained through Observation Checklist before and after intervention

Variable Before
No. of Patients / attendants
(mid session)
Inside Immunization room 37 10
Outside Immunization room 0 22
Queuing none yes
Greeting of clients by FHW none yes
Baby holding technique Incorrect Correct
Injection technique Incorrect Correct
Rubbing of injection area
by attendants
Yes No
Post immunization instructions No/inadequate Yes
Advice regarding next visits No Yes
Family planning advice Not provided Provided
Record keeping
Registers Fair Good
Immunization cards Incomplete Complete
Syringe Disposal Improper Proper
Space utilization Improper Proper
Overcrowding Present
(9 ft2/head)
(36 ft2/head)
Room cleanliness Untidy (syringes littered) Tidy
Mopping floor/session Once Twice
Cross ventilation Inadequate Adequate
Supervision No Yes
Vaccine status
VVM for OPV Stage I ( 8-9 vials
in Stage III)
Stage I
FIFO & FEFO* rule
regarding vaccines
Not maintained Maintained
*FIFO and FEFO*-First In First Out and First Expiry, First Out

There was a definite improvement in overall satisfaction level, of attendants (Table –II). Imparting of knowledge to beneficiaries by HW was significantly increased after intervention. According to the attendants, overcrowding was reduced and general cleanliness improved after intervention.

Table II-Scoring* for quality of immunization services based on exit and house to house interviews of clients

Variables Exit Interviews (n=21) House to
1. Complications in past 2 2 2
2. Behavior of FHW 1 1 2
3. Knowledge provision 1 2 1
4. Supply 2 2 2
5. Overcrowding 1 2 1
6. General cleanliness 1 2 2
7. Discipline/punctuality 2 2 2
8. Overall satisfaction 1 2 1
*Criteria for scoring (0-poor, 1-fair, 2-good)
  1. Complication is the past 0-Bleeding / extravasations / ulceration (excl. normal BCG reaction)/neurological, 1 -Prolonged high fever / excessive crying, 2 – No problem / mild fever.
  2. Behavior of female health Worker (FHW) 0 – Rude,1-Good / professional, 2 – Very good / friendly
  3. Knowledge provision 0 -Nil, 1 -Only about next due date of immunization, 2-Type of vaccines, next date, family planning and complication.
  4. Supply 0 -More than one type of vaccines not available on immunization day,1 -1 type of vaccine / syringes not available on immunization day, 2 -Vaccines, syringes and drugs supply always adequate on immunization day.
  5. Overcrowding 0 -Chaos, jostling and excessive prolongation of immunizations sessions, 1-No queuing and prolongation of immunization session, 2-Queuing and immunization in orderly fashion without undue delay.
  6. General Cleanliness0 -Disorderly,1 – Better at the end and beginning, 2-Maintained throughout the session
  7. Discipline/punctuality of F.H.W 0-F.H.W not in seat most of the time during the session. Delayed start of session, 1 -Frequent interruption of immunization session due to non-availability, 2 –F.H.W present throughout the immunization session. Timely start of session
  8. Satisfaction 0-Not satisfied, needs lots of improvement,1-Satisfied, needs some improvement, 2-Very satisfied.


Health and quality of life outcomes are the end results of the structure and processes of care.

We addressed both structural and process changes, which revealed that the outcome was favorable as reflected by client satisfaction. Streamlining the client flow has been a major cause of concern of hospital authorities. The great traffic load of the clients is generated due to non-selection or filtration of attendants7. Often, poor client flow causes long waits that discourage patients from seeking services.

Clinics can improve the client flow through better planning and resource allocation8-11. Diaz et al also observed that queuing and improving client flow i.e. how clients move through the clinic can avoid bottlenecks that cause delays and reduce the quality of care8. Our study also reveals that the client flow inside the immunization room was a major hurdle in delivering optimum quality of services. It was revealed in this study that the time available with health worker for knowledge provision to attendants of beneficiaries increased significantly after the intervention. Health worker could find more time for health education when the client flow system inside the immunization room was streamlined.

It was observed that there was overlapping of two activity units within the immunization room i.e. registration and immunization. It was resolved by separating the two tables. In this manner, the health worker of their respective activity unit did her job at separate stations. It was observed in a study that the separation of two activity units increases the work efficiency5. Sequencing of two jobs i.e. order of performing jobs in series, optimizes some measure of effectiveness, thus increasing the performance of the system, such as total elapsed time or overall cost, etc5.

An additional dimension of care is the satisfaction of clients who require care3. Outcomes of care provision include not only control and prevention of medical conditions but also satisfaction of client with the care provision and quality of life the client enjoys. Very few studies have been conducted in the past to evaluate client satisfaction levels regarding immunization services, quality of client-provider interaction and patient flow12,13.

In the present study, it was found that excessive work load on health worker, overcrowding, improper space utilization, poor client flow, inadequate cleanliness and ventilation of immunization clinic, insufficient health education provision and minor flaws in immunization techniques, were the main factors compromising the quality of immunization services by the health workers.


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(1.) Deptt. of Community Medicine,
(2.) Advanced Paediatric centre, PGIMER, Chandigarh, India
Received : 19.04.05

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