Family Health International – FHI 360
Assessment of Emergency Response Service (ERS) Performance in Madhya Pradesh
Under DFID Contract for Technical and Management Support to Implement the Madhya Pradesh Health Sector Reform Programme
FINAL REPORT
September 2013
DELOITTE TOUCHE TOHMATSU INDIA PVT. LTD.
TABLE OF CONTENTS
CHAPTER SECTION PAGE NO.
LIST OF ABBREVIATIONS 4
1 STUDY BACKGROUND 5
IMPLEMENTATION MODEL 2 11 SENSE – REACH – CARE
2.1 SENSE 13
2.2 REACH 19
2.3 CARE 29
3 SUPPORT FUNCTIONS 35
3.1 HUMAN RESOURCES 36
3.2 QUALITY 47
3.3 SUPPLY CHAIN MANAGEMENT 52
3.4 MARKETING 56
3.5 INFORMATION TECHNOLOGY 61
4 CONTRACTUAL AND INSTITUTIONAL FRAMEWORK 63
5 DEMAND SIDE ASSESSMENT 72
6 ANALYSIS OF COSTS 82
SUMMARY OF KEY OBSERVATIONS & 7 89 RECOMMENDATIONS
8 ANNEXURES 101
ANNEXURE LIST 8.1 Selection of Sample Villages 102 8.2 List of interviews conducted (village-wise) 116 8.3 Comparison of ambulances as per international norms 118 Roles and Responsibilities of key stakeholders involved in carrying out field 8.4 121 operations 8.5 Launch Details of Ambulances & Population coverage per district 122 8.6 Facility Feedback 124 8.7 Minimum qualifications and recruitment process for EMTs, Pilots and ERO 125 8.8 Assessment parameters and tool used for EMT assessment 126 8.9 List of consumables and equipment present in sample ambulances assessed 130 Comparison of cases handled by 108 and Janani Express Yojana (JEY) in 8.10 132 Sagar District 8.11 Financial data submitted by EMRI 133 Details of year wise parameters for costing ratios – no. of ambulances, 8.12 135 emergencies handled and KMs travelled
8.13 Year wise Costing Detail 136
List of Abbreviations ALS Advanced Life Support ANM Auxiliary Nurse Midwife AMC Annual Maintenance Contract ASHA Accredited Social Heath Activist AVLT Automatic Vehicle Location Tracking Systems BLS Basic Life Support CAPEX Capital Expenditure CFMS Customer Feedback Management System CME Continuing Medical Education CMHO Chief Medical Health Officer COO Chief Operating Officer DHS Directorate of Health Services EC Executive Committee EM Emergency EME Emergency Medical Executive EMLC Emergency Medical Learning Centre EMT Emergency Medical Technician ERC Emergency Response Centre ERCP Emergency Response Centre Physicians ERO Emergency Response Officer ERS Emergency Response Service FEFO First Expiry First Out FMS Feedback Management System FT Fleet Technicians GoMP Government of Madhya Pradesh GPS Global Positing System HIS Hospital Information System HR Human Resource IEC Information, Education and Communication IFT Ineffective Calls IT-IS Information Technology and Information System JSSK Janani- Shishu Suraksha Karyakram KAP Knowledge Attitude Practice MO Medical Officer MoU Memorandum of Understanding OLMD On-Line Medical Directions OPEX Operating Expenditure PCR Pre-Hospital Care Record PM Program Managers PPP Public-Private Partnership PRI Panchayat Raj Initiative QMS Quality Management System RM Regional Manager SCM Supply Chain Management TL Team Leader UA Unavailed Cases UAC Unattended Calls VB Vehicle Busy
CHAPTER 1
STUDY BACKGROUND
Assessment of ERS Performance in Madhya Pradesh Final Report
Background of the Scheme
1.1 The Government of Madhya Pradesh (GoMP) entered into a MoU with GVK EMRI, a not-for- profit organization, to provide integrated emergency response services (medical, police and fire) through a toll-free number - 108, across the State in a phased manner.
1.2 The services were launched in July 2009 and covered 10 districts with 102 Basic Life Support (BLS) ambulances till December 2012 – Bhopal, Gwalior, Jabalpur, Indore, Rewa, Sagar, Sehore, Damoh, Datia and Hoshangabad.
1.3 The 108 service was further extended to the other 40 districts in 2013 with 352 BLS ambulances. GVK EMRI and GoMP plan to launch another 100 BLS and 50 Advanced Life Support (ALS) ambulances in the state to increase the depth of service and ensure presence of at least 1 ALS ambulance per district to handle extremely critical cases.
Context
1.4 Given the context of 108 services in the state of Madhya Pradesh, GoMP sought an external evaluation of the current status of emergency management services being provided by EMRI to identify strengths and areas of improvement of the model. MPTAST, who was assigned the responsibility for this evaluation, contracted Deloitte to carry out the same.
Objectives and Scope of the study
1.5 The Scope of Work of the study is to: Assess the appropriateness and relevance of the management and implementation arrangement, such as MoU, roles and responsibilities, network hospital etc. Assess the quality of infrastructure, services and knowledge, attitude and practice (KAP) across the Sense – Reach – Care model. Evaluate the efficiency and effectiveness of model in terms of performance as well as costs involved in the ERS Assess user level satisfaction with respect to quality, timelines and effectiveness of the services being provided and unmet needs Assess the effectiveness of enroute basic lifesaving services provided by the ambulance staff Assess key issues and bottlenecks affecting efficiency and effectiveness of ERS Provide recommendations relating to aspects such as policy level changes, management and implementation arrangements and processes to improve staff KAP and scope for cost reduction and sustainability.
.
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Approach and Methodology
Approach 1.6 The approach adopted by the Deloitte team was aimed at ascertaining both user as well as supply aspects of the model as illustrated in the following exhibit -
Exhibit 1.1: Approach followed
1.7 On the supply side, while the focus was to assess systemic and structural issues through discussions with key staff from GoMP and GVK EMRI, the objective for demand side assessment was to ascertain responses from users, non-users, field level workers and influencers on parameters such as awareness, availability / timeliness (whether an ambulance was available and how long the service took), quality (what was the condition of the ambulance, preparedness of the staff) etc.
Methodology 1.8 An overview of the methodology followed for the study is presented in the following exhibit.
7 Assessment of ERS Performance in Madhya Pradesh Final Report
Exhibit 1.2: Study Methodology
Sampling plan
1.9 The mechanism followed to finalize the sample has been given below. Districts and Bocks: Field visits were carried out in 3 representative sample districts of MP, covering urban and rural areas. 3 blocks per district were visited. The selection of districts and blocks was based on analysis of data sought from EMRI1 on parameters such as geographic coverage, years of operations, no. of emergencies handled and response times. The list of districts and blocks was then finalized in discussion with GoMP and MPTAST.
Exhibit 1.3: Sample of district and blocks
Urban Blocks Rural Blocks District No. Name of block No. Name of block Gwalior 2 Gwalior-Urban 1 Bhitarwar Gwalior-Rural Sagar 1 Sagar-Urban 2 Banda, Garhakota
Ashta, Budhni, Sehore 0 None 3 Nasrullaganj Total 3 6
Villages: For each of the selected sample blocks, villages were categorized as “Frequent” and “Infrequent” based on the no. of emergencies received from the villages of the blocks for the period October to December 2012. The methodology used for selection of villages is given in the Annexure 8.1. For rural blocks, at least 4 frequent and 2 infrequent villages
1 The new 40 districts were not considered for the study as services in these districts have been operational for less than 6 months.
8 Assessment of ERS Performance in Madhya Pradesh Final Report
were covered. For urban blocks, the overall block level sample sizes were covered without further geographic categorization.
1.10 Key stakeholders met during the assessment is given below
Exhibit 1.4: Key Stakeholders Met
Level Key Stakeholder Groups No. Covered Total Sample
GoMP . 108 Nodal Officer 1 1 . COO . Sense, Reach and Care teams State . Quality team . SCM team EMRI 28 28 . Marketing team . Hospital relations team . Technology teams . Finance and HR teams . Chief Medical Officer of Health 1-2 5 GoMP . District Programme Manager per district For 3 districts District . District Magistrate (optional) . Operations in-charges (Emergency 3 EMRI 1 per district Management Executives) For 3 districts 14* . Doctors at Govt Health care facilities (CHC s) ~2 per block For 9 blocks Block . Ambulance staff and 18 o EMTs (paramedical staff) 2 per block Below For 9 blocks o Pilots (ambulance drivers) . Users, non-users, Field Level Workers, Influencers ~60 per block 559 etc. Total no. Interviews conducted 627
* In 4 blocks only 1 hospital was visited as all cases were taken only to the nearest CHC. * In addition to the above, 9 ambulances (1 per block) were assessed for sufficiency of infrastructure *Annexure 8.2 provides village wise list of interviews conducted.
1.11 Detailed assessment tools for various stakeholders to be met were developed for facilitating structured discussions and data collection. A detailed methodology and analysis plan was then agreed and shared with MPTAST.
Analysis and Final Report
1.12 An evaluation of EMRI was carried out based on the detailed analysis of information collected during discussions with various stakeholders. A Draft report was then submitted to MPTAST which included an overview and analysis of 108 services being provided by EMRI covering key strengths, issues and recommendations
1.13 This Final report includes analysis of cost data provided by EMRI and feedback received from GoMP on the Draft Report.
9 Assessment of ERS Performance in Madhya Pradesh Final Report
1.14 This report has been drafted under the following sections detailing various aspects of the service.
Implementation model of the 108 service: Sense-Reach-Care and assesses Section – 2 processes followed, key performance indicators and monitoring aspects. Section – 3 Findings and analysis of all support functions within GVK EMRI. Contractual and institutional framework of the public private partnership between Section – 4 GVK EMRI and GoMP Section – 5 Feedback on the service from users, non-users and field functionaries.
Section – 6 Analysis of cost data in terms of key cost indicators and trend of expenditure
Section – 7 Summary of key observations and recommendations
Section – 8 Annexures
Limitation
1.15 As agreed during the inception phase, the evaluation is limited to data as of December 2012 (102 operational ambulances)2. Thus, the financial and operational impact of the new ambulances launched in 2013 is not covered in the study (Although, we have attempted to compare operational costs for the period Jan-June 2013 against financial estimates proposed under Schedule A of the revised MoU).
2 As agreed with MPTAST in the beginning of the project.
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CHAPTER 2
IMPLEMENTATION MODEL SENSE-REACH-CARE
Assessment of ERS Performance in Madhya Pradesh Final
IMPLEMENTATION MODEL – BACKGROUND AND SCOPE
2.1 The EMRI operational model is based on Sense > Reach > Care of an emergency. The emergency transportation, conducted in an ambulance, is provided free of cost. The transportation is coordinated by the Emergency Response Centre (ERC), which is operational 24-hours a day, 7- days a week. In addition, the call to the number 108 is a toll free service accessible from any landline or mobile cellphone. EMRI ambulance fleet includes Basic Life Support ambulances (BLS) containing critical drugs and equipment required for handling emergencies.
Exhibit 1.1: Scope of 108 services
Type of Service Services Provided • All medical emergencies and Referrals to higher facilities post ERCP verification Medical • Drop back to home for pregnancies not covered. Police* • All types of police cases, including medico-legal cases Fire* • All types of fire emergencies, including medico-legal cases * Cases handled through coordination with respective state departments
OPERATIONAL MODEL – EMERGENCY HANDLING PROCESS
2.2 The operational model followed by EMRI is depicted in the following exhibit below.
Exhibit 1.2: Operational Model
2.3 The following sub-sections detail the findings of the evaluation of these core functions – Sense Reach Care.
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2.1 SENSE
2.1.1 The Sense function of the ERS works through a 24 X 7 X 365 centralized call centre, also known as the Emergency Response Center (ERC), located at Bhopal. The ERC is currently staffed with 85 Emergency Response Officers (EROs), 2 Team Leads (TL) and a Manager. The ERO is responsible for call handling and the Team Leads and the manager coordinate rostering and monitoring activities.
Scope of Responsibilities
Exhibit 1.1.1: Scope of activities for Sense
Primary role 2.1.2 Receiving calls of 108: The function of sense is to attend to all calls that land at 108, including: Emergency Calls - Calls that result into either a medical, police or fire dispatch. Effective Calls - Calls that are related to emergencies but do not result in dispatches, including repeat, follow up, service cancellation and feedback calls. Ineffective Calls - Calls that are not related to any sort of emergencies including silent, wrong, nuisance, no response calls etc.
2.1.3 Dispatching ambulances: On identifying the location of the emergency, EROs coordinate with nearby ambulances to identify and dispatch the closest available ambulance. In cases where all ambulances are busy, the ERC has a separate desk to track vehicle busy cases by dynamically coordinating with ambulances and keeping callers constantly updated of the status.
2.1.4 Coordinating with ERCPs: ERO is also responsible to connect EMTs (Emergency Medical Technicians in the ambulances) to ERCPs (Doctors at ERC) for Online Medical Direction (OLMD), if required.
Secondary role 2.1.5 Case Closure – The case closure process mandates ambulance staff to call the ERC on a separate “manager-on-duty number” to provide additional EM information such as diagnosed EM, reach times and hospital details, before attending to another case. This information is used for generating the daily automated report.
2.1.6 48 hour follow-up – This is a customer centric process initiated by EMRI to collect feedback from all callers on their experience with 108 and status of patient within 48 hours of emergency.
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2.1.7 Support Services - Apart from the calls mentioned above, ERC provides other support services such as receiving calls from ambulance staff on updation of vehicle status (off-road, servicing, busy etc.), registering staff grievances etc.
Assessment Findings: Primary and Secondary functions of ERC
2.1.8 The findings and observations made during the assessment visits are detailed below –
a. Well defined call taking process: A clearly defined process guides the call taking process which is constantly reviewed and updated in order to improve efficiency and caller experience. For example, the ERO process was launched only in April as an improvement to the earlier CO-DO (Call Officer – Dispatch Officer) process, which involved different officers for call receiving and ambulance dispatch. This change was done to enhance caller experience by having only one point of contact and to reduce call handle time.
b. Proactive vehicle busy desk: The vehicle busy desk is helpful to better engage with the caller in distress and reduce waiting times.
c. Good customer feedback process in place: The 48 hour follow up initiative is a good feedback mechanism for the service. Discussions with beneficiaries also showed that this feedback was appreciated among callers and contributed to their satisfaction. During the evaluation, it was observed that due to the sudden increase in EM calls as a result of new ambulance launches in Jan-May 2013 period and insufficient manpower, while the follow up was being done, the 48 hour timeline was not maintained.
d. Well-designed Sense application: The Sense application implemented by GVK EMRI for handling calls is well designed and structure based on the ERO algorithm ensuring minimum deviations and errors. The application is adequately supported by switches, servers and data storage hardware.
e. Weak Case closure process: The case closure process also releases the ambulances on the ERO application, showing them as available for the next dispatch. It was observed during the assessment visits, due to delays in case closures, ambulances are not released on the online application. This could lead to longer call handle time as the exact ambulance status is often not available during dispatches, requiring EROs to call all nearby ambulances to finalize one.
Operational Indicators
Types of Calls 2.1.9 The following table provides a snapshot of the call related data since July 2009:
Table 1.1.2: Operational indicators – Type of calls
Jul- Dec Jan- Jun Jul-Dec Jan- Jun Jul- Dec Jan- Jun Jul- Dec Parameters ‘09 ‘10 ‘10 ‘11 ‘11 ‘12 ‘12
Total No. of Calls Received 17,046 33,717 30,983 33,605 22,274 29,019 23,702 per day Unattended Calls (UAC) per 199 373 162 227 127 146 253 day (%) (1.17%) (1.11%) (0.52%) (0.68%) (0.57%) (0.50%) (1.07%)
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Total No. of Calls Attended 16,847 33,344 30,821 33,378 22,147 28,873 23,449 per day EM Calls % 2.0% 1.4% 2.5% 2.5% 4.7% 3.0% 3.8% Effective Calls % 3.2% 1.2% 1.8% 1.4% 2.5% 1.5% 1.7% Ineffective Calls % 94.8% 97.4% 95.7% 96.1% 92.8% 95.5% 94.5% All Data provided by EMRI *Analysis is limited to Dec 2012 as data for Jan-May 2013 has not been provided *Certain data gaps were observed in data provided by EMRI on calls attended
Assessment Findings: Call Types
2.1.10 Low percentage of Unattended Calls (UAC) till Dec’12: Unattended calls are the calls that are missed at the ERC due to busy lines. As can be seen from the table, unattended calls have constituted approximately 1 % of the total calls, which indicates well planned capacity to handle the indicated number of calls per day. However, during the evaluation period, a significantly higher % of UAC was observed at the ERC. For instance the UAC on 28th May was observed to be approximately 15% on the Dynamic report displayed at the ERC. Discussions with officials in the Sense and Field Operations department teams have indicated that this percentage has been more than 10% over the last 2 months. It is difficult to estimate the actual percentage and the reasons for increase due to lack of sufficient data.
2.1.11 High percentage of Ineffective Calls Ineffective calls constituted approximately 95% of the total attended calls, which is very high. However, this % ranged between 80-85% in June’ 13 (as observed by the team) due to increase in EM Calls owing to the launch of 352 new ambulances. Deloitte team conducted a dipstick analysis of ineffective calls by listening to 60 calls to analyse the composition of ineffective calls. Table 1.1.3: Sample of Ineffective Calls evaluated
Percentage of Calls sampled Call Type Description ineffective calls (minimum 3) No Response After call connection, no response from caller 17.4% 10 Wrong Call Wrong number dials 2.5% 3 Nuisance Call Intentional/ Abusive calls 65.3% 33 Disconnection after initial conversation/ Disconnected 9.6% 5 connection Pop up generated on computer screen, but call Missed Call 0.9% 3 not connected to General Enquiry Deliberate calls enquiring about non 108 matters 0.6% 3 call Silent Calls Caller cannot be heard 3.7% 3 Total 100% 60 *Dipstick conducted on 28/5/13 *50 calls were randomly selected based on the above percentage of ineffective calls *A minimum of 3 calls was taken for each category where there were lower number of calls as per above bifurcation
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2.1.12 Key analysis from the above evaluation is presented below - Wrong Categorization: As seen in the following table, the actual percentage of call categories varies significantly in comparison to the current split. 48% of the sample calls were wrongly categorized. Appropriate categorization and frequent analysis of varying call patterns would be important to develop organization level strategies and draw prioritized action plans to address and reduce each of the call categories.
Table 1.1.4: Comparison of Classified and Actual Proportions
Percentage of Percentage of total Percentage of Type Wrong after correct Possible cause Ineffective calls categorization categorization No Response 17.4% 20% 30% Network congestion Wrong Call 2.5% 100% 0% Awareness Nuisance Call 65.3% 56% 28% Awareness Technology ,network or Disconnected 9.6% 40% 19% awareness Missed Call 0.9% 67% 7% Shortage of EROs General Enquiry 0.6% 0% 8% Awareness call Silent Calls 3.7% 67% 8% Technology or network
Varying causes of ineffective calls: - Network related: While the overall percentage of ineffective calls is daunting, over 50% of the calls are possibly due to network and connectivity problems at the source, which cannot be directly addressed by EMRI. - Manpower related: The % of missed calls could be a function of available manpower. This % should be considered by EMRI while planning for their manpower. - Awareness related: The composition of nuisance calls (including abusive calls) is an area of concern as the handling time is comparatively longer in these cases, thus impacting manpower. Nuisance calls should be addressed through appropriate communication strategies in coordination with the Government.
2.1.13 In MP, given the composition of calls, GoMP and EMRI need to develop strategies to bring down this number to approximately 50% over the next 2 years. However, this target needs to be established based on analysis of trends of ineffective calls of States with matured EMRI operations such as Gujarat and Andhra Pradesh.
Types of Emergencies 2.1.14 The following table provides a snapshot of the dispatch related data since July 2009 :
Table 1.1.5: Emergency Related Information
Jul- Jan- July-Dec Jan- Jun Jul- Jan- Jul- Dec Parameters Dec Jun ‘10 ‘10 ‘11 Dec ‘11 Jun ‘12 ‘12 ‘09 Types of Emergencies Medical Calls Received per day 171 254 392 431 520 459 514 Police Calls Received per day 30 32 31 41 38 39 33
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Jul- Jan- July-Dec Jan- Jun Jul- Jan- Jul- Dec Parameters Dec Jun ‘10 ‘10 ‘11 Dec ‘11 Jun ‘12 ‘12 ‘09 Fire Calls Received per day 0.32 0.31 0.32 0.13 0.09 0.01 - Vehicle Busy per period (% of 10 19 58 54 95 63 91 medical calls) (5.8%) (7.5%) 14.8 12.5 18.3 13.7 17.7
Assessment Findings: emergency Types
2.1.15 Mostly Medical Emergencies: Over 90% of emergencies reported are medical emergencies. While the number of medical emergencies handled has constantly increased over time, no increase in the number of police and fire emergencies has been observed.
2.1.16 High % Vehicle Busy Cases: The vehicle busy % reflects the capacity of the operational ambulances to handle current number of emergencies. As can be seen from the graph below, the increasing number of vehicle busy cases is an area of concern. Since the analysis is limited to December 2012 i.e. fleet size of 102 ambulances (before the launch of the new 352 ambulances), the impact of the launch of new ambulances on vehicle busy could not be analysed. It is suggested that GoMP closely monitors the vehicle busy % given the launch of 352 + 102 new ambulances.
Table 1.1.6: Vehicle busy cases in comparison with total medical emergencies
600 20.0% 500 15.0% 400 300 10.0% 200 5.0% 100 0 0.0% Jul- Dec Jan-June July-Dec Jan- June July- Dec Jan- June July- Dec Medical Ems ‘09 ‘10 ‘10 ‘11 ‘11 ‘12 ‘12 Vehicle Busy cases
Monitoring Mechanisms
Monitoring call center operations 2.1.17 The monitoring processes of call centre operations have been observed to be very good. The team leaders and the manager play a vital role in ensuring that daily operations of the call centre are well planned and closely monitored. Mechanisms followed by sense include: Weekly rostering of EROs based on call volumes followed by hourly tracking of call variations to ensure optimum availability of EROs. This is also backed by automated reports tracking the status and efficiency of each logged in ERO. Dynamic displays in the ERC detailing current, daily and monthly information relating to no. of calls being handled, no. of waiting calls, UAC, no. of dispatched ambulances and types of emergencies
ERO performance 2.1.18 All calls attended by the call centre are recorded through a voice logger. The Quality Team is responsible for auditing calls for each employee and identifying issues in call efficiency/duration, language, skill sets and case closing. These audit findings are collated by the team leaders to
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evaluate ERO performance using parameters such as process knowledge, call quality, attendance, call handle time and productivity.
Assessment Summary: Sense
Well defined and clear processes in place guide the call handling process at the ERC backed by well- structured and implemented hardware and software. EROs was found to be motivated and adherence to defined process was high. Adequate monitoring systems are in place for call center operations and well handled by the team leads.
