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Journal of the Academy of Hospital Administration


Author(s): S. Bedi, S.D. Behera, S.K. Arya, S. Singh

Vol. 18, No. 1 (2006-01 - 2006-12)

Key Words: Quality Systems, Standards, SPOs, Quality Initiative


The need for quality system evaluation in hospitals is well established. However lack of basic standards including standard operating procedure (SOPs) for hospitals makes this a difficult job. SOPs have been found to be of immense use in proper working, training of personnel and favourable outcomes. Thus SOPs are an essential pre-requisite for any Quality initiative. With this aim a study was conducted in two hospitals in the NCR of Delhi, with regard to status of knowledge and practice of Standard Operating Procedures was used to suggest guidelines/measures for writing Standard Operating Procedures for hospitals. A pre-tested semistructured questionnaire was administered to randomly selected sample of physicians and nurses in two hospitals (n = 175). The study has revealed that there is general awareness of the concept of SOPs, but written SOPs are available in very few instances. The study also shows that commonest method of learning how to perform procedures in the workplace is by verbal instructions by seniors, which very often leads to variations. There is a felt need among healthcare workers for SOPs in their workplace, which are drafted by end users by consensus. However, SOPs should be customised to suit existing practises in different healthcare institutions.


The need to adopt quality measures and have it validated by quality evaluation systems is now well established. Studies show that these have significant potential to enable provider organizations to improve quality without increasing costs1. However the absence of healthcare standards, both structural and process, in our country makes this a difficult task. A fledgling effort in terms of structural standards may be present, albeit arbitary and not evidence based or comparable to international standards, which in the absence of process quality would not facilitate the achievement of the desired favourable outcomes.


As per Donabedian, standards are professionally developed expressions of the range of acceptable variations of a norm or criterion2.

Standard Operating Procedures

A SOP is a written set of instructions that someone should follow to complete a job safely, with no adverse effect on personal health or the environment, and in a way that maximizes operational and production efficiency3.

Need for writing SOPs(3)

  1. To serve as a training document for teaching users about the process for which the SOP was written.
  2. To provide people with all the safety, health, environment and operational information necessary to perform a job properly.
  3. SOPs act as Clinical Guidelines.
  4. SOPs and CQI in Healthcare-The key concepts in CQI4 i.e. reduction in variation and improvement of processes has need for standards as a basic.
  5. SOPs specify job steps that help standardize services and therefore quality.

Barriers to SOPs

Despite the widespread development and awareness of need of guidelines in the developed countries, there are certain barriers to their adoption like physicians not aware of their existence, contents or may not agree with these5.

Pre-requisites to creating SOPs

Commitment of top management coupled with will and knowledge to develop SOPs and belief in the usefulness of SOPs are essential pre-requisite for creating SOPs6.

Standards should be set for all services and are of two types-general standards and specific standards7. General standards set the level of service and objectives Specific standards deal with specific issues such as infection control practices in laundry or safety in radiology or OT cleaning measures and are based on specific criteria, which are discrete and measurable. Although who will set these standards and will these be uniform for all healthcare institutions remains to be seen. In any case SOPs are the first step towards quality evaluation-whether for accreditation, certification or grading.

SOP is therefore an important document in terms of quality measures and evaluation and it would be deemed proper to know where we stand in terms of SOP writing and adoption in our health care institutions. In view of the foregoing it was decided to conduct a survey of hospitals to find out the status of SOPs in these hospitals and use this study to suggest guidelines for writing SOPs.


To conduct a study in two hospitals in the NCR of Delhi, with regard to status of knowledge and practice of Standard Operating Procedures and to use this study to suggest guidelines/measures for writing Standard Operating Procedures for hospitals.


The study was conducted in two hospitals in the NCR of Delhi. One hospital was a secondary level care hospital and the other was a tertiary level care hospital. The sample consisted of physicians and nursing staff from various specialities of both hospitals. Randomly selected sample of physicians and nurses (n = 175) of these hospitals were chosen for the study. Selected subjects were interviewed with the help of a semi-structured pretested questionnaire to elicit information about the status of SOPs in their respective hospitals. Respondents were assured of confidentiality of identity and consent was taken from them. The response rate was 88%.


The observations are tabulated as under.