However, the manpower planning process would need to be more robust. At an organization level, the high percentage of ineffective calls, unattended calls and vehicle busy cases would need to be addressed jointly by the management, sense, field operations, and HR and marketing teams. An initiative to tackle the problem of longer case handle time due to delays in case closures is the current plan to launch AVLTs (Automatic Vehicle Location Tracking System) in the coming quarter
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2.2 REACH
2.2.1 This section focusses on the two aspects of the Reach function- Fleet and Field Operations.
FLEET
2.2.2 Currently the fleet of EMRI in Madhya Pradesh consists of 454 BLS ambulances stationed across the 50 districts of the state. Additional 150 ambulances have been purchased by GoMP and will be added to the fleet in 2013, 50 of which shall be ALS ambulances.
2.2.3 The fleet consists of smaller vehicles such as Maruti Suzuki Omni, Maruti Suzuki Eeco and Tata Sumo as well as larger vehicles like Force Traveller and Tata Motors Tata 407. The deployment of vehicles is finalized in discussion with GoMP after considering factors such as topography, distance from health facilities, urban-rural split of population etc. The ambulances are stationed at public health facilities and police stations, which results in strengthening field level relations with these key stakeholders and in receiving help from them, such as accommodation for ambulance staff, support for medico-legal cases, office space etc.
Scope of Responsibilities
2.2.4 The Fleet team, consisting of 2 Field Coordinators (FCs) and 5 Fleet Technicians (FTs), is responsible for managing the procurement and maintenance of vehicles. The key responsibilities of the team include: Vehicle refurbishment, registration, branding and insurance Ensuring scheduled maintenance and any repairs of vehicles Coordinating contracts with service centers for servicing and tyre changes and with fuel stations Accident management Pilot training
Assessment Findings: Fleet
2.2.5 Relevant equipment in 108 ambulances in comparison to international norms: As part of a dipstick survey conducted by the Deloitte team, ambulance equipment currently available in EMRI BLS ambulances were compared to one of the international standards for BLS developed by the National Association of State EMS officials (NASEO) 3, comprising of American College of Surgeons, American College of Emergency Physicians, National Association of EMS Physicians, Emergency Medical Services for Children, American academy of Paediatrics and National Association of EMS officials. The detailed list and categorization of ambulance is provided in the Annexure 8.3. An analysis of status of availability of equipment in sample ambulances has been discussed in the quality section.
2.2.6 The key observations and findings from the survey are- Apart from cold packs, hazardous materials reference guide and patient care SOPs the current list of equipment which are available in the ambulance are sufficient for pre hospital care provided in the ambulance. More specialized equipment like defibrillators, nasogastric tubes, pediatric feeding tubes, endotracheal tubes, pediatric backboard and splints, infant oxygen masks, large bore
3 Source: http://www.nasemso.org/Councils/PEDS/documents/AmbulanceEquipmentGuidelinesJune2012.pdf
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hypodermic needles for managing shock and pneumothorax etc. are requirements of higher level of care which are part of ALS. Since there are no ALS ambulances in place current training of EMTs also hasn’t included use of these specialized equipment. Most equipment like protective gear, helmets, TRIAGE tags etc. which are listed in the last ‘Not Relevant’ group are either required in case of Mass Casualty Incidents (MCI) for which EMRI are in the process of developing SOPs for (mentioned in SOPs shared with the evaluation team) or are not relevant to the level of care provided by the EMTs in the current setting.
2.2.7 Well established Vehicle Maintenance process: Vehicle maintenance, related to periodic servicing and accidents, is undertaken by EMEs (district level operations managers) in coordination with the fleet team. During the assessment visits it was observed that in each district, the fleet team has very strong vendor tie ups, resulting in early turn-around times of the 108 ambulances. Also, to help EMEs and pilots better monitor vehicle servicing, a detailed picture manual for servicing and formats for accident claims have been designed by the state fleet team and distributed. These are good initiatives to ensure high levels of compliance to processes
2.2.8 Online Fleet Management System to monitor uptime – In order to ensure maximum uptime, the fleet team uses a well-designed online application, called the Fleet management System, to continuously track on-road and off-road status of ambulances and analyse vehicle performance. This application is also linked to the sense application to dynamically update status of ambulances.
2.2.9 Stringent Fuel and Tyre Management: Refuelling of vehicles is done through fuel cards recharged at the state level. In cases where fuel cards are not available, the EME is responsible for negotiating credit facilities for the vehicles at local fuel stations. Purchase of tyres is done at the state level through a tender process, while the delivery is done in the districts. Both these processes ensure better monitoring of utilization and costs. However, an area of improvement is that the current daily limit of INR 1,500 per ambulance was found to be insufficient for filling the vehicle to its capacity leading to frequent refuelling. This rate is currently being reviewed by the state fleet team by conducting a thorough analysis of key fleet parameters.
Operational Indicators
2.2.10 The details of operational indicators of the Fleet are presented below:
Table 2.2.1: Operational indicators- Reach4
Jun Jun
Dec Dec Dec
Jun
Mar
Dec Dec Dec
-
- -
- -
- -
Parameters -
‘09 ‘10 ‘10 ‘11 ‘11 ‘12 ‘12 ‘13
Jul Jul
Jan
Jul Jul
Jan Jan Jan Total number of 55 55 87 94 99 102 102 286 ambulances Avg. No. of Trips per 3.9 4.4 4.8 4.3 4.9 4.0 4.3 3.3 Ambulance per Day
4 Source – Data provided by GVK-EMRI
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Jun Jun
Dec Dec Dec
Jun
Mar
Dec Dec Dec
-
- -
- -
- -
Parameters -
‘09 ‘10 ‘10 ‘11 ‘11 ‘12 ‘12 ‘13
Jul Jul
Jan
Jul Jul
Jan Jan Jan Avg. Distance Travelled 26.33 26.155 29.31 30.67 31.19 32.79 32.29 35.15 per Ambulance per trip Fuel Efficiency (per KM) 9.05 9.33 9.27 9.32 9.31 9.31 9.08 9.95 Ambulance Uptime % 98.32 98.44 98.12 99.07 98.55 98.32 97.97 98.03 Ambulance breakdown rate 0 0 0 0.08 0.09 0.2 0.25 0.12 % Service adherence % 100 100 100 100 100 100 100 94.6 Average tyre mileage NA NA 45,299 43,948 45,253 44,603 45,310 47,281 achieved Hours of training per pilot 1.38 2.59 2.3 3.48 1.71 1.03 1.36 2.21
Apr ‘10 - Mar‘11 Apr ‘11 - Mar‘12 Apr ‘12 - Dec‘12 Avg. Time taken per Ambulance* (Base to 26:43 28:21 29:18 Scene) - in mins
: Urban 23:40 26:07 27:34 : Rural 29:01 29:52 30:29 * Data for reach times was provided for different time periods – Annual April to Mar
Assessment Findings: Fleet performance
2.2.11 The following findings summarize the above table - Increase in fleet sizes: The number of ambulances has increased from 55 to 286 from July 2009 to March 2013. 5
Good adherence to scheduled servicing: Service adherence has been 100% until January 2013, which corresponds with the low ambulance breakdown rate. However a dip in service adherence during the period Jan-Mar 2013 could be because of the fleet and field teams being engaged in the launch of new 352 ambulances. It would be important to ensure that service adherence is back on track w.e.f. May 2013
Varying fuel efficiency due to launch of smaller ambulances: Fuel efficiency remained stable around 9.3 km/l, though it reduced slightly in the period July-December 2012, possibly due to the increasing age of the vehicles. In the period January-March 2013, the fuel efficiency peaked to 9.95 km/l and this can be attributed to the deployment of new small vehicles.
Varying trips per ambulance due to launch of new ambulances: The average number of trips per ambulance per day steadily increased, peaking at 4.9 in the period July-December 2011. While this figure fell to 3.3 in the period January-March 2013 due to launch of new ambulances, it will take some time for the operations to stabilize in the new areas being covered by the service.
5 In relation to data available for fleet. Currently EMRI has 352 operational ambulances
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Increasing distant travelled per trip: The increase in distance covered per trip before January 2013 could be attributed to better coverage of 108 services including more remote villages owing to increasing awareness. The sudden increase from Jan – March 2013 could possibly be due to more spread population and dispersed health facilities of the newer districts. A detailed analysis could not be done as district-wise data for launches in the new 40 districts is not available.
Base to Scene time6: The rural base to scene times meet the international standards of 40 mins; however the urban reach times are more than the standard of 20 mins. However, observation of urban cases during field visits and discussions with the state fleet team indicate that this high reach time could be attributed to the fact that most urban ambulances serve cases in the peripheries of the city / urban area thus resulting in longer reach times.
FIELD OPERATIONS
2.2.12 Field operations are managed by 1 Regional Manager (RM) and 6 Program Managers (PMs) at state and regional levels, 23 Emergency Management Executives (EMEs) at district level, and 1095 Emergency Management Technicians (EMTs) and 1140 Pilots (Drivers) at the ambulance level.
Exhibit 2.2.2: Structure of field operations team
Scope of responsibilities 2.2.13 Field Operations team at the state, district and field level are required to interact and liaison with a number of internal and external stakeholders to ensure efficient functioning. The exhibit below highlights the scope of responsibilities of the field operations team –
6 “ Ambulance Response Time in Developing Emergency Healthcare Systems” – Jochen Schmidt
22 Assessment of ERS Performance in Madhya Pradesh Final Report
Exhibit 2.2.3 – Scope of Responsibilities
2.2.14 The detailed roles and responsibilities of key stakeholders involved in carrying out field operations are mentioned in the Annexure 8.4. The following section highlights key findings of the field operations.
Findings: Field Operations
2.2.15 Good population coverage: EMRI targets to follow WHO benchmark of deploying one ambulance per one lakh population7 based on factors such as district coverage, average reach time, average trip distance etc. However, till Dec 2012 with operations only limited to 102 ambulances across 10 districts, this benchmark was difficult to achieve (population per ambulance was 1,56,503). With the launch of additional 23 ambulances in these 10 districts the ratio has reduced to 1,27,706.
7 Source – “Publicly Financed Emergency Response and Patient Transport Systems Under NRHM” by NHSRC report
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Exhibit 2.2.4 – Population Coverage per Ambulance in Initial 10 Districts (Dec’12 vs. May’13)
2.2.16 For the newly added fleet of 352 ambulances, the focus was entirely on district coverage. As shown in Annexure 8.5, currently the entire population of Madhya Pradesh (64,54,55,485; Census 2011) is covered by 454 ambulances, making the population per ambulance is 1,42,171. With the state planning to add another 150 to make the total ambulances 602, the population coverage would almost meet the target of 1,00,000.
2.2.17 Inadequate liaising with District administration: As per the MoU, GoMP has the responsibility of providing base stations and shelter for the ambulances. For the recent launches(like in Sehore), EMRI officials – Program managers and EMEs, effectively coordinated with District administration i.e. District Collector, CMHO and Superintendent of Police to identify appropriate base stations either at local police stations or at health facilities.
2.2.18 As per MOU, each district is required to hold quarterly District committee meetings chaired by the District Collector along with other members such as Superintendent of Police, CMHO, District Fire Department Head, and EME etc. to review 108 operations. However, none of the districts assessed were holding the quarterly district committee meetings. It was observed that none of the district officials were aware of the need and objectives of the district committee. There is a need for more formal and frequent communication from the state to districts informing them of the requirements of the MoU and monitoring their adherence.
2.2.19 Hospital Tie-ups: EMRI has defined a process to capture details of services, specialties, resources and infrastructure available across health facilities in each of the districts. EMEs play a vital role in coordinating with hospitals, collecting information, forwarding information to the EMRI state office and monitoring relationship with each of the hospitals. EMEs also provide advocacy to the Chief of Hospital on the importance of stabilizing critical EM patients before referring them to any other facility when required. Data collected from hospitals is then entered into Hospital Information systems (HIS) application which is linked to the case closing application of SENSE, in order to allocate each emergency to the corresponding hospital.
2.2.20 Across the initial 10 districts, the HIS survey was filled for 1,266 hospitals. However, collected data of partner hospitals has not yet been made available to the ambulances, which could help ambulance staff in advising relevant hospitals to beneficiaries. The process for enrolling hospitals for the new districts is underway.
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2.2.21 There is a need for EMRI to transition from collecting hospital information to maintaining hospital relationships with network hospitals in order to maximize the utilization data collected. Some of the findings and issues include – District EMEs also did not have periodic data to analyse the number of cases being taken to each of the hospitals, which could help them analyse and conduct hospital discussions to increase hospital readiness. No relationship building initiatives with the hospitals were undertaken to ensure acceptance of cases by partner hospitals, increase usage of vital information recorded in the PCRs or enable field level trainings at partner hospitals.
2.2.22 Field Level HR: The EME at each district is responsible for managing field HR i.e. EMTs and the pilots. The EMTs and pilots directly report to the EME of each district. Discussions with EMTs and pilots indicated a high level of confidence and trust on their respective EMEs. Overall a high level satisfaction amongst field staff on the role and capabilities of the EME. Exhibit below depicts field related activities undertaken by EME for the ambulance staff
Exhibit 2.2.5: Field Activities undertaken by EME
• Prepare Duty roster • Track vehicle performance through daily discussions with
EMTs ambulance staff • Checks on any issues and grievances of ambulance staff • Monthly Rewards & Recognition • Periodic events such as the EMT day, Pilot day • Performance appraisal Pilots • Grievance Redressal
2.2.23 Regular Drug indenting sand equipment checks: For each ambulance the EMT is required to conduct a regular drug indenting and equipment check and raise a monthly indent for the required drugs. EMEs are also required to conduct bimonthly stock checks of each ambulance. In addition, quarterly vehicle audits are conducted by the quality team.
2.2.24 During our assessment it was found that overall Basic living saving equipment and drugs were found to be present in the ambulances except for some minor equipment gaps due to ongoing repairs.
2.2.25 All non-compliance issues as indicated by the quality team are addressed in coordination with the SCM team. This process keeps a constant check on compliance of ambulances to recommended guidelines.
2.2.26 Spreading Awareness: The most frequently undertaken awareness building activities are - Demos-Demos are conducted in every village in the district by gathering people, informing them about 108 services and how to use them, showing the ambulance equipment and how EMRI can be helpful in case of any emergency. Follow-up with ASHAs - EMEs are in constant contact with ASHAs who keep a track of pregnant women for planned deliveries and this provides an opportunity to spread awareness among the potential users. News Articles- Given the popularity of the scheme, details of special cases, ambulances launches of pilot and EMT days are well covered by the district level print media. This is also an important form of district level marketing to spread awareness of the service.
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2.2.27 During the assessment it was observed that very few demos were undertaken across all the sample districts over the last 6 months due to the increasing number of cases.
Good Practices observed in Sehore District
EMTs and Pilots have developed good linkages and rapport with the district authorities and local people in their respective coverage areas through high level of interactions with village influencers as part of IEC/BCC activities.
The EME in charge has also taken an initiative to contact local movie theatres for playing slides on availability and scope of 108 services before the start of every movie
2.2.28 Interaction with Sense: As discussed in the Sense section, the field operations team interacts with the Sense team for sharing three types of information – Case closure, Vehicle busy and off road vehicles.
2.2.29 While the vehicle busy and off road reporting mechanisms are being implemented well, delays have been noticed in the case closure process mainly due to the increasing number of cases. This leads to free ambulances being reflected as busy and longer dispatch times at EROs level. However, EMRI is now planning to launch the AVLTs (Automatic Vehicle Location Tracking System) in the coming quarter in order to address above issue.
Monitoring mechanisms for the Reach (fleet and field operations) Function
2.2.30 The following exhibit describe the existing monitoring systems in place:
Exhibit 2.2.6 – Monitoring systems implemented by the Reach team •Regional Manager - Monitors and analyses operational and non-operational details including expenditure reports State Level •Fleet Head - Defines performance parameters and monitors key fleet processes such as vehicle maintenance, service adhrence, fuel and tyre management etc. Fleet & Field •Regular conference calls and monthly meetings with EMEs and PMs Ops
•Programme Manager and Emergency Management Executives responsible for monitoring at regional and district level •EME receives and collates Daily Vehicle Checklist from Pilots. Also receives details on District Level number of cases, servicing, fuelling, distances and expenditures Programme Manager •PM Analyses data shared by EME for each district
•At the field level, the pilot fills out a Daily Vehicle Checklist. This is shared with the EME. •The pilot keeps the EME informed about servicing, refueling and ambulance breakdowns Field Level •The EME also gives operational and non-operational details to the EME on a daily, weekly and monthly basis
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Assessment Findings: Monitoring systems of Reach 2.2.31 COO review: All EMEs and PMs are required to attend a monthly meeting organized at the state level. The aim of this meeting is to discuss issues faced at the field level and any performance improvement parameters. However, these meetings had not been conducted between November 2012 and May 2013 due to the organization being busy in the expansion of services in 40 new districts. The monthly meetings have resumed since June 2013.
2.2.32 State level monitoring: State level monitoring of the reach function is done by the fleet head and the regional manager. Comprehensive daily and monthly reports are submitted by the EMEs and are collated & analyzed by the state teams. The following exhibit highlights the monitoring mechanisms in place.
Exhibit 2.2.7 – Existing Monitoring Mechanism
2.2.33 Field level monitoring: Each vehicle is supposed to maintain the following registers which are filled by the EMTs and Pilots on a regular basis and shared with the EME. These registers are well maintained at the field level checked by the EME and quality teams during their ambulance audits. Key registers include: Vehicle checklist Vehicle log book/Trip sheet Stock Register Attendance Register Handing over Register Pre Hospital Care Records
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Assessment Summary: Reach
The Reach processes are well defined, implemented and managed by the fleet and field teams. Strong district-level vendor tie-ups and a comprehensive vehicle performance tracking mechanism drive vehicle efficiencies. Initiatives such as the servicing manual, accident reporting formats and the fleet management system improve adherence to protocols. Some areas of improvement include more frequent analysis of reach times and distances to address the increasing trends and introducing variable daily financial limits for fuel refilling based on urban/rural base station, trip distances and proximity to fuel stations.
The field operations team manages and handles staff and operations reasonably well. EMTs and pilots reflect a high level of confidence and motivation in carrying out their daily tasks. Areas of improvement include delays in case closures, un-planned field marketing activities, weak liaising with district administration and weak hospital relationship processes.
Overall, the reach function has clear implementation and monitoring processes. The team would need to better liaise with both external (partner hospitals and district administration) and internal (marketing and hospital relations) customers.
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2.3 CARE
2.3.1 The CARE component of the EMRI operational model consists of providing pre-hospital emergency medical attention to the patients. It consists of three sub components – CARE cell at the ERC, Pre-hospital Care Record Cell and Emergency Learning Centre, led by the Head (EML&C). It essentially entails services provided by trained Emergency Medical Technicians (EMT) in ambulances equipped with basic life support equipment to tackle any type of emergency within the first “Golden Hour”.
Exhibit 1.3.1: Organisation structure of the EML&C
CARE - ERC
Scope of Responsibilities
2.3.2 The CARE function at the State level comprises of Emergency Response Care Physicians (ERCPs), who are located in the ERC. The ERCPs are qualified MBBS graduates, preferably with prior clinical experience. The following exhibit depicts their roles and responsibilities:
Exhibit 2.3.2: Roles and responsibilities of an ERCP
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Assessment Findings: CARE - ERC
2.3.3 Well defined SOPs in place: GVK-EMRI has detailed Standard Operating Procedures (SOPs) in place to ensure the level and quality of care is maintained in all ambulances.
2.3.4 Provision of good OLMD: Trained medical technician in a mobile and well equipped set up along with 24*7 telephonic assistance support a qualified physician are the key strengths of the 108 EMRI care model. This ensures that quality of care is maintained at all times, especially in the ‘golden hour’ of an emergency. However, it was observed that there was high dependency of EMTs on ERCP advice and there were several instances of the ERCP line being busy due to insufficient number of ERCPs.
2.3.5 Inadequate field visits: ERCPs are required to visit the ambulances to understand the field conditions and challenges faced by EMTs and guide them. While these periodic visits are effective initiative to evaluate EMTs, the last round of ambulance inspections by ERCPs was conducted in November-December 2012. Since then, no further assessments have been carried out by the ERCPs, owing to the significant increase in the volume of emergency calls.
Emergency Learning (EML)
Scope of Responsibilities
2.3.6 Emergency Medicine Learning Centre is responsible for training EMTs and Emergency Response Officers on the Care component. A brief snapshot of the EMLC department’s responsibilities is as follows:
Exhibit 2.3.3: Activities conducted by EMLC
2.3.7 EMT Preparatory training: New EMTs are mandated to undergo the EMT Preparatory Training Program. This is a phase wise program as detailed in the table below. EMRI has documented treatment protocols / Pre Hospital Care Standing orders for clinically addressing various emergency conditions in collaboration with the Stanford School of Medicine. Each protocol enlists steps to handle a particular emergency before connecting with the ERCP. This is an integral part of the EMT Preparatory Training.
2.1.2 The training program was originally used to be held for 60 days. However, due to the increase in number of EMTs in the system (352 ambulances added between January and April 2013), since January 2013 the training program has been modified for new recruits and is now completed in a period of 35 days itself.
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2.3.8 Given below is a brief comparison between old and revised training schedule:
Exhibit 2.3.4: Activities conducted by EMLC
Training sessions 60-day training program 35-day training program* 28 days with 4-day ambulance Institutional training for posting and 2-day ERC visit (+1 15 days with no leaves theoretical concepts and skills day leave) Ambulance phase training 10 days (+1 day leave) 10 days with reduced duration Hospital phase training 10 days (+1 day leave) 10 days with reduced duration Leave 1 day Evaluation including 8 days Included in the above schedule remediation** * Prepared by national CARE team of GVK EMRI after prioritizing critical areas to be covered. Revised training format already piloted in Uttar Pradesh ** Evaluation (written +oral viva) conducted by professors from medical institutions in MP with 60% marks as qualification criteria
2.3.9 Mentor EMT Program: Considering that the revised format of EMT preparatory training could impact quality of pre-hospital care being provided by the new EMTs, EMRI has designed the following methods to continue to improve the knowledge and skills of the EMTs : Mentor EMT program: This program was initiated in April 2013, wherein older EMTs (1 per district) have been designated as mentor EMTs to provide on-field handholding support to new EMTs. Refresher trainings every 6 months
2.3.10 Certification Training by National Care Team: In addition to above, a refresher training program for 5 days was held in Hyderabad for existing EMTs (102) under the Global Certification Program (GCP) which includes training on Basic Life Support (BLS) and International Trauma Life Support (ITLS).
2.3.11 Refresher Training by State Care Team: This training is conducted annually once for 3-5 days at the State training center in Bhopal. This training is mandated for experienced EMTs, on specific needs identified through various evaluations and monitoring mechanisms which are in place. For the newer EMTs, it is planned to be held twice a year.
Assessment Findings: EM Learning
2.3.12 Shortened EMT preparatory training – It was observed and reiterated by some EMTs that the shortened duration of the EMT preparatory training affected their level of retention of knowledge and confidence in handling patients. However, variation in this was observed during Deloitte’s field evaluation of EMTs. 2 EMTs who were trained in the older training module also had poor technical knowledge. The effectiveness of the shortened training duration of the EMT Preparatory training is yet to be formally evaluated to see any impact on knowledge retention and care provision by the EMTs.
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2.3.13 Irregular Refresher Trainings: Refresher training / certification programs for EMTs are a good initiative to increase their confidence and motivation. However, no comprehensive plans, detailing training schedules, numbers and dates, are in place currently to initiate the bi-annual refresher plan at least for the new EMTs.
2.3.14 Monthly CMEs for EMTs: EMLC conducts Continuous Medical Education (CME) activities for EMTs including circulation of medical emergency-based questionnaires among all EMTs on a monthly basis. Responses are mandated to be filled in and forwarded to the EMLC for evaluation. This activity has been designed to encourage the EMTs to provide inputs on training needs, revisions required in training and course material. This initiative is appreciative and promotes knowledge among the EMTs.
2.3.15 On-field handholding support through Mentor EMT program: The objectives and the implementation mechanism of the mentor EMT program were not clear among EMEs. As shown in the table below, there is variable understanding and implementation of the mentor EMT program across districts visited. Given the criticality of the program, it would be important for EMRI to institutionalize standard mentoring guidelines for EMEs, design a skill assessment tool for EMTs and share a proposed development plan for identified EMTs based on the areas of improvement.
Table 2.3.5: District Level variations in Implementation and understanding of Mentor EMT program initiative
Observations District Mentor EMT Duration Target EMTs Covered ambulances with both old and new Sehore 2 days at each location EMTs. Minimum 2 days at each location. Duration could differ from EMT to EMT. Gwalior Covered only ambulances with new EMTs (Mentor EMT interviewed was at the same location for over 10 days). Covered ambulances with both old and new Sagar 1 day at each location EMTs
Pre-Hospital Care Record Cell (PCR Cell)
Scope of Responsibilities
2.3.16 For all cases handled, EMTs are required to submit a copy of the filled PCR form to the receiving hospital. The second copy is retained in the ambulance and a third copy is sent to the PCR Cell at the State EMRI headquarters. This cell is involved in documentation, analysis and storage of these PCR forms received from the field. The PCR cell activities and process followed is shown in the exhibit below:
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Exhibit 2.3.6: Activities of PCR cell
Assessment Findings: PCR Cell
2.3.17 EMT feedback through critical case evaluation: The filled PCR forms of all emergencies are sent to the PCR cell by the EMTs, which are then sorted to identify critical cases based on standing order given by the ERCPs.to identify missing/fake PCR forms. The critical cases are then evaluated by the ERCPs for appropriateness of care provided and its criticality in saving the patients’ life. The process helps ERCPs evaluate and monitor quality of pre-hospital care being provided by EMTs. Key findings from the EMT evaluation are also used to identify training needs.
2.3.18 Currently, feedback is given to the EMT only in case of any observed error either in provision of care or documentation. However, this process could be improved further by clearly determining a fixed number of PCRs to be evaluated per EMT for periodic feedback.
2.3.19 Lives Saved: CARE generates a monthly report on ‘lives saved’, which is defined as the total number of critical cases with aberrant vitals which were provided appropriate care by the EMTs. Factors that decide lives saved are: critical cases, provision of appropriate care, well documented PCR and stable patient condition within 48 hours of emergency. The total number of “lives saved” by 108 EMRI services since the commencement of the service is as follows:
Table 2.3.7: Activities of PCR cell
Total lives saved Jul 09 – Apr 10 – Apr 11 – Apr 12 – Period (From Inception - Dec Mar 10 Mar 11 Mar 12 Dec 12 2012) Lives saved 4,080 7,213 9,456 7,183 27,932
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Facility Feedback 2.3.20 As part of the evaluation, Deloitte team visited two facilities each per ambulance where the patients were commonly referred to. The team interacted with the doctors and got feedback on quality of care provided by EMTs using a pre-designed structured tool. A snapshot of the facilities visited along with feedback from doctors is provided in the Annexure 8.6.
Assessment Findings: Facility feedback 2.3.21 MOs satisfied with quality of prehospital care: Most facility doctors were appreciative of the services provided by EMTs. As shown in the table, doctors were satisfied with service quality (especially for trauma and pregnancy cases), response time and quality of PCR documentation.
2.3.22 Areas of Improvement: Some of the areas that need further improvement as suggested by the doctors at health facilities include: Reducing unnecessary ERCP OLMD in few cases, availability of ALS care at least in some ambulances and better patient handover by ambulance staff were the key areas identified by the doctors as areas of further improvement. It was observed that the PCR copy was not stored in all health facilities. Of the 13 facilities visited, the PCR copy was maintained as a practice only in 6-7 facilities. Information in the document was not used by the attending doctors in any facility visited. Many doctors were not even acquainted with the PCR form and did not use any of the critical information it contained. There seemed no special effort by the EMTs in educating the doctors and ensuring its use in treating the patient. This could be worked upon and improved.
Assessment Summary: Care
Availability of well-defined SOPs, 24*7 online medical support from ERCP, availability of trained medical technicians in all ambulances as well as their good knowledge on systems and adherence to protocols are the key strengths of the CARE function. Appropriate training programs and innovations like the mentor EMT program and HIS data base creation are also appreciable.
Areas of improvement that need to be addressed by EMRI include shortage of ERCPs for OLMDD, inadequate processes for evaluation of care provided by ERCP and EMT and poor coordination with government health facilities. Additionally, EMRI needs to conduct a comprehensive evaluation of the effectiveness of the revised preparatory training schedule to identify specific skills gaps.
34
CHAPTER 3
SUPPORT FUNCTIONS
Assessment of ERS Performance in Madhya Pradesh Final Report
3.1 HUMAN RESOURCES
Organization Structure 3.1.1 The GVK EMRI operations in MP is headed by a Chief Operating Officer (COO), who is responsible for the overall functioning of the scheme, liaising with GoMP and adherence to service level parameters. The organization structure adequately represents both core and support functions: Core functions – Sense, Reach and Care, and key support functions – HR, Finance, Quality, Marketing, SCM and IT-IS. The function heads report to the COO, who closely monitors their operational plans and progress on a monthly basis.
Exhibit 3.1.1: Organization Structure8
Role of HR
Scope of Responsibilities 3.1.2 Key responsibilities of the HR function include: Manpower planning Recruitment Training Appraisal and Retention Grievance Redressal
8 Based on the understanding of the evaluation team, exact structure not shared.
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Manpower Planning 3.1.3 There are close to 2400 employees working at EMRI-MP currently. Human resource capacity plans are developed at the beginning of the financial year, in accordance with the requirement of state operations and manpower ratios decided at the national level, by the state HR head, the state COO and the national HR team.
3.1.4 The following table provides staffing details of EMRI with respect to existing staff and recruitment plans for the year given the expansion of services.
Exhibit 3.1.2: Current vs. Planned Manpower at EMRI
Ratios ( if any) Current Additional developed by Total Employee Manpower Planned National HR (A) + (B) (A) (B) team, EMRI Sense ERO 67 55 122 TL 2 2 4 Manager 1 - 1 Sense Total 70 57 127 Reach EMT 2.4-2.5 / 1095 400 1495 ambulance Pilot (per ambulance) 2.4-2.5 / 1140 400 1540 ambulance EME 1 per district* 23 17 40 PM 1 per 5 EMEs 6 2 8 RM 1 per 300 ambys 1 1 2 FT 5 - 5 FC 2 - 2 Operations 2 - 2 Reach Total 2273 819 3092 Care Physicians 7 2 9 PCR Cell 6 - 6 EMLC trainers 4 - 4 Care Total 17 2 19 Support Functions Human Resources 6 - 6 SCM 4 - 4 IT/IS 4 - 4 IEC 1 - 1 Quality 4 2 6 Finance 3 - 3 Support Total 22 2 24 Total 2382 880 3262 *40 EMEs are planned for 50 districts. 10 EMEs shall manage two districts each due to smaller sizes of identified 10 districts
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Assessment Findings: Manpower Planning 3.1.5 The process for annual manpower planning followed by EMRI is comprehensive and well adhered to at the state level. Discussions with the HR head and the COO also highlighted that the national team regularly reviews adherence to the plan and deviations, if any, which is a good monitoring mechanism in place. However, an area of improvement is the process followed to derive required number of EROs, which was not developed in concurrence to annual call and emergency forecasts.
3.1.6 Some of the findings with respect to sufficiency of staff in comparison to the requirement are given below: Sense EROs: Discussions with the sense and HR teams and the COO have highlighted that the number of EROs for the current call volume is insufficient, thus contributing to the high levels of unattended calls.9 Sense- TLs: The current number of 2 TLs and 1 Manager is not sufficient to handle the 24/7 ERC for 3 shifts. While recruitment plans are in place, to enable a more structure planning process for sense TLs, HR could evaluate defining a TL: ERO ratio. EMEs: During field visits, it was observed that to effectively monitor ambulance operations, the average number of ambulances that an EME could effectively monitor is 15. With EMRI planning to have 40 EMEs for 602 ambulances, this ratio would be sufficient. Ambulance Staff: The current ratio of pilots and EMTs per ambulance is 2.4 and 2.5 respectively, which has been developed by the national HR team based on the 6 day working week on field and the current staff leave policies. Field visits have shown that these ratios are adequate with respect to the current scale of operations. However, in case EMRI plans for more village-level demos and refresher trainings, these ratios might have to be revisited for the state. Support Manpower: Broadly, the current manpower is necessary for the various support and operational functions to work efficiently. There is a need to hire more support staff in the quality function to enable periodic audits of all 602 ambulances.
Recruitment Process 3.1.7 Recruitment for field level staff takes place at the state office through open advertisements with clearly mentioned qualifications and requirements. Efforts are made to hire local people for the field level positions to ensure retention. The minimum qualifications and recruitment process for EMTs, Pilots and EROs has been mentioned in Annexure 8.7. It is to be noted that in states such as Andhra Pradesh and Karnataka, the salaries of EMTs and Pilots have been found to be low and are currently being revisited10. An analysis of the same could not be done for MP due to lack of data.
3.1.8 For senior positions, the recruitment process involves interviews with state and national functional and HR teams. This 2-step recruitment process ensures monitoring quality of new hires and adequate negotiation of compensations.
9 Ineffective calls were observed to be high in May 2012 due to a sudden increase in emergencies and shortage of manpower 10 http://www.deccanchronicle.com/130807/news-current-affairs/article/how-can-108-staff-live-such-low-pay- high-court
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Training 3.1.9 The responsibility of organizing trainings for all employees lies with HR. While HR plans and schedules trainings, and conducts modules on organization orientation, HR processes and soft skills, all technical and process related trainings are carried out by respective core functional teams.
3.1.10 EMT Training: As discussed in the Care section, the Emergency Medical Learning team (EML) under the Care function is responsible to conduct trainings for EMTs. The 60 day preparatory training is conducted based on pre-hospital care protocols developed by the national Care team in collaboration with Stanford school of medicine. The training was found to be comprehensive and well-structured. In MP, to meet the EMT requirement for the launch of 502 new ambulances, the training duration was reduced to 35 days, the effectiveness of which is yet to be estimated.
3.1.11 Pilot Training: The Pilots undergo a 5 day foundation course which consists of 8 days classroom training and 2 days on-job training at their posting. During this training, tips to increase ambulance mileage, tracking mechanisms to ensure timely maintenance of the ambulance and defensive driving techniques are provided. 2-3 day refresher training programs are also organized on a need basis for pilots identified by EMEs. Additionally, FTs and FCs also provide on-site training at the ambulance during their scheduled field visits. This training was found to be sufficient for the pilots as only experiences drivers are hired as pilots.
3.1.12 ERO Training: The EROs undergo a comprehensive 21 day training programme where they are trained on process, geography of the state and typing skills. As part of the training programme, EROs are also provided training through screening of live calls and call simulations. This training program is delivered by the Quality team, Sense manager, Sense team leads and senior EROs, to ensure a good understanding of the various processes related to EROs.
Appraisal and Retention Appraisal 3.1.13 EMRI follows an annual appraisal process. The appraisal process starts with self-evaluation by each employee. This is followed by a technical evaluation of each employee by his/her immediate supervisor. A performance rating is given to each employee on the following parameters: Technical Knowledge Process Knowledge Planning and Organization Communication Customer Orientation/Service
3.1.14 Increment slabs are decided by the State and National HR and Finance teams based on budgets approved by the government for the respective year. Field visits have shown that while EMTs and Pilots were very motivated about the tasks, there is a general dissatisfaction on the level of remuneration currently being given.
Retention 3.1.15 A number of recognition programmes are being implemented by EMRI, especially for the field staff. Some examples include: Monthly Reward and Recognition programme, where nominations for best performers are made from the field and a certificate and token gift is given to one EMT and one Pilot every month Sports activities for the field level staff on a regular basis
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Field celebrations of festivals and special days such as Pilot day and EMT day, where contributions of pilots and EMTs are highlighted and celebrated.
Sports activities and celebration of special days for the field level staff
3.1.16 Overall the organization recognizes the importance of retention and mostly uses non-monetary retention and motivation techniques.
Grievance Redressal for staff 3.1.17 V Care: EMRI has launched a Grievance Redressal mechanism called VCare in 2013, which requires EROs to register staff grievances onto the application and provide complainants with unique grievance ids. The grievance data is then accessed by the related function - HR, Quality, Finance, SCM or Fleet, who are then required to address the issue within 24 hours of its receipt through detailed discussions with the complainants. An awareness campaign was initiated by HR to ensure all field level employees were made aware of the VCare facility for grievance redressal.
3.1.18 This is a good initiative by the organization to better address staff grievances. The process is still new and needs to stabilize. For example, a common issue observed is poor communication between the related function and the complainant on the grievance closure process The HR and quality teams need to audit some VCare complaints to further improve the resolution process
Evaluation of Knowledge-Attitude- Practices (KAP)
3.1.19 The following section highlights the findings of KAP analysis of key operational staff: Sense – EROs Reach – Pilots Care – EMTs
EROs 3.1.20 An evaluation of 10 EROs was undertaken by Deloitte to assess their knowledge and practices. The parameters used for the evaluation include:
Empathy towards caller measures the ability of the call taker in clearly recognizing and understanding the situation of the caller and nature of emergency being reported. Process knowledge measures the call officers proficiency of prescribed SOPs Responsiveness measures the effectiveness of the call officer in addressing the needs of the caller in a timely and appropriate manner. Communication skills measures the ability of the call officer to collect and share correct information with all involved stakeholders – caller, ambulance staff, doctors at the call centre, police dispatch officer etc.
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3.1.21 The following table summarizes the findings of the evaluation: Table 3.1.3: Summary of ERO evaluation
Gwalior Sagar Sehore
Parameter
ERO 1 ERO 2 ERO 3 ERO 4 ERO 5 ERO 6 ERO 7 ERO 8 ERO 9 ERO ERO 10 ERO
Empathy towards caller Process knowledge Responsiveness Communication skills
Good Average Poor
3.1.22 Overall, it was found that all EROs were confident about the process and adhered to the laid down process for all calls and conversed with callers patiently to understand and gather all required information. While being guided by the main process, EROs also exercised enough flexibility to handle variations posed by each emergency. All EROs were good in Hindi and all other dialects of the state. Experienced EROs were also observed to provide handholding support to new staff by constantly guiding them on the process. The motivation level of EROs was very high resulting in an energetic and positive environment in the ERC.
EMTs 3.1.23 This section highlights findings on EMT assessment. As detailed earlier, 9 EMTs, 14 facilities11 and 36 PCRs were evaluated across the 3 districts.
3.1.24 The table below highlights the profile of the EMTs interviewed. Effort was made to interview both old and new EMTs.
Table 3.1.4: Summary of EMT Profile
Gwalior Sagar Sehore
EMT
Profile
EMT EMT 1 EMT 2 EMT 3 EMT 1 EMT 2 EMT 3 EMT 1 EMT 2 EMT 3
BSc BSc, MSc Educational BSc, (Paramed DHCP, DMLT (on- BHMS BHMS BSc DHCP Qualification DMLT pathology DCA going) ) Experience
-Total 3 months 5 years 5 years 6 months 1 year 3 years 2 years 4.5 years 2 year
-In EMRI 3 months 3 years 18 months 6 months 1 year 9 months 5 months 4.5 years 9 months
11 Some facilities visited were common as most cases were referred to same facilities.
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Gwalior Sagar Sehore
EMT
Profile
EMT EMT 1 EMT 2 EMT 3 EMT 1 EMT 2 EMT 3 EMT 1 EMT 2 EMT 3
Trainings 30 days + 10 days -Joining 30 days 55 days 30 days 60 days 60 days 60 days (ITLS, 55 days 55 days BLS, BLSO) Yes – 5 -Refresher - No - No - - No - days Twice (3 -National & 5 days) Once Once Once (8 Once trainings at No –ITLS, No (ITLS and No No (4 days days) (ITLS) Hyderabad BLS, BLS) ITLS) BLSO
3.1.25 Key findings: All EMTs met the required qualifications as defined by HR (Annexure 8.7) All EMTs underwent the preparatory program implemented by the EM Leaning team The older EMTs underwent ITLS and BLS certification program at the national level from certified trainers. This process is beneficial as these EMTs could now be places in the 50 ALS ambulances. Only 1 of the 4 EMTs with more than 1 year experience in EMRI went through refresher training, highlighting the need for more frequent and better planned.
EMT Evaluation Parameters 3.1.26 The EMTs were evaluated using a pre designed structured schedule which was designed based on the EM SOPs provided by EMRI to the evaluation team. Annexure 8.8 details the assessment parameters and the tool used for the assessment. The broad domains used for evaluation are given in the below exhibit. For technical knowledge, each EMT was evaluated on general protocols and 2 of the three specific protocols related to medical, trauma and pregnancy.
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EMT assessment findings 3.1.27 Given below is a snapshot view of the overall impression of the assessment of Emergency Medical Technicians. Table 3.1.5: Summary of EMT Profile
Gwalior Sagar Sehore Assessment EMT EMT EMT EMT EMT EMT EMT EMT EMT Domains 1 2 3 1 2 3 1 2 3 Technical Knowledge General Medical Trauma Pregnancy Others Systems Documentation * Where possible, direct handling of cases was also observed to check adherence
Good- Correct response without Average-Response fair with Poor-Poor/Incorrect response with
probing probing probing
Technical Knowledge 3.1.28 The following table highlights key findings:
Table 3.1.6: Key findings of EMT evaluation of technical knowledge
Type of Areas of assessment Findings Protocols • 6 out of 9 EMTs had average to poor knowledge of the general protocols. • Six out of nine EMTs showed excessive dependence on ERCPs Patient assessment and even at the stage of patient assessment. General components of history • All EMTs were aware of lifesaving and assessment protocols protocols taking and assessing like CPR, GCS, BLS and AVPU. vitals • Five of the nine EMTs interviewed were confident and spontaneous in providing complete information about these protocols • Overall, one EMT had good knowledge, 3 had average while 2 had poor knowledge in this area. • All EMTs, needed probing in specific areas like observations Management of required in anaphylactic reactions and ideal patient position Medical medical emergency knowledge in a case of seizures. protocols cases like seizures, • The EMTs were not very conversant with the details and cardiac arrests etc. standard procedures for managing medical emergencies. • The dependency on the ERCP’s advice in managing medical emergencies was high among most EMTs interviewed.
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Type of Areas of assessment Findings Protocols • Overall, two EMTs each had good, average and poor knowledge in this area. • Four EMTs were able to confidently answer questions on Management of Trauma conditions in which they had to actively manage cases like vehicular and non- protocols amputations, poisoning, bleeding etc. vehicular trauma cases • Most EMTs interviewed needed probing in theoretically detailing out management protocols, signs and symptoms of shock, head injury and abdominal injuries etc. • Overall, five EMTs had poor knowledge in this area. Considering that pregnancy related emergencies constitute a significant proportion of all emergencies, this is an area of concern. • On extensive probing basic management protocols of emergency child birth and basic management of placenta were Pregnancy Handling pregnancy elicited from most EMTs. However, overall knowledge of other Related related emergencies. pregnancy related emergencies was very poor, including PPH, cases spontaneous abortions, prolapsed cord, and pre-eclampsia. • The % of pregnancy related calls received by 108 ambulances is the highest as compared to others. However it was observed in the evaluation that the technical knowledge level in EMTs regarding this was the poorest in comparison to other areas like medical emergencies and trauma cases.
3.1.29 Overall, the EMTs were conversant with standard management protocols of conditions they had attended themselves and not with those which they are mandated to be aware of theoretically. The Operating manuals were not available in all ambulances nor were most EMTs aware that they should be having it as a ready reference in their vehicles.
3.1.30 Also, it was observed that the EMTs trained in formal paramedic courses like DHCP and BSc (Paramedical) or with at least 1year of experience were relatively better equipped to handle emergency cases and had a higher level of overall conceptual clarity. Thus, there is a need to regularize refresher training as gaps in the understanding of basic EM protocols were found amongst the newer EMTs. No clear difference in EMT skills between the two types of preparatory training undergone could be drawn.
Systems knowledge 3.1.31 All the EMTs interviewed had good and consistent knowledge of systems and processes to be followed with respect to call handling, patient handover, drug and equipment indenting and demos.
3.1.32 An issue which was highlighted by some EMTs and also observed by the team was the absence of the ERCP advice in the filled PCR forms. This was due to the line being continuously busy or there being no connectivity. The PCR copies which were scrutinized by the team also had no mention of the ERCP names in a large number of them and contained common instructions like O2, V.M. and LLP.
Documentation 3.1.33 The team checked and verified records and registers which were mandated to be maintained by the EMT, including patient/clinical (PCR, patient data etc.), inventory (stock of drug, equipment,
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Bio-medical waste etc.), vehicle checklists (fleet and quality related etc.) and administrative (attendance, demos etc.) documents.
3.1.34 Considering the large amounts of documents which are mandated to be maintained by EMTs, the overall quality of documentation in all ambulances was found to be satisfactory. Most EMTs had records updated up to the same day of interview or the previous day. Exceptions include : 3 continuous cycles of vital monitoring is sometimes not done as mandated but information on the same is filled in the form. Stock registers were not updated in some ambulances Demo registers were not available . General observation 3.1.35 Overall, it was observed that EMTs were courteous and sensitive to the needs of the patients. They received calls and answered the patients politely and tried solving their queries regarding ETA (expected time of arrival) or any first aid if required. The EMTs also tried alleviating the callers’ anxiety in the best way possible and counseled them on any immediate pain alleviation techniques for e.g. immobilization, using a tourniquet for arresting blood flow or cold fomentation if required in some cases. Additionally, they provided counseling on schemes like JSY in government facilities to pregnant women en route to the facility.