Questions Doctors Nurses
1. Awareness of SOP
  • Yes 50% 87.5% 46.15% 88.4%
  • No 22.7% 12.5% 15.2% 7.6%
  • Faint idea 27.7% 0% 38.4% 3.8%
2. Presence of any manual with instructions regarding how to perform your job in your department?
  • Yes 13.6% 12.5% 7.6% 57.6%
  • No 86.3% 87.5% 92.3% 42.3%
3. If yes, were you given a copy of this to read when you joined work in this department?
  • Yes 9.0% 0% 7,6% 50%
  • No 91% 100% 92.3% 50%
4. Have you read this manual completely?
  • Yes 9% 0% 0% 50%
  • No 91% 100% 100% 50%
5. If you have not read the manual or if none was given to you, then how did you learn to perform the tasks of your present job?
  (a) Training was given 13.6% 6.25% 7.6% 7.6%
  (b) Verbal instructions given by
27.2% 81.2% 46.10% 57.60%
  (c) Learnt on-the-job by own self 54.5% 0% 0% 27%
  (d) Verbal Instructions + self learnt 0% 12.5% 15.3% 7.6%
  (e) Combination of training verbal
instructions & self learnt
4.5% 0% 30.7% 0%
6. Is there a manual of how to perform any other job in your department for jobs other than that of yours?
  • Yes 0% 12.5% 0% 26.9%
  • No 100% 87.5% 100% 69.2%
7. Is there a written down procedure for patient flow processes in your department?
  • Yes 0% 6.25% 7.6% 23.07%
  • No 100% 93.7% 92.3% 76.90%
8. Is there a written down protocol of clinical care pathway for diseases in your department?
  • Yes 13.6% 12.5% 15.3% 23.07%
  • No 81.8% 87.5% 84.6% 76.90%
9. Do you think such a manual is necessary or appropriate to help you to perform your job successfully?
  • Yes 77.2% 100% 100% 100%
  • No 18.1% 0% 0% 0%

Study shows that awareness regarding SOPs is high in the tertiary hospital among both clinicians and nursing staff, whereas in Secondary Hospital, 50% of the doctors and nurses (approx) are aware. A majority of doctors in both hospitals informed that there are no written guidelines in their workplace. In cases where these are available, very few were provided with a copy of guidelines, and to none in Tertiary care hospital. Those who got the copy reported that they read these completely.

Awareness of SOPs

Nurses (87%) in the Secondary Hospital informed that there are no written guidelines in their workplace. On the other hand, in the Tertiary Care Hospital, 58% of the nurses reported that their hospital has written guidelines for certain procedures in some of the areas. This was confirmed by checking with chief of nursing in the hospital.

However only 50% of those who work in the area where these are available, were actually given a copy of the same and thus only they had read these and were aware of the same.

As regards the procedure (where there are no guidelines), questionnaire was intended to elicit information as to how the respondents learnt to perform the procedures. This question had three choicestraining, verbal instructions from seniors and learnt by self on-the-job. The respondents responded by marking either a single choice or by a combination of choices. It is seen that doctors as well as nurses learn the procedure by a mix of training, verbal instructions from seniors and on their own. In the secondary hospital, doctors (55%) learnt on their own, whereas in tertiary hospital 81% reported to have learnt by verbal instructions from their seniors and on their own by observing their peers and seniors (12.5%).

Nurses in the secondary hospital have learnt by verbal instructions from seniors (46%) and by a combination of all three (30%). In the Tertiary Hospital, majority of the nurses have learnt by verbal instructions by seniors (58%), followed by self learnt (27%). In both hospitals, there are no formal training programmes either for doctors or nurses. (The respondents, who had chosen training as their response in the above question when asked, clarified that they were referring to training during the course of their nursing/medical education.)

Regarding the existence and practice of patient flow processes and clinical care pathways in the hospitals, doctors in the secondary hospital informed that there are no written down procedures for patient flow process in the hospital, but there are some written down protocols for clinical care in the hospital (13.6%). Scenario in the Tertiary Hospital is also not very different. Here only 6% of doctors reported that there are written down procedure for patient flow processes and 12.5% reported about presence of written down protocols for clinical care pathways in the hospital.

Very few nurses in the secondary hospital reported that written down procedures for patient flow processes (7.6%) and written down protocol for clinical care pathways (15.3%) were available. In the tertiary Hospital, the scenario is better and 23% nurses reported that written down procedures for both patient flow processes and clinical care pathways are in existence in their hospital.

Almost all doctors and nurses in both hospitals are in agreement that such guidelines are necessary. There were two open ended questions to elicit information regarding

  • Who should make such SOPs
  • Manner in which such SOPs should be written to ensure that these are easily understood and followed.