Pilots 3.1.36 An evaluation of 9 Pilots was undertaken by Deloitte to assess their knowledge and practices. The parameters used for the evaluation included:
Process Understanding measures the level of operational and technical understanding the pilot has with regards to the processes defined by the fleet team. Records maintenance measures the completeness and correctness of documents and records that are required to be filled by pilots Vehicle Maintenance measures adherence of pilots to processes related to maintenance of vehicles, including scheduled servicing, refueling, tyre management, accident management etc. Medical Equipment measures initiatives taken by pilots to ensure availability of required equipment and timely indent of non-functional equipment, in coordination with EMTs. Pilots were also measured for timely filling of oxygen cylinders in the ambulance
3.1.37 The following table summarizes the findings of the evaluation:
Table 3.1.7: Summary of Pilot evaluation
Assessment Gwalior Sagar Sehore Parameters Pilot Pilot Pilot Pilot Pilot Pilot Pilot Pilot Pilot 1 2 3 4 5 6 7 8 9 Process Understanding
Records Maintenance *
Vehicle Maintenance Medical Equipment –
Availability & Maintenance * As detailed in the ambulance checklist Good – Consistence Adherence of Average –Adhoc implementation of Poor - No implementation of SOP SOP SOP
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3.1.38 Following are some of the key observations of the assessment: Process Understanding: Process understanding among pilots was reasonably good. 7 out of 9 pilots had an excellent understanding of fleet processes including vehicle maintenance, accident management, insurance recovery, fuel management, tyre replacement etc. However, 2 pilots were found to be average in their process understanding skills. Records Maintenance: Documentation levels were observed to be excellent with pilots clearly maintaining records of daily vehicle usage information related to no. of trips, distance traveled, quantity of refuel, break down details, accident information, if any etc. Vehicle Maintenance: All pilots assessed were found to be good in maintaining the vehicle as required by SOPs defined by the Fleet team. The scheduled service timelines were being adequately monitored and adhered to, supported by strong on-field vendor. The pilots were observed to be especially good at implementing local initiatives to increase tyre efficiency like rotation of Tyres, ensuring and optimum pressure. The fleet handbook distributed by the state fleet team was found to be very useful to the pilots. Availability and maintenance of medical equipment: In 7 out of 9 ambulances, the pilots played an active role in constantly monitoring the status of equipment and oxygen in the ambulances, by ensuring timely indenting, reporting non-functionality to EMEs, attempting local repairs , where possible etc.
Assessment Summary: Human Resource
HR processes: The planning, recruitment and annual appraisal processes are robust and are well handled by the recruitment team, supported by comprehensive review mechanisms by the national HR team. The state has also implemented good non-monetary performance, retention and grievance redressal measures, resulting in high levels of motivation among staff. An area of improvement is the manpower planning process for sense which should be done based on call and emergency forecasts, and trends of call handle time.
KAP of staff: Overall, EROs, EMTs and Pilots were observed to be very good in processes, empathy towards beneficiaries and documentation. Staff was found to be very motivated about the tasks being undertaken. EROs, were found to be adept at the call handling process EMTs were conversant with standard management protocols of conditions they had attended themselves but not with those which the EMTs were mandated to be aware of theoretically. They also required frequent ERCP advice for some infrequent conditions. Thus highlighting the need for more robust mechanisms of refresher trainings, especially for new EMTs. Pilots were found to be very good in process knowledge, vehicle maintenance and documentation. There was limited need for any kind of an exhaustive refresher training program as most pilots had prior driving experience
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3.2 QUALITY . Scope of Responsibilities
3.2.1 The Quality team in EMRI, comprising of 4 members, is responsible for driving and monitoring service quality and process adherence through clearly defined processes and periodic review mechanisms. The following exhibit details the scope of activities currently undertaken by the team.
Exhibit 3.2.1: Current responsibilities of the quality team
ISO Certified Quality Management System 3.2.2 At the core of the quality function of GVK-EMRI is its Quality Management System (QMS), certified in ISO 9001:2008, which consists of processes defined across core and support functions .As part of this initiative, the organization has a long term quality policy statement to guide the policy initiatives of the state. The policy also clearly shows the vision the organization has in establishing systems and policies.
Exhibit 3.2.2: Quality Policy of GVK-EMRI
We are committed to ‘Sense, Reach and Care’ every Emergency in the state, with the best in the world standards, ensuring delight to Customers, Associates, Partners and Investors through ― Visionary leadership ― Continual improvement by innovation and technology
― A suitable , scalable, and replicable business model
3.2.3 The quality function is responsible for periodic up gradation of all processes, monitoring of process adherence and review of status of the organization with respect to the defined vision.
Ambulance Go-Live Audits 3.2.4 The quality team is responsible to conduct pre-deployment audits during the launch of new ambulances after completion of all fleet and supply chain related activities, such as vehicle
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procurement, refurbishment, registration, and drug and equipment stocking. The following exhibit shows the stage of quality go-live audits in the life-cycle of new ambulance procurement.
Exhibit 3.2.3: Stage for New Ambulance Go-Live Audits
3.2.5 As part of the Go-Live audits, the quality team checks whether new ambulances meet the required compliance standards in terms of equipment, drugs, records, vehicle documents etc. If the vehicle meets the required standard, the quality team transfers them to the field operations team for deployment; else they are sent back to the SCM team to address identified gaps.
Sense 3.2.6 Key activities undertaken by the quality team with regards to the Sense function have been detailed in the following exhibit.
Exhibit 3.2.4: Scope of Sense related Quality Audits
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ERO Evaluation 3.2.7 The quality team conducts periodic audits of all types of calls (EM calls, 48 hour follow- up and case closing), either through retrospective listening of recorded calls or through live call barging. The EROs are evaluated on process adherence, handle times, language and skill sets. Feedback based on findings is then shared with the EROs either monthly or bi-monthly.
Analysis of Vehicle Busy and Unavailed Cases 3.2.8 This is a recent initiative of the quality team where one of their team members dynamically tracks Vehicle Busy (VB) and Unavailed12 (UA) cases as they occur. Once they are intimated by Sense of the occurrence, they are in constant touch with the VB help desk and the respective field operations team to understand issues faced, operational errors, if any and possible mitigation steps that could be implemented. They also provide real-time telephonic training advising EMEs on more efficient tracking systems that could be implemented for UA and VB cases.
Analysis of ineffective calls 3.2.9 The main process in place for addressing ineffective calls (specifically nuisance calls) is the periodic identification and blocking of frequent callers. A dynamic frequent caller report generated by the IS team is used for identifying frequent callers.
Custodians of the Operational support Desk 3.2.10 The quality team is also the custodian for four applications that are integral to the sense and reach operations.
Sense VCare for grievance handling E Visit for recording visitor feedback at the state level Reach Fleet Management System (FMS)for monitoring vehicle uptime Customer Feedback Management System (CFMS )for 48 hour follow-up
Reach – Ambulance audits 3.2.11 All ambulances are audited by the quality team once a quarter based on a checklist covering manpower, fleet, operations and supply chain management.
Care 3.2.12 Currently, the team does not conduct particular audits related to provision of care by EMTs and medical direction by ERCPs. EMT audit: The plan is in place to launch care audits. Audits on EMT care shall be done by integrating with the existing process followed by ERCPs to evaluate EMT care based on PCR evaluation of critical cases. Feedback shall then be provided to all EMTs in a more organized manner. ERCP audit: ERCP audits would be conducted on the lines of ERO audits where the CARE lead shall a fixed number of audits of medical direction and IFT calls and provide monthly feedback to them. It is important for this initiative to launch as soon as possible as care provision is the backbone of the 108 services
12 Unavailaled cases are cases where the ambulance is dispatched for the call, but it is not utilized by the caller either because the caller transports the case through other means instead of waiting for the ambulance or due to a fraud EM call made
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Supply Chain Management 3.2.13 Periodic supply chain audits are undertaken by the quality team to track indent vs. disbursal of consumables. The team also conducts physical audit of stock vs. stock recorded on Oracle software.
Assessment Findings: Quality 3.2.14 Reasonably good adherence to defined processes: With respect to implementation of the policy and the processes, broadly the evaluation of all functions of EMRI shows that most processes are consistently followed by the teams owing to skilled, experienced and motivated functional teams driving implementation. Adherence is also driven by constant review and monitoring by the national functional teams of GVK EMRI. This additional check on processes is a sure strength to the system. With regards to the state quality team, while there is adequate focus on driving core functions, they play a limited role in ensuring process adherence for support functions.
3.2.15 Inadequate internal auditing processes: The ISO certification requires the organization to identify quality champions and train them to be internal auditors, who would be responsible for periodic audits of defined processes and ensuring high level of compliance with processes. Currently, the quality team has identified only 3 people as internal auditors for all the functions, which are inadequate considering the number of processes would be in excess of 50. There is also no clear plan of internal audit, defining periodicity, responsibility and documentation formats. The last internal audit for support functions was done in September 2012, the findings of which were not shared with the evaluation team, making it difficult to comment on the comprehensiveness of the earlier done audits.
3.2.16 Exhaustive Go-Live Audits: The quality team has exhaustive and well-defined checklists, covering various aspects of the Go-Live audits, including medical and general consumables, equipment, documents, extrication tools, oxygen requirements etc. The process was followed meticulously for the recent launch of 352 ambulances, where the team also developed a launch tracker to monitor progress. This also helped the team identify and address critical paths in a timely manner.
3.2.17 Good ERO Evaluation processes: This evaluation is done regularly by the Quality team and is a critical factor impacting adherence to call taking processes at Sense. EROs also expressed their satisfaction with the process and the benefits of sharing periodic feedback. The findings of the quality audit are also included by the sense team leads into the EROs’ monthly performance evaluation chart.
3.2.18 Analysis of VB and UA cases: This is a commendable initiative by EMRI as VB and UA cases should be focus areas as these are emergencies that EMRI could not handle (except UA cases due to false reporting of emergencies). The importance of the initiative is reiterated by the large proportion of UA and VB in comparison to medical dispatches (4.3% and 17% respectively for the period – July-Dec 2012)
3.2.19 Inadequate monitoring of ineffective calls: While this activity has the potential to be an important step towards addressing the large number of ineffective calls in the ERC, the issues are The process was only implemented till February. It has since been very sporadic and infrequent, as the team was engaged in go-live audits for the 352 new ambulances There is inconsistency with respect to understanding of the process by the various management and operational stakeholders , indicating that it is not a focus in the system
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3.2.20 No other data analysis on ineffective calls is done to come up with exact action plans. It is important for the quality team to carry out monthly analysis of ineffective calls (like the Deloitte dipstick study) to identify possible causes and actions that could be taken.
3.2.21 Comprehensive and periodic ambulance audits: A recent initiative by the quality team was also to train a number of state EMRI officials on the ambulance checklist to conduct a comprehensive audit of all 454 ambulances. The audit was completed in April 2013 and the team is now following up with the supply chain, fleet and field ops teams to close ambulance wise non- compliances. This initiative is an important step in ensuring complete availability of drugs, equipment and infrastructure in ambulances. However, documentation of periodic progress of closure was found to be weak.
3.2.22 Ambulance audits done by Deloitte have shown minor unavailability of equipment (as shown in Annexure 8.9). However, replacement process for non-functional or missing equipment identified during the above audits was already underway.
3.2.23 Irregular SCM audits: It was observed that these audits were only conducted till December 2012 since the team was engaged with the launch of the new 352 ambulances. It is important for the quality team to resume this activity as the store team does not conduct any physical audits, which could lead to gross mismatches between the online system and availability of physical stock.
3.2.24 Operational Support Helpdesk: The applications are being adequately used and monitored by the quality team, which coordinates with the technology team in case of any required modifications.
3.2.25 Minimal Data Analytics: While the team is responsible for driving process adherence, there is minimal focus on evaluating the impact of processes through exhaustive data analytics. Fleet was the only function observed to be conducting in-depth analysis of data to drive operations. Quality team should be the custodian of both processes and performance of key parameters. It is thus suggested that the team has a dedicated associate to produce periodic multi-functional periodic analytical reports in constant coordination with the IS team.
Assessment Summary: Quality
The quality department plays a critical role in the monitoring of internal processes. With their Quality Management System certified in ISO 9001:2008, processes are well defined for all core and support functions. Audits for all core functions are done diligently by the quality team; including new- ambulance go live audits, evaluation of sense manpower – skill, attitude and process knowledge, audits on vehicle busy and unavailed cases and on-field ambulance audits.
There is a need for the team to increase its focus on monitoring and auditing support functions. Currently no internal audits are done by the team to track and drive process adherence of support functions. Other areas of focus for the team need to be audits of medical direction and ineffective calls. Overall apart from the processes, the team should also champion driving service parameters through thorough analyses of existing data.
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3.3 SUPPLY CHAIN MANAGEMENT
Scope of Responsibilities
3.3.1 The 108 operations involve frequent procurement of capital and operational items such as: CAPEX ― Vehicle related: Ambulances, refurbishment, equipment, AVLTs, mobile phones etc. ― Office and infrastructure related: Call center equipment, office furniture, computers, software requirements etc. OPEX ― Vehicle: Tyres and repairs and maintenance of vehicles ― Ambulance infrastructure: Drugs, Consumables, Equipment maintenance and stationery
3.3.2 The supply chain team, comprising of 4 members, is responsible for all procurement and state level inventory management related activities of EMRI. Scope of activities of the state supply chain team includes: Procurement Related o Managing the procurement process o Liaising with national SCM for specifications and national tenders o Organizing and driving procurement committee meetings for all tenders
Store Related o Stock management and distribution for ambulance equipment, consumables and stationery Procurement
3.3.3 Processes for procurement are defined and monitored by the National SCM team of GVK EMRI. The state SCM team then customizes the same for the state, if required and implements the same for all its procurement related activities.
3.3.4 Exhibit 1.3.1 shows the current procurement process in place.
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Exhibit 3.3.1: Snapshot of the Procurement process
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Assessment Findings: Procurement
3.3.5 Comprehensive annual budgeting plans: The process of estimating and budgeting all OPEX and CAPEX that require procurement on an annual basis is guided by a preapproved plan that is developed by the state teams and reviewed at the national level. This process helps the procurement and finance team better monitor procurement with respect to improving cost efficiency.
3.3.6 Adequate review of procurement requests: During the year, any procurement that is required to be done is thoroughly reviewed by the SCM and Finance teams, post discussion with the requesting department on the need, specification and cost of the item to be procured. The recommendation is then shared with the national procurement for a quick review. For large value items, a summary of the recommendation is also sent to GoMP. The national procurement team plays an important role in closely and constantly monitoring state procurement processes.
3.3.7 National procurement for economies of scale: Since EMRI is operational in over 12 states, to take advantage of economies of scale, the national procurement team issues national tenders for frequent or high cost items. This is done only for states which agree to follow the national tender route for specific items. The EMRI-MP team periodically submits letters to GoMP seeking their opinion and approval for planned national tenders. On approval, the final list of nationally tendered items, prices and vendor details are shared with states. This is a valuable benefit that GVK EMRI brings to the partnership as it has the potential to significantly reduce costs for the state.
3.3.8 Good procurement process in place with detailed documentation: In cases of items that are not tendered nationally, the state SCM team procures them depending on the value of the item or service required to be procured. All tender committee meetings and tender openings are adequately documented by the state SCM team (as observed during document review). The document clearly covers details such as members involved, list of bidding organizations, reasons of disqualification, details of bidder wise technical specifications, qualified technical bids, list of selected vendors etc.
3.3.9 Use of Oracle for monitoring procurement: The use of Oracle’s purchase module enables better online monitoring of the procurement process. Since this model is also linked to the finance module, the process ensures that payment to vendors is made only on satisfactory compliance of delivery as per the issued purchase orders, thus enabling the finance team better monitor procurement related costs.
3.3.10 GoMP monitoring: While the internal processes at EMRI appear comprehensive, the level of GoMP monitoring is inadequate. Given the high quantum of annual procurement, the MoU does not state any procurement guidelines. In order to monitor and drive cost efficiencies, there is a need for GoMP to strengthen monitoring processes for both national and state level procurement.
Store, Indenting and Stock management
Store Management 3.3.11 All consumables (general and medical), repaired equipment and record formats to be sent to the ambulances are stocked in the store handled by store staff reporting to the SCM head. Staff at the store, comprising of 1 store manager and 2 associates, are responsible for periodic physical checks of the stock, receipt and verification of vendor goods, dispatch to ambulances and raising timely stock demands.
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Indenting and Inventory Management 3.3.12 Ambulance indents: Ambulances indent required consumables and equipment on a monthly basis in the form a hard copy format provided by the SCM team, consisting of date of indent, current stock, previous month consumption and required stock. The store staff then analyse each indent based on the information furnished by the ambulance on monthly consumption and available stock. Ambulance wise indents are then stocked and packaged to be delivered to the ambulance site.
3.3.13 Documentation of indent dispatch: Ambulance wise indents are entered onto an excel tracker once every 7-10 days by the store staff. Monthly consumptions are calculated for all consumables and compared with available stock to finalize batch sizes of consequent lots.
Assessment Findings: Store Management
3.3.14 Inadequate tracking of ambulance utilization trends due to absence of a computer at the store: The store does not have a computer and printer which are important to implement proper inventory management processes. The same would also enable the store manager better track ambulance wise utilization trends of consumables.
3.3.15 Good store arrangement practices: Drugs, equipment and documents in the store are organized based on recommended store management guidelines including alphabetic sorting and FEFO (First Expiry First Out) principles.
3.3.16 Timely fulfillment of ambulance indents: The indent management process at the store has been observed to be good. Indents are fulfilled in a timely manner which is important given the criticality of service being offered by the organization.
3.3.17 Manual inventory management processes: The current process does not clearly define minimum stock, stock holding time or economic order quantities. It is calculated by the SCM team only based on monthly consumptions. While no apparent stock outs were observed, the current process is manual and time consuming. Skills of staff would need to be enhanced to address the current gap in assessing exact demand. While the organization uses Oracle for purchase process, the same is not used for inventory management. Using some inventory management module for the same would be beneficial for the organization in more accurately tracking consumption and indents.
Assessment Summary: Supply Chain Management
The supply chain management function of GVK EMRI is an important function of the organization. The strength of the function is its clearly defined processes and close monitoring exercised by the national supply chain team of GVK-EMRI. In MP, adherence to these processes was found to be high along with high standards of documentation. The use of Oracle helps the SCM and finance teams better monitor related processes. While store and ambulance indents are managed very efficiently by the team, inventory management is an area of improvement.
At the policy level, better review mechanisms by GoMP, of both state and national procurements, would strengthen the current procurement process and drive cost efficiencies.
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3.4 MARKETING
Scope of Responsibilities 3.4.1 The marketing function of EMRI is responsible for the following activities: Brand management of GVK EMRI, 108 and GoMP Public relations at the state and district level, including press releases Planning ambulance launch events Spreading awareness of the service through appropriate communication strategies
Assessment Findings: Role of Marketing 3.4.2 Till December 2012, EMRI was responsible for handling all IEC/BCC activities for the ERS in the 10 districts where services were operational. However as per the renewed MoU, the responsibility to promote public awareness in emergency response lies with GoMP in consultation with GVK EMRI, which has been given limited annual budgets.
3.4.3 Due to limited annual budgets for marketing, it leaves very less scope for EMRI to promote awareness activities in the state. This often leads to EMRI requesting for special approvals from GoMP for additional budgets.
State level Marketing 3.4.4 The marketing in-charge develops annual plans detailing campaigns and major events to be conducted at the state level in discussion with the COO and the national marketing team, which are then discussed with GoMP and implemented.
3.4.5 At the state level, the various media used by the team has been described in the exhibit below –
Exhibit 3.4.1: IEC/BCC activities undertaken by EMRI
IEC/BCC Activities undertaken by EMRI
• Ambulance branding • Media coverage- print media, TV ads, radio spots, interviews on Doordarshan, • Demonstrations in schools, colleges, • Pledge to Save Lives Campaign • Wall paintings • Hoardings • Stickers on buses • Posters and pamphlets • Water tank paintings
Field level marketing 3.4.6 The plan for field level IEC/BCC activities is drawn up in consultation with the EMEs and PMs. As discussed in the Reach (Field Operations) section, the most frequent awareness mechanisms used on the field include demos, news articles on cases handled and ambulance launches in local newspapers and coordination with ASHAs for using the service for planned deliveries in the absence of JEY.
3.4.7 On an average, 3-4 demos are required to be conducted per district per day. The EMTs and Pilots are also trained on aspects of IEC/BCC activities during their induction period.
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Assessment Findings: State and Field level marketing activities
3.4.8 Significant activities during launches: Ambulances launches are a major means of spreading awareness of the scheme. EMRI has developed detailed processes guiding teams on procedures to be followed for launches including recommended chief guests, panel guests, speakers, involvement of stakeholders and press messages. The marketing function plays a significant role during the launch phase in spreading awareness of the number through press releases and, event and ambulance branding.
3.4.9 Lack of clear target messages: The annual marketing plans are not developed with objectively formulated target messages for various user categories across the state. Analysis of impacting factors such as geography, social status, morbidity patterns, proximity to health facilities etc. are not used to analyze the need and customize target messages. No. of emergency calls received during a period is sparsely used to plan demos in some regions.
3.4.10 Absence of a strategic marketing plan: During the state level meetings with EMRI, it was noticed that there is absence of a strategic communication strategy which details clear marketing objectives and related implementation plans. The current process only lists down annual requirement of marketing material such as badges, caps, posters etc.
3.4.11 Target Campaigns: Very few implemented campaigns target critical awareness needs such as Low awareness levels of fire and police services Low awareness levels of medical emergencies, other than pregnancies and trauma High % of ineffective calls. It was observed that no topic or target message based demos were conducted across the state.
3.4.12 District and Village plans: To develop current demo plans for districts and villages, data from Sense and Reach functions is not adequately analyzed to understand specific issues and prioritize demo locations.
Good Practices from the Field
3.4.13 The following section highlights some good practices observed at the state and district levels, which could be scaled up on a regular basis.
Radio Campaign at the state level: Indore, Jabalpur and Bhopal Districts 3.4.14 EMRI in collaboration with 92.7 FM conducted a radio campaign ‘Pledge to Save Lives’ in Indore, Jabalpur and Bhopal during the Road Safety Week to spread awareness in urban areas on the need to report a trauma emergency as quickly as possible and to give way to ambulances on busy urban roads.
Demos to increase emergency cases: Hoshangabad District
Need of the campaign 3.4.15 An analysis of data from the field indicated that the number of emergency cases being handled per ambulance per day was much lower in Hoshangabad district compared to the average of 10 districts. Demography Average number of trips per ambulance per day
Hoshangabad 2.4* 10 districts average 4.3** *August-December 2012 **July-December 2012
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Implementation plans
3.4.16 Targeting influencers: In order to raise awareness about the 108 service and to increase the number of emergency cases, a comprehensive IEC/BCC plan was drawn up for the district. The aim was to target those who are viewed as decision makers and influencers as well as the general population.
ASHAs - As part of the strategy a number of demos were held at schools, public health facilities and at the ASHA training centre. These demos showcased the ambulances, the equipment available to manage emergencies, the pilots and EMTs knowledge and experience of managing emergencies. The process of calling a 108 ambulance was also explained.
IEC/BCC activities undertaken in the field
Panchayats - Efforts were also made to work along with Panchayats to raise awareness levels of the community. A chopal was held at the Gram Sabha in Panjakarla village where the Sarpanch and 100 villagers took an oath to call the 108 helpline for any emergency. The reach of the chopal goes further than just the 100 villagers covered. The Sarpanch acts as an influencer and at the time of an emergency would encourage the people to call 108.
Community level awareness programme
Impact 3.4.17 Due to the targeted marketing efforts undertaken the number of emergencies per ambulance per day rose from 1.46 in August 2012 to 3.68 in February 2013.
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Strict action leads to reduction in hoax calls: Indore District
Need of the campaign 3.4.18 There were a number of hoax emergency calls being received by the ERC which were traced to Indore district. The callers would request an ambulance to be sent to a specific location to attend to emergency. However, when the ambulance would reach the site they would find that there was no emergency to attend to, thus leading to an increase in the number of unavailed dispatches.
Implementation plan
3.4.19 Print media: To reduce these hoax calls, a targeted IEC/BCC campaign was undertaken. Using the print and electronic media, awareness was raised about how by responding to fake calls ambulances were missing genuine emergencies.
Use of Print media to cut down hoax calls
News Coverage on pinning down of fake callers
3.4.20 Coordination with Police: The marketing team worked along Sense and Field operations to identify the source of the hoax calls. As part of the strict measures taken to reduce the fake calls, 3 arrests were made of people making numerous fake calls. Media coverage of these arrests stressed the importance of using the 108 helpline only to genuine emergencies. Impact 3.4.21 The ERC saw an immediate reduction in number of hoax calls from Indore following this IEC/BCC campaign.
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Assessment Summary: Marketing
The marketing team continues to play an important role at the state level in brand building and developing annual communication plans. The team also monitors demos being conducted at the field level. However, the team needs to focus on following a more strategic approach towards its communication strategies w.r.t identification of target messages, development of need based plans and addressing key gaps such as ineffective calls and medical emergencies in addition to trauma and pregnancies.
At a policy level, the Government would need to decide the way forward for marketing activities with respect to the current arrangement of GoMP being responsible for spreading awareness. GoMP and EMRI would have to evaluate developing joint IEC/BCC plans and define mechanisms for review of additional budgets required for the same.
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3.5 INFORMATION TECHNOLOGY
3.5.1 The Information Technology and Information System (IT-IS) function is responsible for the day- to-day oversight and management of all IT enterprise system implementation within the organization as shown in the exhibit below. The team is also responsible for implementing processes to constantly streamline and redesign various technologies and business systems across all functions to improve system efficiency. This section aims to give a very brief snapshot of the scope of services and highlight some broad technology challenges, if any. The section does not evaluate detailed technical specifications of the solutions being used at EMRI.
Exhibit 3.5.1: Responsibilities of IT-IS Team
Software 3.5.2 A list of key software applications being used in MP operations by EMRI are- ERO application (Sense) Care application to provide OMLD (Care) Daily Automated Reports (Sense) Customer Feedback Management System (HR) V Care for grievance redressal (HR) The applications are detailed in the respective sections on their usage.
3.5.3 Development of Core applications: The national IT team of GVK-EMRI monitors the development and changes to any of the applications being used. These applications have been developed by technical partner, Tech Mahindra. The national team adequately tests and evaluates applications before launching them for use in the states.
3.5.4 Maintenance of Core applications: The IT team’s main responsibility is to ensure 100% uptime of all core 108 applications which include the Sense (all related applications - call taking and ambulances dispatch), case closing and fleet applications, since this affects the organization’s
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main service of handling 108 calls that land on 108. With the current server uptime being more than 99.9%, the IT team does a commendable job of undertaking adequate preventive steps to keep a check on downtime.
3.5.5 Report Generation: While EMRI stores all call and EM data, the IT-IS team member is responsible to ensure that all planned and automated reports, both internal and to the Government, are generated on schedule as is the case currently. The team also collates other adhoc report formats submitted to them by the various functions based on an evaluation of their criticality and approval of the COO.
3.5.6 Other software- The team is also responsible for defining specification of all other software required to be procured for the staff and renewing required licenses.
Hardware 3.5.7 All hardware specifications and application design is coordinated and monitored by the National IT-IS team. The benefit is the incorporation of best practices and efficiencies collated from all GVK-EMRI’s implementation states.
3.5.8 The state IT-IS team ensures timely procurement, preventive maintenance and issue redressal for all hardware involved in the system, including . Data storage discs for information and call recording.13 . Nortel communication system at the call center . Voice logger at sense . All other admin and application servers
Assessment Summary: Information Technology
The IT-IS systems of GVK- EMRI are well designed to enable efficient call handling, safe data storage and data analysis. This support function is a mainstay for smooth functioning of 108 services in the state. Through its partnerships with Tech Mahindra to develop core application, EMRI designs, reviews and updates its IT systems nationally.
The state IT team does a commendable job of ensuring more than 99.9% uptime and undertaking adequate preventive steps to keep a check on the same. Overall technology and data are definitely some of the key strengths of the organization. However, there is scope to increase the level of data analysis done at the organization.
13 Data is store in three places – Storage Area Network (SAN) with mirroring in the call center, external hard drives in the EMRI building and in the EMLC.
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CHAPTER 4
CONTRACTUAL AND INSTITUTIONAL FRAMEWORK
Assessment of ERS Performance in Madhya Pradesh Final Report
Introduction 4.1 As discussed in Chapter 1, the 108 service functions through a Public Private Partnership (PPP) model between GoMP and GVK EMRI. GVK EMRI has been appointed as the nodal agency to provide emergency response services. The current MoU14 between GoMP and GVK EMRI is valid for a period of 5 years (November 2012-2017).
Scope of Responsibilities 4.2 Under the MoU, EMRI is responsible for providing technological, leadership, strategic, managerial and operational support for the project. The role of EMRI as per the MoU includes: Provide technological, leadership, administrative and managerial support to produce mutually agreed outcomes Operationalize and maintain fully equipped ambulances on a 24x7x365 basis Ensure 24x7 services at the call centre located in Bhopal Procure ambulances and get them insured and equipped as mutually agreed. Ensure that each ambulance has at least one pilot and one EMT present at any given point of time to provide patient-stabilization, first aid and other pre hospital care Recruit, train and position qualified and suitable personnel for implementation of the project at various levels. Maintain financial transparency in terms of financial planning, disbursal, accounting and auditing Ensure proper and timely monitoring of the services
4.3 On the other hand, the state government is responsible for all capital and operational expenditure of the project including procurement and refurbishment of vehicles, call centre related capital costs, ambulance related operating costs, salaries of staff15 etc. The role of the Government as per the MoU includes: Disbursal of OPEX quarterly and CAPEX on completion of required tender processes Formation and proper execution of state and district committees Review and approve guidelines and procedures for operation of ambulance services Provide parking spaces for stationing ambulances across the state Conduct regular monitoring and evaluation of project activities based on reports submitted by the private provider and review meetings Promote public awareness in consultation with GVK EMRI.
Institutional Structures
4.4 The MoU mandates setting up committees at the state and district levels to advise and monitor the functioning of the scheme according to defined clauses. The following table gives a snapshot of the members, role and current status of each of these committees.
14 Signed on 27th December, 2012. 15 GVK EMRI is required to bear the salaries of senior management placed at Bhopal whose salaries exceed Rs. 12 lacs per annum. In the current situation, only the COO gets a salary greater than the current cap.
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Table 4.1: Committees to be formed as per MoU
Name of Members Responsibilities Current Status Committee (Findings from Field Visits) Advisory Chairman: Chief Secretary To meet at least once a year - The Council is required to Council meet once before December GoMP: Principal Secretaries - Strategic review of 2013. As of June ‘13, the and Commissioners of Health, performance/ implementation council meeting had not been Finance and Home, MD- plans and reports submitted by convened. NRHM EMRI and review of
GVK EMRI: CEO and COO of recommendations submitted by
MP operations Executive Committee. Executive Chairman: Principal -To meet at least once a - No formal EC meetings had Committee Secretary, DoHFW quarter been convened till June’13. However, EMRI constantly GoMP: Commissioner Health; -Review SOPs, status of service communicated with the MD-NRHM; Directors, Health parameters, release of funds, DoHFW Principal Secretary, Services, Medical Education, reports submitted and fund and MD and Commissioner Fire Services, Finance; IG utilization. Issue special NRHM to convey process Police; Special Officer guidelines, where required. updation, extra budgets appointed for ERS MP requirements and launch plans.
GVK EMRI: COO of MP operations
District -Chairman: District Collector -To meet once a quarter - In all three sample districts, Committee the committees were not in GoMP: District Collector; -Review district operations of place. Adhoc reports on CMHO; Superintendent, 108 services – trends of emergencies handled were Medical College, Civil emergencies and reach times, submitted to the district office. Surgeon- District Hospital; ambulance uptime, awareness In Sagar and Sehore, Collectors Chief Municipal Officer; activities, launch progress, and CMHOs conducted District Heads of Fire and feedback on Govt hospitals, frequent reviews mainly during Police Depts. Grievance redressal etc. launch of new ambulances in the district GVK EMRI- District Emergency Management Executive – EME) Special Appointed by the MD, NRHM - To liaison with GVK-EMRI to - A Deputy Director under Officer periodically review their NRHM has been the 108 operations, reports, and Special Officer since June adherence to budget caps and 2011 and is well informed service parameters. about the scheme with respect to its funding, processes and performance.
* Mutually decided nominees (including relevant Deputy Directors and Joint Directors) are also part of the committees.
Assessment Findings: Institutional Structures
4.5 Well defined institutional structures: The new MoU details out the required institutional structures with respect to roles and responsibilities of each of the stakeholders as well as committees at various levels. It is envisioned that the advisory, executive and district committees would advise and review EMRI with regards to its strategic and implementation plans.
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4.6 However, as indicated in the table, committees defined in the MoU have not yet been formally implemented. In most of the cases, either the meetings are not being held or are being held in an informal settings. These meetings are important to ensure continuous appraisal of performance of the services at various levels and help coordination between various stake holders. Infrequent meetings often leads to issues such as: - Lack of integration with police and fire departments, leading to absence of coordinated response as required in medico-legal cases and spreading awareness of 108 for police and fire cases - Inadequate mechanism of reporting to and monitoring by Govt. officials, leading to non-redressal of issues such as high ineffective calls, insufficient audits of support function processes, weak technical knowledge of EMTs, non-adherence to agreed service parameters etc. - Lack of coordination for marketing strategies involving joint communication plans
Funding
4.7 As per the MoU, GoMP bears all OPEX and CAPEX costs. This section seeks to briefly analyze the funding requirements of the MoU. A detailed analysis of the same could not be carried out due to lack of data.
4.8 OPEX: The MoU details out limit per ambulance per month for various budget heads as shown in the following table
Table 4.2: Estimated OPEX per ambulance per month
Limit per S.No Item ambulance % per month (in INR) 1. Ambulance Running and Maintenance 30,800 31.5% 2. Salary 57,500 58.9% 3. General office/Administrative Expenses 4,400 4.5% 4. Recruitment Expenses 2,800 2.9% 5. Marketing Expenses 400 0.4% 6. Miscellaneous, inc Traveling Expenses 1,800 1.8% Total 97,700 100%
4.9 Operational expenses borne by the Government includes all expenses related to 108 operations in Madhya Pradesh. Salaries of senior management of the national operations of EMRI, headquartered in Hyderabad, are not considered as OPEX and are borne by the private partner – GVK-EMRI. The government pays 100% of the OPEX on the basis of quarterly Utilization Certificates (UC) submitted by GVK EMRI. Any expenditure beyond the limit mentioned in the MoU would have to be approved by the Advisory Council. EMRI submits quarterly audited Utilization Certificates to the GoMP detailing funds received during the previous quarter, budget head wise utilization of funds, account balance and estimated budget for the following quarter.
4.10 CAPEX: As stated in the MoU, the Government also bears all capital expenditure including ambulance procurement and fabrication, medical equipment, IT/networking equipment, GPS and adequate space and equipment to run the Emergency Response Centre. The costs for CAPEX do not have a cap, but are on actuals on receiving GoMP approval before procurement and following a structured tender process. The CAPEX for each year is estimated at the beginning of the financial year.
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Assessment Findings: Funding and review 4.11 Budget Cap for monitoring cost efficiency: The revised MOU has included cap on each of the budget heads, which has enabled GoMP to monitor expenses incurred by EMRI. These caps were decided on analysis of previous expense trends in discussion with EMRI. However, it would be important for GoMP to analyze actual expenditures at least bi-annually to revise the caps in a way to drive better cost efficiencies. Trends of other states could also be sought from EMRI and analyzed to fine tune the targets.
4.12 High Opex per ambulance per month compared to the MoU cap: Based on available data, the provisional OPEX per ambulance per month for the year 2012-13 is INR 1,15,244/-. For EMRI, to meet the MoU cap of INR 97,700 for the year 2013-14, budget heads in excess of the given heads would need to be identified and initiatives that could drive required cost efficiencies would need to implemented.
4.13 Quarterly and Annual audits mostly complied with by EMRI: As required by the MoU, EMRI submits annual and quarterly reports of audits conducted by external chartered accountants to GoMP. The formats of submitted UCs, which contain the findings of quarterly audits, have been observed to be in accordance with the recommended formats of Schedule B of the MoU. However, delays in submission of quarterly UCs have been observed in 2013.
4.14 Costing details to be included in the UCs: While the UC is in concurrence with Schedule B and provides details of the expenses incurred, related costing parameters and details of expenses are adequate. Expense heads that could be further included in the UC as annexures include: CAPEX – Details of items procured, no. of units and unit costs Salaries and other allowances – Division of expenses based on staff type and number for the quarter being considered, for EROs, EMTs, Pilots, EMEs, Team Leads and Managers of Sense, Reach and Care and support staff. Ambulance Running Expenses – Apportioning expenses based on no. of operational ambulances for the quarter being considered
Assessment Observations: Procurement
4.15 The 108 operations entail frequent procurement of capital and operational items including ambulances, refurbishment, equipment, medical consumables, ambulance stationery, Tyres etc. As described in Chapter 3.3, EMRI follows an exhaustive procurement system with respect to preparation of annual budgets, periodic national reviews, established procurement committees and defined tender process and documents.
4.16 EMRI also follows a national tender process to take advantage of economies of scale across its operational states. On getting approvals from concerned state governments, the national procurement team issues national tenders for frequent or high cost items. The EMRI team in MP periodically submits letters to GoMP seeking their opinion and approval for planned national tenders. This is a valuable benefit that GVK EMRI brings to the partnership as it has the potential to significantly reduce costs for the state.
GoMP Monitoring 4.17 While EMRI’s internal procurement processes are comprehensive, the level of GoMP monitoring is low given the absence of GoMP representation in the procurement committees designed by EMRI and procurement guidelines in the MoU. In order to drive cost efficiencies of both national and state procurements, there is a need for GoMP to strengthen monitoring processes for both national and state level procurement.
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Review and Monitoring
Service Parameters
4.18 The inclusion of service parameters in the MoU is an important step taken by GoMP towards monitoring operational performance of the service. Currently, the MoU stipulates 9 service parameters to be adhered to by GVK EMRI. The review of performance of EMRI with regards to these parameters starts 6 months from the date of signing the agreement. 4.19 Broadly the parameters are divided into the following categories: Milestone based (indicated as ) – Parameters which are dependent on achievement of a particular milestone. These parameters would have to be constantly reviewed and updated based on the dynamic operational plans of the service Ongoing target based (indicated as ) – Parameters which are based on operational targets of performance indicators. While the parameters would be applicable for consecutive years, targets would need to constantly update based on achievement levels of EMRI. 4.20 The following table presents an evaluation of the current service parameters along with our recommendations.
Table 4.3: Evaluation of Service Parameters for 108 services in MP16
Service Current Category Reason for Change, if S.No Possible change Parameter Threshold any Existing Geographic For the next year this : EMRI has achieved this coverage of the parameter could be changed 1. 100% milestone with the launch district with to include district wise of 352 new ambulances EMRI services population per ambulance. : With the state launching new ambulances this Average number target is still good, for the of emergencies newer ambulances to 2. to be attended by 4.2 stabilize. one ambulance per day (Actual achievement for July-Dec 2012 is 4.3 and Jan-Mar 2012 is 3.3) Average time : The definition of rural and taken to reach 20-30 urban needs to be clarified. : 3. the scene after minutes Currently EMRI classifies the call (Rural) : Target to continue as urban cases on the basis of international standards base station location. This require reach times to be leads to reporting of higher 40 minutes for urban and urban reach time as urban 20 minutes for rural5 ambulances also serve Average time periphery locations of the taken to reach 15-20 (Performance between city/town 4. the scene after minutes April and December 2012 : Urban cases should be the call (Urban) - Urban - 27m 24s and classified based on the Rural - 30m 25s) location of emergency site and not the location of ambulance handling the emergency.
16 “ Ambulance Response Time in Developing Emergency Healthcare Systems” – Jochen Schmidt
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Service Current Category Reason for Change, if S.No Possible change Parameter Threshold any : Target to continue. However the denominator for calculating the ratio is unclear. Suggested to be defined as No. of vehicle : This target could start with District wise Not more busy cases / Total no. of 7.5% for the first year and 5. vehicle busy than 7.5% medical dispatches then reduced to 5% for the calls next year. (Value for Jan - Jul 2012 ranging from 14% to 18%).
: To Continue. Clear Introduce GPS target month to be tracking for all 100% mentioned if not already vehicles (subject within 6 in place. 6. to timely months of clearance by signing :None of the ambulances state MoU had AVLTs at the time of government) study
:Target period should be clearly specified : As discussed in the Sense section earlier, ineffective calls should be reduced to 50% over next 2 years from Address Reduce by 7. : Target period not clear. the current level i.e. 95%17 . ineffective calls 15% However, this target should be finalized based on analysis of trends of ineffective calls across more mature states such AP and Gujarat. : Unclear parameter. Does not give any activity based Could be changed to " Bi- Introduce target. annual sharing of internal Quality audit findings of all Management :This would require the 8. 100% processes and adherence of indicators for Executive Committee to performance to approved skills and define Quality skill and equipment quality equipment Management indicators indicators" and approve their targets
Target could be increased to 97% based on further Average % of : Target To Continue. analysis of current status, on-road vehicles 9. 95% (Performance as of March given the launch of new per day should 2013 - 98%. ambulances. not be less than
17 As of Jul-Dec 2012 data provided by EMRI
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Service Current Category Reason for Change, if S.No Possible change Parameter Threshold any New : This parameter evaluates the effectiveness of the call center in ensuring that Target Value could be 1.5% Monthly average almost all EM Calls are for the first year. Once of % Unattended picked and attended to. 10 1.5% services in new districts Calls should not stabilize, target could be be more than (As per data submitted by revised to 1% EMRI for all months till Dec 2012, this % has never crossed 1.2%)
Reporting Mechanisms
State level 4.21 The MoU requires EMRI to submit periodic reports to GoMP covering operational parameters of the service, including number of trips per ambulance, number and types of patients etc.
Daily and Monthly Reports 4.22 In this regard, the following exhibit gives a snapshot of the daily reports shared by EMRI18with GoMP. Table 4.4 –Format of Report submitted to the GoMP
Daily Format - State wise Today Current Month Launch till Date Call Type Emergency Effective Ineffective Dispatches Type of emergencies Pregnancy related Vehicular trauma Etc. Monthly Format - State and District wise Month till Date Year till Date Launch till Date Call Type Type of emergencies Reach Times Lives Saved Deliveries in Ambulance District Level 4.23 At the district level, currently EMEs submit adhoc monthly reports covering no. of emergencies and reach times to the district offices.
18 Based on formats shared with the evaluation team
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Key Findings 4.24 Need to strengthen periodic reporting to be submitted by EMRI at the state and district levels: It was observed that EMRI submits daily reports to GoMP at state level consisting of essential data to get an overview of the operations. However, reports at state level could further be improved to include the following parameters based on recommendations from the executive committee.
Daily ― Sense : UAC, call handle time, no. of vehicle busy cases, no. of unavailed cases ― Reach : No. of off-road ambulances, base to scene reach time (including urban and rural split) ― Care : No. of cases given OLMD, No. of IFT (Inter Facility Transfer) cases, no of partner hospital
Monthly ― Status of agreed service parameters, along with detailed remarks of non-compliances, if any ― Findings of core process audits : key findings (strengths, non-compliances and issues) of quality audits of ERO calls and ambulances ― Findings of support function audits: key findings (strengths, non-compliances and issues) of all support functions including SCM, Marketing, state-level fleet, marketing, IT-IS etc. ― Status of District Committee meetings : Status of adherence to quarterly plan of district committee meetings across districts, district wise summary of minutes – strengths, issues resolved, any state-level escalations required etc. ― Findings of population based feedback, if any
4.25 At the district level, details on ambulance wise emergencies handled, reach time, demography of cases handled, patient feedback, IEC activities undertaken, case studies, best practices implemented and issue should be submitted by the EME every month to the District Committee.
4.26 Inadequate review of reports: Overall, it was found that even with the current level of reports being submitted by EMRI, the data is not adequately reviewed by the state and district administration. However, it is important to monitor reports timely or at least review the same during the committee meetings to be appraised of the good practice and areas of improvement of the service
Assessment Summary: Contractual & Institutional Framework
The new MoU signed on 27th December 2012 is well documented and clearly details the roles and responsibilities of GoMP and GVK EMRI. In comparison to the older MoU, this MoU also specifies service parameters and budget caps to enable GoMP to monitor operational and financial performance. The operational service parameters could further be improved to increase objectivity of the parameters. However, the level of monitoring could further be strengthened by ensuring regular meetings of defined committees at various levels and improving the reporting requirement and their analysis. This would help GoMP to constantly supervise EMRI’s implementation plan and provide input for performance improvement Improving these monitoring systems would help both partners develop a shared vision of the service in the state and dynamically define areas of focus as per mutually identified service gaps, which could include addressing ineffective calls, increasing tribal coverage, reducing response times, establishing systems for pre-arrival instructions etc.
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CHAPTER 5
DEMAND SIDE ASSESSMENT
Assessment of ERS Performance in Madhya Pradesh Final Report
Introduction 5.1 As part of the study, Deloitte conducted a demand side assessment to identify strengths and areas of improvement of the 108 service by ascertaining responses from users, non-users, field level workers and influencers on key parameters including: (A) Awareness of 108 services (B) Call Experience and Ambulance Reach time (C) Perception of Quality of Care and hospital handover
5.2 The total sample interviewed in the three sample districts for the assessment is as follows –
Category Total Interviewed Users 299 Non-users 148 FLWs and PRIs 112
5.3 Annexure 8.2 gives details of village wise list of interviews conducted.
5.4 The table below represents the observations and responses made in the sample districts.
(This Space has been left intentionally)
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S.no Parameter Responses (A) Awareness of 108 service 1 Overall Users awareness 98% of the users interviewed were aware of 108 2% of the unaware users were all women and while they were not Yes No aware themselves, someone in their family was aware of the 6 service e.g. mostly husband, father-in-law. 38 Non-Users 299 0 6 113 75% of the non-users were aware of 108. While this shows high 59 51 levels of overall awareness, it also indicates scope of improvement Users Non-Users Field PRI Field Functionaries and PRI members Functionaries All the Field functionaries and 90% of the PRI members interviewed aware of 108 services. 2 Sources of The most common sources of awareness are: awareness - Word-of-mouth (mostly from other users and field level workers) - Observation of ambulance while serving some other emergency in the village - Official communication / announcements - Posters. In Gwalior, particularly, television was the major source of awareness as it is the most urban district of the three.