The clinicians have suggested that SOPs should be:

  • Clear-cut, concise, simple, in an easy language and in the form of algorithms
  • Different for different categories of personnel in the language they can read.
  • Practical as per limitations
  • Can be enforced on ground
  • All concerned should be given a personal copy
  • Should include safety hazards
  • Should be regularly updated.
  • Should take into account all possible exigencies.
  • Should delineate responsibility of all concerned in the process.

The nurses have suggested that SOPs should be:

  • Clear, simple, flexible, brief and easy to understand.
  • More necessary in administration than in clinical side
  • Should be made department wise, disease specific and as per hospital policy
  • Should be demonstrated & regularly updated
  • Copies should be given to all concerned

Majority of clinicians felt that SOPs should be drafted by the department head with input from the users. Some suggested that committees of experts different specialities, from a group of hospitals should write such SOPs for this group of hospitals.

The majority of nurses feel that the senior most nurse/ senior nurses, nursing educators and hospital administration are the right people for this job. Significantly, most respondents (both doctors as well as nurses) have opined that Hospital Administration should be an integral part of team involved in writing SOPs.


The study shows that healthcare workers in hospitals are by and large aware of the concept of SOPs. Written guidelines are available in very few instances and here, either the staff is not provided a copy or all those who get a copy do not read these. This clearly shows that the concept is not practised despite widespread awareness. Available literature on the subject shows that lack of awareness that a guideline exists and lack of familiarity with the details of the guideline are the topmost barriers to SOPs5. Hospital administrators will have to make a note of this and find ways and means to eliminate barriers to adoption of SOPs if these are to be successfully implemented.

Analysis of data shows that the commonest method of learning how to perform procedures in the workplace is by verbal instructions by seniors. Such a practice is not devoid of variation as instruction may vary from instructor to instructor. This is therefore, not conducive to delivery of uniform and predictable quality of healthcare4.

There is a felt need among healthcare workers for such guidelines in their workplace. Healthcare workers desire that these guidelines be simple, comprehensive and applicable. They opined that these should be drafted by the end users and consensus should be there. Both clinicians and nurses suggested that commitment of the leaders should be manifest. The heads of the departments and hospital administration should not only be involved in drafting but also in implementation of these guidelines.


The study suggests that there is a felt need to have SOPs in hospitals. The major bottleneck appears to be perceived lack of commitment by the top management. In this study, the respondents were aware of the benefits of SOPs, how should these be prepared, who should be involved in making and implementing these. This was in consonance with the available literature on the subject. The study suggests that manifest commitment by the top management is essential for the success of such an endeavour. If the healthcare workers are involved in right earnest, the job can be simplified. This will be a big leap in our quest for introducing quality systems and facilitate adoption of accreditation/grading systems in our hospitals.

It is also suggested that SOPs need to be tailormade for each hospital. However, more studies are required to workout generic and specific guidelines for writing SOPs and implementation thereof in different types of hospitals and other health care organisations in our country, since these may differ in scope and limitations.


  1. Wagner C. A Measuring System for Evaluation of Quality Systems, International Journal of Quality in Healthcare, 1999 ; Vol.-11: No. 2, pp 119-130
  2. Donabedian A. Exploration in Quality Assessment and Monitoring, Vol-2, The Criteria and Standards of Quality, Ann Arbor, Michigan, Health Administration Press 1982
  3. Kenneth F. Ten Reasons for Writing Standard Operating Procedures (SOPs) Department of Journalism and Communication, Lehigh University, Bethlehem, Pa, U.S
  4. Leider HL, Nash DB. Improving the Quality of Medical Care, Essentials of Medical Management, Edited by Wesley Curry, and Barbara Linney, American College of Physician Executives, 2003)
  5. Cabana M. and others. “Why Don’t Physicians Follow Clinical Practice Guidelines ? A Framework for Improvement.” JAMA, Oct. 1999; 282(15): 1458-65, Oct. 20, 1999.
  6. Heideman EG, The Contemporary Use of Standards in Healthcare, WHO Division of Strengthening of Health Service, District Health Systems, 1993.
  7. Whittaker S. et al. Status of a Healthcare Quality Review Programme in South Africa, International Journal of Quality in Healthcare, 2000, vol 12 No. 3; 247-250.

(1) S. Bedi is Chief Medical Officer ESIC, Noida
(2) S.D. Behera is Commanding Officer, 177 Military Hospital
(3) S.K. Arya is Associate Professor Dept of Hospital Administration, All India Institute of Medical Sciences, New Delhi
(4) S. Singh is Senior Resident, Dept of Hospital Administration, All India Institute of Medical Sciences, New Delhi

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