3 Awareness of usage of 108 Overall, less than 50% of the respondents across different groups for police and were aware of the use of 108 for police and fire emergencies. fire emergencies Comparatively, frontline workers and PRIs were more aware.
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S.no Parameter Responses 4 Awareness of JEY19 awareness was higher amongst ASHAs and PRI members whereas JEY awareness amongst users/ non users was lower - Ashas: More than 85% of the ASHAs in all the three districts were aware of JEY and were using the service for pregnancy cases, mostly for drop backs. - PRIs: Awareness among PRI members was more than 75% both in Gwalior & Sehore, while in Sagar it was less than 50%. - Users: In Gwalior & Sagar districts, less than 35% of the users and less than 25% of the non-users were aware of JEY services due to its irregular functioning, whereas more than 60% of the users & non-users were aware of the JEY services in Sehore District. 5 Awareness of As shown in the graph below, normal deliveries and accidents have the largest recall for 108. The graph also indicates Emergencies the need for GoMP and EMRI to spread awareness on the usage of 108 for the other medical emergencies. for which 108 could be utilizes
It was particularly observed that ASHAs and ANMs were informed from official communication channels (mostly CMHO) of the use of 108 was only for pregnancies, which is only limited information about the service. This could have had an impact on field awareness. 6 Awareness of More than 80% of the respondents were aware of the role of ASHAs/ AWWs in their village with respect to 108 role of operations. This included spreading awareness of 108, calling 108 and accompanying patients to the hospital frontline However the urban blocks had the highest proportion of respondents who were not aware of any of the roles of workers the Frontline workers.
19 Deloitte conducted a brief comparison cases handled by 108 and Janani Express Yojana (JEY) in Sagar District. Refer to annexure 8.10
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(B) Call Experience and Ambulance Reach time S.no Parameter Responses 7 Refusal of 108 91% of total users interviewed responded that they were never refused 108 services. services Where refused, reasons were: . Engagement of vehicle in another emergency. However, in all such cases the respondents informed that they were told the approximate time the vehicle would take to complete the engagement and reach that location, and hence asked to wait if possible. . Unavailability due to jam or breakdown of vehicle 8 Mobile network In 82% of the cases, callers reported not having issues with regards to mobile network connectivity while calling 108. connectivity The 18% calls with network issues could be a cause for the no-response and silent calls reported at the ERC Mobile network problems were more common in urban blocks because of network congestion than in rural blocks.
9 Call response 76% of calls answered in the 1st attempt, indicating the efficiency of the Sense function of No. of attempts % calls EMRI. 1 attempt 76% 24% of calls being responded beyond 1 attempt could correspond to the call center’s unanswered 2 attempts 16% calls (UAC) during their first attempt. 3 attempts 7% 4 attempts 1% 10 Ambulance In over 90% cases across districts, ambulances reached as per expectations of reach time respondents 96% of the callers/ users reported being told of an indicative time. In most cases, ambulances reach between 10-20 mins. Reason for late arrival of ambulance is often cited as engagement at another emergency
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(C) Perception of Quality of care20 S.no Parameter Responses 11 Availability of Most users and attendants identified key equipment and infrastructure Medical available in the ambulances, including stretchers, first aid kits, oxygen 311 261 243 equipment in cylinders etc. 27 ambulances 21 *Respondents were probed only for equipment that are easily visible and not equipment such as BP instruments, suction machines etc. that may be either difficult for the users to Stretcher First Aid Oxygen Others Does not identify. cylinders Know 12 Attendants No cases have been reported where attendants were not allowed to travel with the patient to the facility accompanying patients On an average 2-3 attendants per patient have been allowed by the ambulance staff 13 Presence of In 98% cases, attendants/ callers/ users were aware of the presence of the EMT in the ambulance. EMT in Only 2% of respondents in Gwalior and Sehore each reported that they were not aware of the EMT’s presence. ambulance Possible reasons for users/ attendants not knowing about the presence of the EMT was be due to the fact that the EMTs did not get off the vehicle to assist the attendants in taking the patients to the ambulance 14 Physical 62% of total respondents reported receiving some medical attention/examination in the ambulance. examination 8% of respondents were not aware or could not comment on the medical attention they received in the ambulance. /Investigation of *It is important to note that in 35% of pregnancy cases, no care was provided as in most cases, users reported not requiring any care as the patients ambulance was called for transportation of a normal delivery. 15 Physical In pregnancy related cases: Users reported the following care provided examination/ - 47% : Usage of BP machine Investigation - 46% : Usage of Stethoscope conducted in - 34% : Physical Examination various cases - 27% : Enquiry of obstetric history Vehicular Trauma cases : Users reported the following care provided - 39% : Application of tourniquet / pressure - 24% : Usage of injection of IV drip - 22% : Usage of BP machine - 20% : Usage of stethoscope - 18% : provision of oxygen mask Non-Vehicular Trauma cases 21– Users reported the following care provided - 73% : Usage of stethoscope - 71% : Usage of BP machine
20 As discussed with the MPTAST team, an attempt was made by the evaluation team to estimate the user’s perception of quality of care. However, the limitation is that the user is mostly unaware of both the equipment available and the care being provided. Thus this section is only indicative of quality of care as perceived by the user.
21 Includes fall from the roof, consumption of poison, burn etc.
77 Assessment of ERS Performance in Madhya Pradesh Final Report
(C) Perception of Quality of care20 S.no Parameter Responses - 31% : Administration of oral medicine or IV drip 16 EMT Behaviour 78% of the respondents have indicated that the EMTs were empathetic and helpful. They handled the cases well, and were patient in understanding the complaint of the user. EMTs would escort the users from the site of emergency to the vehicle and ensure their comfort in the ambulance before proceeding towards the hospital. The major complains of users not satisfied with EMT behavior included not helping attendant bringing the patients to the ambulance. 17 Choice of health Type of Hospital facility Over 95% of the respondents were taken to government facilities (usually the closest CHC) in emergency cases. The other 5% were mostly taken hospitals located in the District Headquarters or Bhopal (in case of Sehore). Choice of Hospital Across districts, 94% of the respondents were satisfied with the choice of health facility. Across blocks, in around 60% of the cases, the facility the patient was to be taken to was decided by the user/ attendant. In most cases where the EMT/ Pilots decided the facility, it was understood to be the closest CHC in the area and the respondents concurred with this decision. In the cases that weren’t satisfied, since the choice of facility for more than 60-70 Kms, EMTS dropped the cases at the closest CHCs.
18 Handover at Over 90% of the respondents stated being handed over at the facility in a convenient manner. facility - In most cases respondents were satisfied with the EMT’s level of empathy and involvement during handover including transfer to hospital stretcher and waiting upto the completion of admission formalities. In the rest of the 10% of cases, issues raised included - EMT did not brief the nurse during handover - EMT/Pilot did not assist the attendant in hospital admission 19 Payment for 98% responded free of charge services 2% of interviewees were asked for payment (6-7 cases of ~INR 50) either at the health facility or at the ambulance provided These cases were observed in the urban blocks of Gwalior and Sagar
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Overall Rating: Demand Side Assessment
5.5 Apart from the above responses, the study also involved capturing respondent rating on the services utilized for the following parameters: Call process Ambulance reach time Ambulance cleanliness Care provided Attitude of staff Handover at health facility
5.6 The ratings were based on the following scale:
User Rating Corresponding points awarded22
Very Good 5 Good 4 Average 3 Poor 2 Very Poor 1
5.7 On a scale of five, the overall rating as given by the users for each of the parameters has been summarized below:
Handover at Call Ambulance Ambulance Care Attitude Districts health process reach time cleanliness provided of staff facility Gwalior 4.13 4.07 4.11 3.91 4.04 4.03 Sagar 3.99 3.94 4.07 3.95 4.00 3.93 Sehore 4.08 4.01 4.06 3.69 4.02 3.99 Overall 4.07 4.01 4.08 3.85 4.02 3.98
While the user gave good rating to the call process, ambulance reach times, ambulance cleanliness, attitude of staff (EROs, EMTs and Pilots), clear areas of improvement include care provided in the ambulance and the handover support at the health facility. These have also been reflected in the user response discussed earlier.
22 Response styles of users and attendants varied with respect to the service rating. Responses could be marginally biased with respondents not differentiating between “Good” and “Very Good”
79 Assessment of ERS Performance in Madhya Pradesh Final Report
Summary
(A) Awareness of 108 services The overall awareness levels of the service and the number-108 are high, mainly due to the on- field impact of the service, resulting in awareness through the informal word-of-mouth channel. Field workers (mainly ASHAs) and PRIs have also been observed to play the role of information agents at the village level, counseling villagers to utilize the service in case of emergencies. However, there is still low awareness with respect to utilization of 108 for medical emergencies, other than accidents and pregnancies, and police and fire cases
Thus, it is important that GoMP and EMRI target these awareness gaps while designing state- level communication strategies to increase service utilization. Comprehensive information on the scope of 108 services should also be provided to village influencers, through formal communication channels to ensure spread of correct messages in villages.
(B) Call Experience and Ambulance Reach time Users have appreciated the round-the-clock availability of call services, simplicity of call process, attitude of call taking officers and negligent refusal of ambulance requests. In most cases, all users were completely aware of the process, and often gave the required information even before being asked, thus reducing the call handle time. In 76% cases, the call was answered in the first attempt; however the other 24% could correspond to the unattended calls at EMRI’s end which could be addressed by manning adequate EROs.
The timely arrival of 108 vehicles usually within a short time regardless of the time of the day has led to user confidence in the service. Further, in cases of delay, the ability of the ERO to communicate this delay to the caller makes the service quality even more appreciated by the respondents.
(C) Perception of Quality of Care and Hospital handover Provision of care provided by the EMT and availability of equipment in the ambulance was appreciated by the respondents to be pain relieving/ lifesaving in nature. However, in 22% cases, respondents expressed concerns on either the support provided by EMTs to transfer patients to the ambulance or the lack of any enroute care or counseling. This is a concern that would need to be addressed by EMRI. Given the limited knowledge of the respondents on the care required to be provided, the sufficiency and effective of pre-hospital care is difficult to estimate.
Patients were satisfied with the choice of health facility, even though in 60% cases, the EMTs decided for them. However, 10% of the respondents highlighted issues concerning handover at the facility by the ambulance staff. These may be looked into and the process further streamlined for better service in this regard.
Overall The respondents expressed high reliability and trust on the service, which has been formed due to consistent timeliness, service quality, and helpful attitude of staff, as can be seen from the ratings discussed in the previous section.
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Beneficiaries Speak
“Marij Aspataal jaldi pahuch jaata hai. Turant uska upchar shuru ho jaata hai. Turant pahuchne ke karan seva jaldi mil jaati hai”
(The patient is quickly taken to the hospital. The treatment is also provided instantaneously. With the advantage of reaching the health facility timely, the treatment is also provided timely) - Geeta , GH Birla, Gwalior
“Tatkal aa jati hai (The service is quick). Ab Aspatal jaane mein koi dikkat nahi hoti” - Pirambal, Sorai, Sagar
“Treatment is given on the way. It comes very fast. They are available 24X7. Especially in villages where there is no mode of transport, it helps to reach the facility” - Girdharilal, Sagar Urban
“It is fast and comes on time. At the call center, they don’t disconnect the call. 48 hours after the emergency, they call to enquire and take feedback on EMT/pilot.” - Krishna Uika, Bayan, Sehore
“Emergency service takes less time. There is timely treatment. It saves money and time. It is free for all. There is no distinction among patients” - Sunil Kumar, Ron, Sagar
“If the vehicle was not there, I wouldn’t be alive.” -Gyanbai, Chourai, Sagar
“Very happy with the services. Being from a tribal community, I was glad that someone was there to take me to the doctor without any bias” -Ramvathi Adhivasi, Girwai, Gwalior Rural
“Patients get care on time. Transportation is quick and money is saved. Ambulance has requisite facilities” -Archana Mishra, ASHA, Gwalior
“Achha kaam kar rahe hain. Din ho ya raat, woh kabhi mana nahi karte.” (They are doing a good job. They never refuse to come, whether day or night)
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CHAPTER 6
ANALYSIS OF COSTS
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Analysis of Costs
6.1 This chapter consists of analysis of costs of EMRI 108 operations in Madhya Pradesh over the last 4 years of operations
6.2 The 108 service in Madhya Pradesh has been operational with 102 ambulances till December 2012 in 10 districts. It was further decided to extend the service to the remaining 40 districts in 2013 and accordingly, 352 ambulances were launched between January and May 2013, and another 150 ambulances are planned to be launched before the end of the year, covering all 50 districts.
6.3 Hence, the current phase of expansion is yet to complete and stabilize in terms of operations. This kind of an expansion phase is typically characterized by an increase in operational staff, their trainings and other launch related activities (marketing, IEC, procurement of medical consumables, etc. for new ambulances), thus resulting in increase in operational expenditures.
6.4 Considering that the above expansion phase is still on-going and operations are yet to stabilize, our financial/ costing analysis is primarily limited to data upto Dec’12, although we have also attempted to compare data for operational costs for the period Jan-June 2013 against financial estimates proposed under Schedule A of the revised MoU (under Section II, below).
6.5 Broadly, the analysis has been divided into two sections: SECTION I : Analysis of Operational Costs - Year-wise trends of key cost indicators and select expense heads SECTION II : Comparison of operational expenses per ambulance per month for the periods Apr – Dec 2012 and Jan – Jun 2013 with the limits provided in Schedule A of the current MoU.
SECTION I - ANALYSIS OF OPERATIONAL COSTS
Basis of Costing
6.6 Costs incurred by GVK EMRI for the 108 operations since its launch in July 2009 upto December 2012 were collated and analyzed. The following table details the key cost components on which data from EMRI was collected.
Exhibit 6.1 : Components of Costing Analysis
Ambulance Running and Maintenance related expenses . Covers fuel, tyre replacement, vehicle repair, maintenance and insurance, equipment repair and maintenance, and drugs & consumables Human Resource related expenses . Covers salary of line and support staff including basic salary, HRA, PF, mobile reimbursement and other employee benefits, and training Communication and Tech Support related expenses . Covers telephone expenses including landline and mobile of the call center and ambulances, internet, equipment maintenance including AMCs and other hardware and software tech support Administration related expenses . Covers Office maintenance expenses such as rent, electricity, housekeeping, courier to ambulances etc., staff related expenses such as staff travel, motivation events, uniforms etc. and other admin expenses related to auditing, recruitment, tendering etc. Marketing related expenses . Covers marketing including content creation and state and field level implementation of media and IEC activities Note : Annexure 8.11 provides the details of data provided by EMRI
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Analysis of Key Cost Indicators
6.7 Key cost indicators were calculated to analyze year wise trends and enable comparison of EMRI’s performance in MP with other mature EMRI states such as Andhra Pradesh, Assam, Rajasthan. The indicators covered for this analysis include:
Operational expenses (Opex) per ambulance per month Operational expenses (Opex) per emergency handled Operational expenses (Opex) per km travelled
Exhibit 6.2 : Performance of key Cost Indicators (Amounts in INR) Parameters 2009-2010 2010-2011 2011-2012 Apr to Dec 2012 No. of operational months 9 12 12 9 No. of ambulances* 48 69 97 102 Average Kms per trip 17 36 38 40 No. of emergencies handled 50,599 116,048 148,467 114,857 Total Operational Expenses# 572 Lakhs 1,063 Lakhs 1,261 Lakhs 1,001 Lakhs Key Costing Indicators Operational expenses per ambulance per month 132,478 128,448 108,347 109,084 Operational expenses per emergency handled 1131 916 849 872 Operational expenses per km travelled 65.53 25.81 22.47 21.80 *Source : Based on data provided by EMRI. Weighted Average of month-wise operational ambulances has been considered, since the number of operational ambulances varied on month-on-month basis due to phased launch of ambulances, (Details of calculation provided in Annexure 8.12) # See Annexure 8.13 for detailed head wise breakup of operational expenses
Key Observations
Opex per ambulance per month: There is an overall declining trend - Operational expenses per ambulance per month have decreased from INR1,32,478 (launch) to INR 109,084 (December 2012), indicating that GVK has been able to manage the operational costs effectively with stabilization of operations over the years.
A comparison of the above indicator with AP model (the first state with 108 services) also suggests that the MP model is in line with the costs achieved in AP after the first 3 years of operations (INR 1.09 Lakhs in MP in comparison to INR 1.05 Lakhs in AP). This is despite significantly lesser number of operational ambulances in MP as compared to AP, and without considering the impact of inflation between the two reference periods.
Exhibit 6.3 : Comparison of Opex / Amby / Month between MP and AP at the end of 3 years of operations
Indicators Andhra Pradesh* Madhya Pradesh Launch Month April 2005 July 2009 No. of ambulances at the end of 3 years 652 102 Kms per trip 29 40 INR 1.05 Lakhs INR 1.09 Lakhs Opex per ambulance per month (FY 2007-08) (Apr – Dec 2012)
*Source: “Study of ERS – EMRI model” : National Health Systems Resource Centre (NHSRC, 2009)
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Opex per Emergency handled : In MP, the Opex per emergency handled has also been decreasing from INR 1,131 in 2009-10 to INR 872 in 2012. While this reflects improvement in operational costs per emergency by 23% over three years, the cost per emergency handled in AP (after 3 years of operations) was significantly lower i.e. INR 56523 in 2008, as reflected in NHSRC study. However, it is important to note that the total number of emergencies handled per day in AP during the study period was approximately 350023, while the average number of cases handled per day in MP during the period Apr – Dec 2012 was only ~ 400 per day. Also since the number of ambulances was significantly higher in AP, the fixed costs of the services are apportioned over more ambulances and thus emergencies. Also, the higher Kms per trip in MP (as compared to AP) could also have an impact on this ratio. Given the expansion of 108 service into 40 new districts in MP with 502 new ambulances, this ratio is expected to reduce further.
Opex per Km travelled : The Opex per Km travelled in MP has decreased from INR 65.5 in 2009-10 to INR 21.8, including a major expected drop in the 1st year due to increase in the cases covered and kms per emergency handled. This is comparable to cost per km across EMRI operations in states such as Assam and Rajasthan which recorded Opex per Km travelled of INR 2524 and INR 22 respectively after around 3 years of operations.
Analysis of Select Expense heads
6.8 The following exhibit highlights trend of the key expense heads over past three years and relevant ratios. Exhibit 6.4 : Select expense heads and Relevant Ratios
(Amounts in INR) Analysis Analysis Analysis Apr-12 to Analysis Financial Year 09-10 10-11 11-12 Ratio Ratio Ratio Dec-12 Ratio No. of operational 9 12 12 9 months No. of ambulances* 48 69 97 102
No. of emergencies 50,599 116,048 148,467 114,857 handled Average Kms per 17 36 38 40 emergency Salaries 29,565,936 68,439 68,937 71,817,566 61,698 56,468,057 61,512 Per amby 57,080,117 Per amby Per amby Per amby per month per month per month per month Ambulance repair, 880,510 2,038 3,527,578 4,260 4,886,225 4,198 5,697,555 6,206 maintenance and Per amby Per amby Per amby Per amby Refurbishment per month per month per month per month Fuel Cost of 5,962,079 117.8 17,270,747 148.8 21,229,723 143.0 15,184,944 132.2 ambulance Per Per Per Per Emergency Emergency Emergency Emergency handled handled handled handled Medical 2,201,048 43 4,443,428 38 3,718,297 25 2,887,343 25 consumables Per Per Per Per Emergency Emergency Emergency Emergency handled handled handled handled Communication 2,303,201 46 3,232,531 28 2,368,533 16 1,667,034 15 expenses Per Per Per Per Emergency Emergency Emergency Emergency handled handled handled handled Administration and 9,207,215 21,313 15,546,029 18,775 12,735,041 10,941 10,661,811 11,614 Travelling Per amby Per amby Per amby Per amby per month per month per month per month Training 2,461,774 5,698 2,463,078 2,975 3,993,947 3,431 3,143,267 3,424
Per amby Per amby Per amby Per amby per month per month per month per month *Weighted Average as detailed in Exhibit 6.2
23 “Study of ERS – EMRI model” conducted by National Health Systems Resource Centre (NHSRC, 2009) 24 “Publicly Financed Emergency Response and Patient Transport Systems under NRHM” - conducted by National Health Systems Resource Centre (NHSRC, 2012) 85
Salaries: Although, overall salary costs have increased (in absolute terms) over the period considering expansion of services, cost of salaries per ambulance per month has decreased from INR 68,439 in 2009-10 to INR 61,512 in 2012 (i.e. ~10% decrease). Most of this decrease could be attributed to the fact that as the number of operational ambulances increase, while ambulance staff increases accordingly, the no. of support staff (non-ambulance staff25) does not increase proportionally.
Ambulance repair and maintenance: The repair, maintenance and refurbishment expenses per ambulance per month have increased significantly from INR 2,038 in 2009-10 to INR 6,206 in 2012. This could be attributed to the aging of ambulances. Since the ambulances are already in the 4th year of operations, a significant number26 of ambulances had to go through the recommended vehicle refurbishment procedure, usually involving a complete overhaul of the engine, interiors, brake systems and other important vehicle components. This cost is expected to be high for the older ambulances over the next few years as the maintenance cost would continue to increase in order to attain fuel efficiency and maintain vehicle condition despite their aging.
Fuel: The fuel cost per emergency handled for the year 2010-11 shows an increase in comparison to 2009-10, which could be attributed to the significant increase in distance travelled per emergency during this period. While the distance travelled per emergency has further increased in subsequent years, fuel costs per emergency handled have come down indicating implementation of efficiency measures undertaken by EMRI with respect to optimum utilization of vehicles and well-monitored refueling processes.
Medical Consumables: The cost of drugs per emergency handled has been consistently decreasing. This has been achieved by focusing on procurement efficiencies, optimum indenting of drugs and strict monitoring by field managers and the quality team.
Communication: Similarly, there has been a substantial decrease in the cost of communication per emergency handled. As shared by EMRI, this could be achieved due to periodic (almost bi- annual) negotiations with telecom providers on optimum call plans based on detailed analysis of provider wise composition of calls made and received at the call center and the ambulances. Also constant attempts are made to ensure an optimum mix of telecom providers for PRI lines (Primary rate Interfaces, which provide multiple call lines for the call center) to reduce overall communication expenses.
Administration: The administration expenses per ambulance per month have been decreasing with a marginal increase in the period April - December 2012. These expenses cover: . office maintenance expenses - including rent, housekeeping, courier to ambulances, diesel for power back up, security, electricity etc. . staff related expenses - including travel of field staff & support staff, staff motivation events and uniforms . other expenses - including auditing, tendering, recruitment etc. As shown later in Exhibit 6.5, administration expenses currently account for ~8.5% of overall operational expenses and this share is expected to reduce post the launch of new ambulances as the fixed costs would be apportioned across all new ambulances.
Training: The training costs for 2009-10 have been observed to be the highest owing to related EMT and pilot preparatory training programs required to be undertaken for new ambulance launches. The costs have stabilized in 2011-2 and 2012 post a slight increase in comparison to 2010-11, owing to fixed number of refresher trainings being conducted annually. However as discussed in Section 3.1, the current level of refresher trainings being conducted is insufficient, and this cost is expected to increase in case more robust classroom and on-field refresher trainings are undertaken.
25 Salaries of non-ambulance staff usually account for 30%. This is based on salary breakup data provided by EMRI. However an analysis of the actual trend could not be carried out due to non-availability of data for the rest of the years 26 Exact number of ambulances not available with EMRI
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SECTION II – PERFORMANCE IN COMPARISON TO MOU ESTIMATES
Analysis and Findings
6.9 The following section compares the overall and head wise Opex per ambulance per month for the periods Apr – Dec 2012 and Jan – Jun 2013 with the estimates provided in Schedule A of the current MoU in MP.
6.10 However, it is recognized that since the new 502 ambulances (planned to be launched for 2013) are not yet fully operational, this comparison only indicates how the current costs are comparable to the future estimates decided and identify indicative key areas where costs could be considered for reduction to achieve the targets. This exercise would be more meaningful once all 604 ambulances are launched and have stable operations.
6.11 The following exhibit provides the details of the cost components covered in the MOU format.
Exhibit 6.5 : Comparison of Opex per Ambulance per month
Target for 2013-14 as per Expenses for Apr-Dec Expenses for Jan-June MOU 2012 2013 Opex per Opex per Opex per S.No Item amby per amby per amby per % % % month (in INR month (in month (in lakhs) INR lakhs) INR lakhs) 604 102 328 No. of Ambulances (As detailed in Annexure (6 monthly average as shown in (As per the MoU) 8.12) Annexure 8.12) Ambulance Running and
Maintenance Fuel Cost of 1 0.227 23.20% 0.165 15.16% 0.158 18.19% ambulance 2 Tyre Expenses 0.020 2.00% 0.019 1.78% 0.010 1.16% Ambulance repair, 3 maintenance and 0.028 2.90% 0.066 6.07% 0.031 3.57% Refurbishment 4 Vehicle insurance 0.005 0.50% 0.006 0.58% 0.003 0.30% 5 Medical consumables 0.028 2.90% 0.031 2.88% 0.028 3.17% Salary 6 HR Expenses 0.575 58.90% 0.615 56.39% 0.398 45.73% General office
/Administrative Expenses Communication 7 0.016 1.60% 0.018 1.66% 0.009 1.00% expenses IT/Equipment 8 maintenance and Tech 0.007 0.70% 0.016 1.42% 0.001 0.11% support Administration 9 Expenses and 0.039 3.90% 0.116 10.65% 0.074 8.50% Travelling Recruitment Expenses 10 Training 0.028 2.90% 0.034 3.14% 0.156 17.95% Marketing Expenses 11 IEC 0.004 0.40% 0.003 0.26% 0.003 0.32% Total (In Lakhs) 0.977 1.091 0.871
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Key Observations
Overall opex per ambulance per month – The overall opex per ambulance per month for the period Apr-Dec 2012 (INR 1,09,100) was much higher than the target indicated in the MoU (INR (97,700), however the same has improved in the period January to June 2013 (INR 87,081) with 454 ambulances launched in a phased manner. However, it is important to note that the new ambulances launched are not yet fully operational and additional costs may be incurred during the year once the operations of the expanded fleet stabilize and handle more emergencies.
Scope of Cost reduction
Based on comparison of the individual cost heads against the MOU estimate27s, the following expense heads are the potential areas of costs reduction : . Ambulance repair, maintenance and Refurbishment, . Medical consumables . Administration Expenses and Travelling
While training also appears high this is due to the preparatory training programs for EMTs and Pilots required to be conducted for all new 502 ambulances.
However, increase across these variables could be influenced by the flux in operations due to the current expansion phase of the service. These ratios are expected to change once operations of all 604 ambulances stabilize.
Based on analysis of 108 call data (as discussed in Section 2.1), ineffective calls constitute approximately 95% of the total attended calls, which is very high. These calls could be due to various reasons such as network, manpower and awareness related factors, etc. and have adverse cost implications in terms of ineffective manpower and infrastructure utilisation. Hence, it is important to address the high % of ineffective calls (especially awareness related, which constitute around 35% - 40% of total calls) to reduce “Sense” related manpower & infrastructural costs.
Conclusion
6.12 In conclusion, the key costing indicators related to 108 operations in MP have shown decreasing trend and are largely comparable with the performance of the 108 service across other operationally mature states of EMRI. An analysis of year wise trends of select expense heads shows an overall decreasing trend especially across salaries, fuel, medical consumables, communication and administration, indicating steps taken by the organization towards bringing in cost efficiencies through improved operational and monitoring processes.
6.13 A quick analysis of the current operational costs for the period April-Dec 12 and Jan-Jun 2013 with respect to the cost estimates provided in the current MoU indicates that current costs are in line with the targets, however, administration, medical consumables and repairs and maintenance are the potential areas of cost reduction as the expansion phase stabilizes. Also, addressing the high % of ineffective calls would help in reducing “Sense” related manpower costs28 significantly.
27 As a % share of the estimates of total operational expenses 28 Since the study was limited to Dec 2012, analysis of current sufficiency of manpower and thus exact scope of reduction is not covered – NOT REQUIRED HERE 88
CHAPTER 7
SUMMARY OF OBSERVATIONS AND RECOMMENDATION
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Assessment of ERS Performance in Madhya Pradesh Final Report SUMMARY OF KEY OBSERVATIONS
7.1 Provision of 108 services is an important step taken by GoMP towards addressing the critical issue of timely accessibility to quality care in the state. As noted in the first Common Review Mission of the NRHM, the EMRI partnership is one of the most successful public private partnerships (PPP) of the country. In MP, this service has been operational for over 3 years providing integrated emergency services.
7.2 Overall, the evaluation shows that the service meets its objectives of providing 24*7 quality and timely pre-hospital care, evidenced by the high levels of satisfaction amongst users, field functionaries and health care service providers.
Strengths and Weaknesses
7.3 The following section summarizes key strengths and areas of improvement of the current operations of the 108 service.
Key Strengths 7.4 The exhibit below summarizes the critical success factors of the model
Exhibit 5.1: Strengths of EMRI
. Efficiently functioning 108 Emergency Response Center, with clearly defined call handling SOPs and adequate infrastructure
. Well-equipped ambulances and good vehicle maintenance, owing to strong vendor tie-ups and a comprehensive vehicle performance tracking mechanism.
. Adequate population coverage, at 100,000 population per ambulance, on completion of launch of 602 ambulances, which is in concurrence with WHO norms.29
29 Recent international norms suggest that there should be one ambulance for every 50,000 population “ Ambulance Response Time in Developing Emergency Healthcare Systems” – Jochen Schmidt
90 Assessment of ERS Performance in Madhya Pradesh Final Report
. Provision of SOP based pre-hospital care, by trained medical technicians with online medical support from ERCPs. As evaluated by MOs of government hospitals, relevant enroute care provided by the EMTs.
. Implementation of customer friendly processes, such as 48 hour patient follow-up and vehicle busy desk.
. Skilled and motivated staff at both the state and field levels
. ISO 9001:2008 certified Quality Management System, consisting of detailed operational and monitoring processes.
. Decreasing trends of operating costs comparable with the performance of the 108 service across other operationally mature states of EMRI, enabled by organization level strategies aimed at improving operational and monitoring processes30.
Areas of improvement 7.5 The following are the identified areas of improvement:
Awareness related . Low awareness on service utilization for medical emergencies, other than pregnancies and accidents due to inadequate IEC/BCC activities . Ambiguity on roles and responsibilities amongst GoMP and EMRI with respect to IEC/BCC activities . Unclear strategy on the role of 108 service in handling police and fire emergencies leading to inadequate awareness on the same
Operations related . High % of ineffective calls leading to ineffective utilisation of ERC resources . Gaps in technical knowledge of EMTs . Insufficient demand assessment practices in respect of drugs and consumables . Lack of clarity in respect of HR/ Administration processes among field staff . Weak Hospital Tie ups
Monitoring related . Inadequate monitoring of operations including key service parameters, adherence to MoU clauses, financial parameters, and procurement processes etc. by GoMP. . Inadequate monitoring of support function processes and closure of non-compliances from ambulance audits Cost related . Potential cost reduction in the areas of administration, medical consumables and repairs and maintenance as the expansion phase stabilizes.
30 Since the new 502 ambulances are not yet fully operational, the analysis covered in the study only shows the changing trend of the expenses and does not reflect the true performance of the service with respect to the MoU estimates. It is therefore recommended that a detailed costing analysis be done 6 months after stabilization of operations all 604 ambulances to clearly identify areas of cost reduction
91 Assessment of ERS Performance in Madhya Pradesh Final Report RECOMMENDATIONS
7.6 This section outlines key recommendations to improve operational efficiency and service utilization. These are based on our analysis of issues as presented in the previous chapters.
1 Comprehensive IEC/BCC to increase awareness of all elements of the service
Context: Awareness levels for utilization of 108 services for medical emergencies other than accidents and normal pregnancies are still low. The primary reason for this is lack of adequate on-field IEC/BCC activities targeting certain gaps. Due to its limited budgets, the only planned activity undertaken by EMRI is village demos, which is inadequate to bring about required behaviour change.
Given that the responsibility to promote public awareness lies with GoMP, it is important for both EMRI and GoMP to develop plans together to address awareness gaps.
Recommendation: Clarity on the responsibility of IEC/BCC activities . Till December 2012, EMRI was responsible for handling all IEC/BCC activities for the ERS in the 10 districts where services were operational. However as per the renewed MoU, the responsibility to promote public awareness in emergency response lies with GoMP, in consultation with GVK EMRI, which has been given limited annual budgets. . It is important for the Executive Committee to decide and agree upon the way forward for required IEC activities. For example, in the case of ineffective calls while the targets for achieving lower ineffective calls have been given to EMRI, since the responsibility to spread awareness lies with GoMP, the way forward is not clear.
Development of Joint Communication Plans and regular monitoring: . It is recommended that the current arrangement continues with extra budgets to be allocated to EMRI based on the planned communication strategy. . EMRI should develop long and short term communication plans for IEC/BCC activities in the state, detailing geographical focus, focus areas, media tools, expected outputs, planned timelines and required budgets based on in-depth periodic analyses done on trends of ineffective calls. These plans should be reviewed by GoMP and budgets should be approved accordingly. . Regular review to ensure adherence and course correction (if required) should be conducted through executive committee meetings. . GoMP should also provide support in coordinating with other Govt departments or bureaus such as Police department, IEC bureau etc., wherever required.
Information dissemination to Influencers: . It has been observed that village influencers, including PRI members and field functionaries, play an important role in spreading awareness and impacting service utilization. It is thus important to improve awareness of this group. To initiate the
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process, it is advisable that GoMP state officials instruct district administrations to issue formal communications to all field functionaries, covering required focus areas for including kinds of services available under 108, policy on choice of hospital, difference between JEY and 108 etc.
2 Clarity on the objective of 108 service – Integrated or Medical?
Context: As observed in the beneficiary feedback and ERC information, awareness levels of usage of 108 service for police and fire cases is very low. It is primarily perceived as a health initiative. This problem is further compounded by the fact that forums such as the executive and district committees, which are meant to be joint forums to develop joint strategies, are inactive, thus continuing to emphasize the health focus of the service.
Recommendation: . It is important for GoMP to decide the strategic purpose of the service – Integrated or primarily medical with police support. - Integrated: If the understanding is that it is an integrated service, then the executive committee meetings should play an important role and should be forums for deciding joint strategies between the health, police and fire departments. Also the responsibility to spread awareness of using the number for police and fire should be jointly owned by the respective departments.
- Primarily medical with police support: If the decision is that it would be primarily a medical service with police support, then the current arrangement would continue, however the executive committee meetings should be regularized in order to periodically seek required support from police and fire departments on particular issues faced by the service.
Addressing ineffective calls through increased data analysis and targeted BCC 3 activities
Context: Ineffective calls constitute approximately 95% of total attended calls. An analysis of call handle time for the period July-Dec 2012 indicates that approximately 40% of ERO time is spent in handling these ineffective calls. This has cost implications in terms of ineffective manpower and infrastructure utilisation. It is thus important to address ineffective calls, given its cost implications through appropriate targeted field-level BCC activities.
Recommendation: In addition to the above detailed IEC/BCC activities, the following are some specific activities that could be implemented to address ineffective calls.
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Re-categorization of Ineffective calls . Deloitte’s study shows that almost 48% of ineffective calls are wrongly categorized, leading to incorrect identification of underlying causes. EMRI should evaluate consolidation of certain call categories (such as merging no-response and silent calls, and general enquiry and wrong calls) and training EROs specifically for increasing their understanding of the various categories to address this issue.
Analysis of trends and best practices of other states: . In order to develop effective strategies, EMRI should study the trends of ineffective calls in other matured states in terms of operations and set benchmarks/ targets for reduction of ineffective calls in MP. Any successful and cost-effective practices implemented in other states should also be identified that could be implemented in MP. It is suggested that the analysis be conducted across all operational states of EMRI. The states could be categorized on the number of operational years, to take into account the effect of stabilized operations on ineffective calls into the following categories are: 0-2 yrs., 2-4 yrs. and > 4yrs.
Implementation of Targeted Demos: . The marketing team should develop demos specifically targeted on ineffective calls including relevant collaterals and role play story boards for the ambulance staff. These would help the ambulance staff spread awareness to the target population clearly focussed on the ineffective calls.
Increased role of GoMP officials and functionaries in prevention of ineffective calls: . During launch conferences and other district level communications, senior officials from GoMP, including the Chief Minster, Health Minister, officials from DoHFW and police department (state and district) may also insist on the importance of the ‘108’ number and the consequences of misusing the same. . Exemplary actions should be taken by the state police, based on monthly reports submitted by EMRI, on repeated nuisance callers, which may be followed by print articles on the same.
4 Formal institutionalization of state and district level committees defined in the MoU
Context: The state and district level institutional structures defined in the MoU to monitor EMRI’s strategic and implementation plans have not yet been formed. These committees would be important to strengthen service monitoring by GoMP and address key strategic and operational issues such as: Strategic - Ambiguity on roles and responsibilities with respect to IEC/BCC activities - Role of 108 in handling police and fire emergencies Operational - Lack of data transparency with respect to 108 operations - Non-adherence to agreed service parameters - Absence of required communication plans - Facility handover problems faced by 108 ambulances at the district level
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Recommendation: Regularizing Executive Committee meetings: . The first step towards strengthening institutional structures is to establish the executive committee. Subsequently, the quarterly EC meetings should develop into active forums for monitoring EMRI performance. . It is recommended that the meeting should involve presentations by EMRI on the quarter’s operational and financial performance, followed by detailed discussions between GoMP and EMRI on issues, progress and way forward. . The following matters could be covered in the EC meetings: - Review of joint communication plans covering implementation strategies, timelines, required budgets etc. - Review of Performance (with updations, if any) w.r.t. service parameters and plans to address gaps - Financial performance with reference to the MoU - Implementation status of additional MoU requirements such as, EMRI : population based feedback, dynamic website, AVLTs GoMP : Pre-Arrival Instructions - EMRI’s internal audit findings as mandated by ISO 9001:2008, with a focus on non-compliances and process changes, if any.
Regularizing District Committee Meetings: . Awareness needs to be enhanced amongst district level functionaries on the clauses of the MoU and their role in monitoring local operations 108 services. Following action need to be taken at the state level in this regard: - Developing and circulating guidelines on the role of district administration in monitoring EMRI operations - Collecting bi-annual updates from District committees on the status of 108 operations in the district
5 Amendments to existing service parameters
Based on a detailed analysis of the service parameters, both on-going-target and milestone based, modifications to some of the parameters have been suggested in order to improve the objectivity of the parameters. As discussed in table 4.3, the following are the parameters for which changes are being suggest either in terms of redefining the measure or an explanation for the current parameter or a new measure
Service Current Category Reason for Change, if S.No Possible change Parameter Threshold any Existing
Geographic For the next year this : EMRI has achieved this coverage of the parameter could be changed 1. 100% milestone with the launch district with to include district wise of 352 new ambulances EMRI services population per ambulance.
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Service Current Category Reason for Change, if S.No Possible change Parameter Threshold any : Target to continue. However the denominator for calculating the ratio is unclear. Suggested to be defined as No. of vehicle : This target could start with District wise Not more busy cases / Total no. of 7.5% for the first year and 2. vehicle busy than 7.5% medical dispatches then reduced to 5% for the calls next year. (Value for Jan - Jul 2012 ranging from 14% to 18%).
:Target period should be clearly specified : As discussed in the Sense section earlier, ineffective calls should be reduced to 50% over next 2 years from Address Reduce by 3. : Target period not clear. the current level i.e. 95%31 . ineffective calls 15% However, this target should be finalized based on analysis of trends of ineffective calls across more mature states such as AP and Gujarat. : Unclear parameter. Does not give any activity based Could be changed to " Bi- Introduce target. annual sharing of internal Quality audit findings of all Management :This would require the 4. 100% processes and adherence of indicators for Executive Committee to performance to approved skills and define Quality skill and equipment quality equipment Management indicators indicators" and approve their targets
New : This parameter evaluates the effectiveness of the call center in ensuring that Target Value could be 1.5% Monthly average almost all EM Calls are for the first year. Once of % Unattended picked and attended to. 5. 1.5% services in new districts Calls should not stabilize, target could be be more than (As per data submitted by revised to 1% EMRI for all months till Dec 2012, this % has never crossed 1.2%)
31 As of Jul-Dec 2012 data provided by EMRI
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Note:
are milestone based parameters, which are dependent on achievement of a particular milestone. These parameters would have to be constantly reviewed and updated based on the dynamic operational plans of the service are Ongoing target based parameters, which are based on operational targets of performance indicators. While the parameters would be applicable for consecutive years, targets would need to constantly update based on achievement levels of EMRI.
6 Strengthening monitoring of EMRI’s procurement processes
Context: As discussed in section 3.3, the procurement processes at EMRI, both operational and monitoring, were found to be reasonably satisfactory. However, the level of GoMP monitoring appeared inadequate, given the high quantum of annual procurement. Also from discussions, no clear documented approval of the current process was observed. Hence the following recommendations are made to ensure that there is an inbuilt monitoring system in place for GoMP.
Recommendation: Formal approval of EMRI’s current procurement process – state and national: . It is recommended that GoMP formally reviews, suggests modifications and approves current procurement processes followed by EMRI currently for national tenders and state procurement. This will ensure that for all future procurement done by EMRI, the processes followed are in concurrence with GoMP’s requirements.
Analysis of GVK-EMRI’s national benchmarks by GoMP: . Since GVK EMRI is operational in over 12 states, almost similar items would be procured in other states as well. As a practice for procurement of any high value or quantity item, it could be a best practice for GVK EMRI to submit and discuss with GoMP the current national benchmarks with respect to its price. Once the final price in MP is fixed, variations from these national benchmarks should be documented as part of the procurement process. This will assist GoMP in tracking national standards and prices in a structured manner.
However, it may not be possible to consistently ensure that the final prices are below the submitted national a number of parameters affect price such as number of bidders, level of bidders – national vs. state, location of delivery, scale of operations etc. As discussed, variations should be documented.
7 Strengthening on-going trainings for EMTs
Context: While EMTs were conversant with emergency SOPs for cases previously handled by them on ERCP advice, they were weak in other cases that were required to be known theoretically to prepare them for all medical emergencies. Discussions with EMTs and the state-level care team highlighted the fact that refresher training programs were not being conducted regularly.
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Recommendation: Regularize refresher programs for EMTs: . The Care team needs to regularize the current refresher modules by developing an annual training calendar detailing trainee names and dates of training. This would also help field operations and HR teams plan for manpower rostering in advance. As visualized by the Care team, the refresher could be conducted annually once for older EMTs and bi-annually once for the EMTs trained in the shortened preparatory training program.
Inputs to training programs: . Key gaps operational / knowledge gaps should be identified based on findings from the following sources and should be incorporated into the existing training program: - Regularize current adhoc process of EMT evaluation based on patient care records of critical cases, by defining a minimum number of PCR evaluations to be done per EMT. - Structured evaluation of new EMTs by Mentor EMTs - Comprehensive evaluation of the new EMT program, to be conducted by EMRI
Extended on-field training through network hospitals: . The current preparatory program requires EMTs to undergo training in emergency rooms(ER) of large hospitals. This could be replicated on an ongoing basis by developing a quarterly or bi-annual schedule for each EMT to train in the ERs of EMRI’s network hospitals of the district in consultation with the care team.
Strengthen hospital tie-ups: 8 Shift from hospital information management to Hospital Relationship management
Context: EMRI has a process to capture details of services, specialties, resources and infrastructure available across health facilities in each of the districts through surveys conducted by their district EMEs. Currently this information is only used for assigning handled emergencies to respective hospitals as part of their database. These established tie-ups and information are not used by EMRI to address any of their field requirements such as case-based selection of hospitals, on-field trainings etc.
Recommendation: Regularize refresher programs for EMTs: The Care team needs to regularize the current refresher modules by developing an annual training calendar detailing trainee names and dates of training. This would also help
Provision of consolidated hospital information list should be made available to the ambulance staff. In cases of a critical emergencies, this list would enable the ambulance staff take the patient to the nearest appropriate health facility.
EMEs to report types of cases and no. of cases reported in the health facility. . It is suggested that EMEs share the no, of emergencies accepted by each of the partner hospitals with the district committee. This could also help in discussion hospital wise
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feedback with the district administration in terms of ease of handover, availability of infrastructure, attitude of MOs etc.
Conduct periodic meetings with Medical officers at the health facilities: . The field operations team should conduct periodic meetings with the MOs at the health facilities to discuss service feedback and field level issues (if any). These meetings also provide an opportunity to inform the doctors on correct usage of PCR forms accompanying an emergency patient, which has been observed to be an issue with most hospitals.
Hands-on training to new EMTs in hospital ERs: . Another initiative to train the newly inducted EMTs can be done by providing hands-on training in the hospital ER. This also helps in building relation with the doctors and paramedical staff.
9 Improving quality processes related to monitoring support functions and closure of ambulance non-compliances
Context: For the core functions of EMRI, while the audits are carried out diligently, minor gaps were observed in monitoring of closure of ambulance audit non-compliances, especially related to medical equipment. With respect to support functions (including HR, SCM, Marketing, IT-IS etc.), while the teams are monitored closely by the national teams, state-level reviews of process adherence needs strengthening.
Recommendation: Systematic process to track ambulance non-compliances: . The state-level quality team should work closely with field operations and SCM teams to ensure that all ambulances meet compliance standards. A clearly developed tracking sheet should be used to track observations made during audits, assigning clear responsibilities for necessary action and regular follow to ensure timely closure.
Internal audits of support function processes . The quality team must initiate internal audits for all support function processes. The objectives of the internal audits should be to check relevance of existing processes, adherence and status of performance indicators. Steps to be followed include - training of at least 8-10 senior officials as internal auditors - developing a well-defined bi-annual internal audit plan with a clear documentation and non-compliance closure mechanism
10 Improving Inventory management practices
Context: While no apparent cases of stock outs or excess stock were observed, currently the reorder quantities are calculated only on monthly consumptions using excel sheets. The process does not clearly define minimum stock, stock holding time or economic order quantities. The current process is manual and time consuming.
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Recommendation: Training to SCM staff (Procurement and Store): . As a first step, SCM staff should be provided training on concepts such as Adjusted Consumption method and Economic Order Quantity (EOQ), safety stock norms etc.
Implementation of desired inventory management practices: . A detailed demand assessment sheet should be developed for all store items to assess exact demand levels, which could include norms for safety stock, monthly consumptions, economic order quantities etc. to be decided by the state SCM team, in consultation with the national team. The national team should handhold the state team for 2-3 months in raising indent orders based on the demand assessment sheet. Once stabilized, the organization could also decide to use an enterprise solution (probably an extension of the current used Oracle) for inventory management and demand assessment. The tracker and the use of SAP would automate the effort thus reducing the probability of errors. Also it is suggested that this exercise be done once all the ambulances are stabilized. Since our visits were conducted during the interval when the launches were still on, it was difficult to separate drugs required for operational ambulances from those required for the launch of the new ambulances.
11 Employee handbook for line staff
Context: Discussions with field EMRI staff has highlighted there is lack of clarity on administrative/ HR processes, especially on compensation break up.
Recommendation: Designing an Employee Handbook: . It is suggested that EMRI should develop an Employee Handbook providing clear understanding of all processes related to ambulance staff. The handbook could include – - Reporting structure - Roles and responsibilities - Grievance redressal system and escalation mechanisms - Payroll and reimbursements - Leave entitlements - Rewards and recognition
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CHAPTER 8
ANNEXURES
Assessment of ERS Performance in Madhya Pradesh Final Report
Annexure 8.1 Selection of Sample Villages
Details the data sent by EMRI and the data comparison table used to finalize the sample
For block, 4 green “frequent” and 2 red “infrequent” villages were met
GWALIOR G I R D B H I T A R W A R S.No Village No. of Ems S.No Village No. of Ems Village Count 177 Village Count 106 Average 4.5 Average 3.6 EM Total 2917 Total 520 Null 509 Null 143 Net EM Total 2408 Net Total 377
S.No Village No. of Ems S.No Village No. of EMs 1 GWALIOR 1618 1 ADAMPUR 27 2 ADUPURA KHALSA 79 2 CHINOUR 27 3 RAIRU 31 3 BHITARWAR 26 AMROUL(AMROL 4 GHATIGAON (BARAI) 30 4 81) 15 5 BILHETI 20 5 DEORI KALAN 13 6 MOHANA 18 6 GOHINDA 13 7 BARAI 16 7 MEHGAON 9 8 UTILA 16 8 RARUA 8 9 GIRVAI 14 9 SILHA 8 10 JAKHARA 13 10 BANWAR 7 11 PURANICHAVNI 13 11 BHORI 6 12 BILARA 11 12 KHEDA TANKA 6 13 KULETH 11 13 MAINA 6 14 PANIHAR 10 14 BAGWAI 5 15 SONSA 10 15 DUBAHA TANKA 5 16 DUHIYA 9 16 GHARSONDI 5 17 MAHARAJPURA 9 17 KARHIYA 5 18 RENHAT 9 18 PURA BANWAR 5 19 SIRSAUD 9 19 RAHI 5 20 SOJNA 9 20 URWA 5 21 SUPAWALI 9 21 DEOGARH 4 22 DORAR 8 22 ERAYA 4 23 MOHNPUR (MURAR) 8 23 HARSI 4 24 NAYAGAON 8 24 KHADICHA 4 25 RAMPURA 8 25 KHAIRWAYA 4 26 SONI 8 26 MOHANGARH 4
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S.No Village No. of Ems S.No Village No. of EMs 27 BADAGAON 7 27 RAJAUA 4 28 BAHADURPUR 7 28 SAHARAN 4 29 BIJOLI 7 29 SAN KHINI 4 30 KHERIYA KESHAR 7 30 SEHBAI 4 31 PIPROLI 7 31 SINHARAN 4 32 SUSERA 7 32 SUKHNA KHIRYA 4 33 ANTRI 6 33 SYAU 4 34 BASTARI 6 34 BADKI SARAY 3 35 BERJA 6 35 BAJNA 3 36 GOWAI 6 36 CHARKHA 3 37 JIGANIYA 6 37 CHHIRATA 3 38 JIGSOLI 6 38 CHITOLI 3 39 KUWRPUR 6 39 DUBAHI 3 40 LAXMANGARH 6 40 ITMA 3 41 NAUGAON 6 41 JAURA 3 42 NIRAWALI 6 42 MASTURA 3 43 TIGHRA 6 43 MASUDPUR 3 44 ARON 5 44 RICHHARI KHURD 3 45 BADORI 5 45 BASAI 2 46 BANDHOLI 5 46 BELGADHA 2 47 GUTHINA 5 47 BERNI 2 48 IKEHARA 5 48 DAULATPUR 2 49 RAI 5 49 DHOBAT 2 50 SENTHRI 5 50 DONI 2 51 SIHOLI 5 51 GARHI SALAMPUR 2 52 SIRSA 5 52 GUJAR BANWARI 2 53 SURO 5 53 HIMMATGARH 2 54 BEHAT 4 54 JAKHWAR 2 55 DANGGUTHINA 4 55 KACHHAUA 2 56 GURRI 4 56 KAITHI 2 57 HASTANAPUR 4 57 KAITHOD 2 58 JAMAHAR 4 58 KHADAUA 2 59 JARGA 4 59 KHURDPAR 2 60 KAKRARI 4 60 LADHWAYA 2 61 MAHARAMPURA 4 61 MUSAHARI 2 62 MILAWALI 4 62 PACHORA 2 63 PAR 4 63 PIPRAUA 2 64 PARSEN 4 64 RITHONDAN 2 65 RATWAI 4 65 RUAR 2
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S.No Village No. of Ems S.No Village No. of EMs 66 RAWAR 4 66 SHYAMPUR 2 SIKROUDA(SIKROD 67 ROODHPURA 4 67 A) 2 68 RORA 4 68 SONTA KHIRIYA 2 69 AKBARPUR 3 69 AMARDHA 1 70 BHADROLI 3 70 BAJHERA 1 71 CHAK KESHOPUR 3 71 BANIYA TOR 1 72 CHARAIREHANTA 3 72 BASONDI 1 73 DABKA 3 73 BELA 1 74 GANESHPURA 3 74 BERKHEDA 1 75 GIRGAW 3 75 BIRGAWAN 1 76 JEBRA 3 76 CHIRROLI 1 77 JINAWALI 3 77 DHAKAD KHIRIYA 1 78 KAITHA 3 78 DONGARPUR 1 79 KHERIYA MODI 3 79 FATEHPUR 1 80 KHUDAWALI 3 80 GADAJAR 1 81 MALNPUR 3 81 GADHOTA 1 82 MEHADPUR 3 82 GIJORRA 1 83 MUGALPURA 3 83 JATRATHI 1 84 NAGOR 3 84 JHANKARI 1 85 NAINAGIRI 3 85 JUJHAR PUR 1 86 ODPURA 3 86 KAKARDHA 1 KHEDA 87 PATAI 3 87 BHITARWAR 1 88 RAMAUA 3 88 KHEDI DABARIYA 1 89 SIROL 3 89 MACHHARIYA 1 90 SIYAWARI 3 90 MAHUTHA 1 91 SURAJPURA 3 91 MANIKPUR 1 92 VIKRAMPUR 3 92 MARAGPUR 1 93 VIRPUR 3 93 MAUCHH 1 94 AJAYPUR 2 94 NAJARPUR 1 95 BARAUA NURABAD 2 95 NAYAGAON 1 96 BERKHEDA 2 96 NIHONA 1 97 BILPURA 2 97 NIKODI 1 98 DAYELI 2 98 PALAYACHHA 1 99 DONGARPUR TAL 2 99 PURI 1 100 GUNDHARA 2 100 RAWAT BANWARI 1 101 HARJANPURA 2 101 RICHHARI KALAN 1 102 HUKAMGARH 2 102 RICHHERA 1 103 JAGUPURA 2 103 SHEKHUPUR 1
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S.No Village No. of Ems S.No Village No. of EMs 104 KAIMPURA 2 104 SIRSULA 1 105 KERIYA PDYAPUR 2 105 SURAJPUR 1 106 KHEDI 2 106 TEKPUR 1 107 KHERIYA BHAT 2 108 KHERIYA KULETH 2 109 KHERIYA MIRDHA 2 110 KHURERI 2 111 LAKHNOTIKALAN 2 112 LAKHNOTIKHURD 2 113 MAU 2 114 RAIPUR 2 115 RASHIDPUR 2 116 SHANKRPUR 2 117 TEHLRI 2 118 THAR 2 119 TURAKPURA 2 120 UDAIPUR 2 121 BADAGAONJAGIR 1 122 BADERAFUTKAR 1 123 BAHANGIKALAN 1 124 BAHANGIKHURD 1 125 BARAHANA 1 126 BARAUAPICHHORE 1 127 BARETHA 1 128 BASOTA 1 129 BEHATA 1 130 BENIPURA 1 131 BHATPURA SANI 1 BHATPURA(BRAHMAN 132 ) 1 133 BHAVANPURA 1 134 BHELAKALAN 1 135 BIRAMPURA 1 136 CAKRAMPUR 1 137 CHAKMAHARAJPUR 1 138 CHANDPURA 1 139 CHANDUPURA 1 140 CHHONDA 1 141 DHANELI 1 142 DHUWAN 1
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S.No Village No. of Ems S.No Village No. of EMs 143 GADROLI 1 144 GAJIPURA 1 145 GANGAPUR 1 146 GANPATPURA 1 147 GOSI PURA 1 148 HABIPURA 1 149 HIMAPURA 1 150 HIRI 1 151 JAKHODI 1 152 JLALPUR 1 153 KHERIYA KACHHAI 1 154 KHODUPURA 1 155 KRIPALPUR 1 156 MADHA 1 157 MAHESHWARA 1 158 MAITHANA 1 159 MUKHTYARPUR 1 160 SAHASARI 1 161 SANTALPUR 1 162 SARASPURA 1 163 SEKRA 1 164 SHEKHPURA 1 165 SHYAMPUR 1 166 SIHARA 1 167 SIKRAWALI 1 168 SIKRODA FUTKAR 1 169 SIMIRIYA TANKA 1 170 SINGHARPURA 1 171 SONAPURA 1 172 SUNARPURA KHALSA 1 173 SUNARPURA MAFI 1 174 SUPAT 1 175 TIHOLI 1 176 TILGHANA 1 177 UMMEDGARH 1
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SAGAR BANDA GARHAKOTA S.No Village No. of Ems S.No Village No. of Ems Village Count 157 Village Count 106 Average 5.8 Average 6.1 EM Total 1205 Total 527 Null 292 Null 76 Net EM Total 913 Net Total 451
S.No Village No. of Ems S.No Village No. of EMs 1 BANDA 122 1 GARHAKOTA 110 2 ABDAPUR 64 2 BACHHLON 31 3 DALPATPUR 33 3 UMARA 23 4 SAHAWAN 22 4 HARDI 15 5 SHAHGARH 21 5 CHHULLA 13 6 NIMON 19 6 PIPARIYA DIGARRA 13 7 HIRAPUR 18 7 RON 13 8 CHHAPRI 16 8 UDAIPURA 10 9 BINAIKA 13 9 DARARIYA 9 10 GANYARI 13 10 MADIYA AGRASEN 9 11 KHATORA KALAN 13 11 GHOGRA 8 12 RURAWAN 13 12 KUMRAI 8 13 PATAUWA 12 13 BASARI 7 14 TARPOH 12 14 CHANAUVA BUJURG 7 15 TIGODA 12 15 CHOURAI 7 16 KANTI 11 16 PHULAR 7 17 BARAJ 10 17 SANJARA 7 18 BHEDAKHAS 10 18 SHAHPUR 7 19 KETHORA 10 19 JARIYA KHIRIYA 6 20 PATAN 10 20 RATNARI 6 21 BAGROHI 9 21 BAMHORI GARAY 5 22 MAJHGUWAN 9 22 BARKHERA GAUTAM 5 23 PAPET 9 23 CHANDRAPURA 5 24 BUDHAKHERA 8 24 KEKARA 5 25 FATEHPUR 8 25 PIPARIYA BHATOLI 5 26 HANOTA PATKUI 8 26 VIJAYPURA 5 27 JASODA 8 27 BERKHERI KALAN 4 28 PIPARIYA CHOUDA 8 28 BICHHIYA 4 29 PIPARIYA IMLAI 8 29 BORAI 4 30 SIMARIYA KALAN 8 30 KHEJRA 4 31 SORAI 8 31 MADHO 4
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S.No Village No. of Ems S.No Village No. of EMs 32 BAMANA 7 32 MAHUWA SEMARA 4 33 BILAGRAM 7 33 PIPARIYA AHIR 4 34 BILAUWA 7 34 PIPARIYA GUPAL 4 35 DHABOLI 7 35 RANGUWAN 4 36 NAHARMAU 7 36 BALEH 3 37 PATARI 7 37 CHARKHARI 3 38 RABARA 7 38 CHOKA 3 39 RAKHSI 7 39 JHUNDA 3 40 SADPUR 7 40 PACHARA 3 41 BAMHORIKHURD 6 41 RAGUWAN 3 42 BHADRANA 6 42 SINGPUR 3 43 GARROLI 6 43 SURAJPURA 3 44 GORAKHURD 6 44 TADA 3 45 KANIKHEDI 6 45 BAMNODA 2 46 MADAIYA 6 46 BELAI 2 47 MUDARI BUJURG 6 47 BHATOLI 2 48 NARWAN 6 48 CHANDOLA 2 49 TINSUWA 6 49 DATPURA 2 50 BEHROL 5 50 KADALA 2 51 BERKHERI 5 51 KUMERIYA 2 52 BESLI 5 52 MADIYA ASKARN 2 53 CHAKERI BINEKA 5 53 MAGARDHA 2 54 CHOUKA BHEDA 5 54 PADQUARI 2 55 GONDAI 5 55 PARASIYA 2 56 JHAGRI 5 56 SORKHI 2 57 MANJLA 5 57 CHANAUVA KHURD 1 58 NANAKPUR 5 58 DEOPURA 1 59 PADWAR 5 59 HINOTA 1 60 PANARI 5 60 JHAGRI 1 61 PIDARUWA 5 61 KAJRAWAN 1 62 RAJOULA 5 62 KHANPURA 1 63 SEMRA AHIR 5 63 KHAROTALA 1 64 BAMURA BINAIKA 4 64 KHERA 1 65 CHILPAHADI 4 65 KHIRIYA KHAWAS 1 66 DATYA 4 66 KUDAI 1 67 INDORA 4 67 KUNWARPUR 1 68 KHAHARMAU 4 68 MADIYA KHURD 1 69 KIRAULA 4 69 MAHESHA KHURD 1 70 KULLA 4 70 MAJHGUWAN 1
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S.No Village No. of Ems S.No Village No. of EMs 71 NEGUWAN 4 71 MOTHAR NAYAK 1 72 RICHHAI SAGAR 4 72 MURGA 1 73 SASAN 4 73 SEVAS 1 74 SIMARIYA CHHAPRI 4 74 TAL SEMARA 1 75 AMARMAOH 3 76 BAMHORI JAGDISH 3 77 BASONA 3 78 CHITAUWA 3 79 GADAR 3 80 JAMUNIYA 3 81 KUWAYALA 3 82 MADANTALA 3 83 MATAYA 3 84 PIPARIYA CHAMARI 3 85 RAKH 3 86 RAMPUR 3 87 RANIPURA 3 88 SAGARI 3 89 SESAI MAFI 3 90 SHEKHPUR 3 91 SIMARIYA KHURD 3 92 TINSI 3 93 ULDAN 3 94 BAGRODHA 2 95 BARKHERA 2 96 BATWAHA 2 97 BILHANI 2 98 GANESHGANJ 2 99 JHADOLA 2 100 KANDWA 2 101 KHIRIYA 2 102 LIDHOURA 2 103 MAGRA 2 104 NOURAJ 2 105 PADRAI 2 106 PARASIYA 2 107 PARSUWAN 2 108 PRAHLAD PURA 2 109 SAJI 2
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S.No Village No. of Ems S.No Village No. of EMs 110 AGARA 1 111 BAGODHA 1 112 BALYALPURA 1 113 BAMNORA 1 114 BARGUWAN 1 115 BIJRI 1 116 CHARODHA 1 117 CHITAULI 1 118 CHOUKI 1 119 DHAND 1 120 DHURMAR 1 121 DILAKHEDI 1 122 GOMATPUR 1 123 HANOTA SAHAWAN 1 124 HARDUWANI 1 125 HINOTI 1 126 JAWARA 1 127 KANDARI 1 128 KANERA 1 129 KARAI 1 130 KHAIRWAHA 1 131 KHAJRA BHEDA 1 132 KHATORA KHURD 1 133 LUDAYARA 1 134 MADIA 1 135 MALAKPUR 1 136 MUDARI KHURD 1 137 MUDIYA 1 138 NAYAKHEDA 1 139 NENDHRA 1 140 NIHANI 1 141 NIWAHI 1 142 PATHARIYA GOND 1 143 PATHARIYA VYAS 1 144 PITHOLI 1 145 RAMCHANDRAPURA 1 146 RAMPURA 1 147 RICHHAI BINEKA 1 148 RODA 1
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S.No Village No. of Ems S.No Village No. of EMs 149 SAGORIYA 1 150 SALAIYA BINEKA 1 151 SASA 1 152 SEMRA DAULAT 1 153 SEMRA SANODHA 1 154 SIGDONI 1 155 SINGRAWAN 1 156 TAGIYA 1 157 TODA 1
SEHORE
ASHTA BUDHNI NASRULLAGANJ S.No Village S.No Village S.No Village Village Count 120 Village Count 52 Village Count 66 Average 2.9 Average 3.8 Average 3.8 EM Total 470 Total 279 Total 290 Null 117 Null 69 Null 80 Net EM Total 353 Net Total 210 Net Total 210
No. No. No.
Village of Village of Village of
S.No S.No S.No EMs EMs EMs
1 ASHTA 50 1 BUDHNI 63 1 NASHRULAGANJ 60 2 ABDULLAPUR 28 2 AKOLA 17 2 AGRA 14 3 DODI 14 3 SHAHGANJ 13 3 GOPALPUR 11 KOTHRI CHHIDGAONMOU 4 KALAN 11 4 BAYAN 10 4 JI (CHHITAGAON) 7 BADODIYA 5 GADRI 7 5 SALKANPUR 10 5 LADKUI 6 6 CHOPADIYA 7 6 JAHAJPURA 6 6 RITHWAR 6 7 HAKIMABAD 7 7 JAJNA 6 7 NEELKANTH 5 PAGARIYA 8 CHOR 7 8 BORI 4 8 PALASI KALAN 5 9 CHHAPAR 6 9 TALPURA 4 9 REHTI 5 GURADIYA SEMALPANI 10 RUPCHAND 6 10 KHANDA BAD 3 10 KADEEM 5 11 JATA KHEDA 6 11 KHOHA 3 11 GILHARI 4 SHYAMPUR 12 TAPPA 6 12 MAKODIA 3 12 HALIYA KHEDI 4 BORKHEDA 13 DUPADIYA 5 13 PANDADO 3 13 KALAN 3 CHICHLAHA 14 ROLAGAON 5 14 PILIKARAR 3 14 KHURD 3
111 Assessment of ERS Performance in Madhya Pradesh Final Report
No. No. No.
Village of Village of Village of
S.No S.No S.No EMs EMs EMs
15 AMARPURA 4 15 UNCHA KHEDA 3 15 DHOLPUR 3 16 ARNIYA GAJI 4 16 BAGWADA 2 16 NANDGAON 3 BAPCHA 17 BARAMAD 4 17 BORDHI 2 17 NIMOTA 3 18 BHATONI 4 18 DEHRI 2 18 PANDAGAON 3 19 BHAU KHEDA 4 19 DEVGAON 2 19 AMBA KADEEM 2 20 KURAWAR 4 20 GWARDIYA 2 20 BAGWARA 2 21 MUNDI KHEDI 4 21 JAHANPUR 2 21 BANKOT 2 JAWAHAR 22 NANAKPUR 4 22 KHEDA 2 22 BORKHEDI 2 RAMPURA 23 KALAN 4 23 JOSHIPUR 2 23 GILLAUR 2 MAHAGAON 24 AMLA MAJJU 3 24 MARDANPUR 2 24 KADEEM 2 BHEEL KHEDI 25 SADAK 3 25 MAUKALA 2 25 MARIYADO 2 26 BOR KHEDA 3 26 NARAYANPUR 2 26 PADALIYA 2 CHACHA 27 KHEDI 3 27 NONBHET 2 27 PANCHOR 2 DEEPLA 28 KHEDI 3 28 SAIDGANJ 2 28 SATRANA 2 29 DEWAN KHEDI 3 29 BAKTRA 1 29 SEEGAON 2 30 GAWA KHEDA 3 30 BANETA 1 30 SUKARWAS 2 31 HIRAPUR 3 31 BEHRAKHEDI 1 31 AMEERGANJ 1 32 KHACHAROD 3 32 BIBDA 1 32 ATRALIYA 1 33 KHADI 3 33 BORNA 1 33 BADNAGAR 1 MEMDA 34 KHEDI 3 34 CHARUA 1 34 BAISAD 1 BASUDEO 35 METWARA 3 35 DIPAKHEDA 1 35 (BANSDEO) 1 36 MUGLI 3 36 DOBI 1 36 BEEJLA 1 37 RICHHADIYA 3 37 DUNGARIA 1 37 BHADAKUI 1 38 SANGA KHEDI 3 38 HOLIPURA 1 38 CHANDPURA 1 CHAUNDA 39 SEODA 3 39 ITWAR 1 39 GRAHAN 1 40 TITORIYA 3 40 JAIT 1 40 CHHAPARI 1 BADARIYA 41 HAT 2 41 KHABADA 1 41 CHORSA KHEDI 1 BAMULIYA KHIDIYA 42 BHATI 2 42 KURMI 1 42 DHANNAS 1 KUSAM KHEDA 43 BHIL KHEDI 2 43 (KUSUM KHED) 1 43 DIGWAD 1 44 CHANNOTHA 2 44 MATTHAGAON 1 44 DIMAWAR 1 DHURADA 45 KHURD 2 45 NEEM KHEDI 1 45 GORAKHPUR 1
112 Assessment of ERS Performance in Madhya Pradesh Final Report
No. No. No.
Village of Village of Village of
S.No S.No S.No EMs EMs EMs
46 JASMAT 2 46 NEHLAI 1 46 HATHIGHAT 1 47 JHARKHEDI 2 47 PAHAR KHEDI 1 47 ITARSI 1 48 KALYANPURA 2 48 PANGRA 1 48 ITAWA KALAN 1 KANNOD JAMONIA 49 MIRZI 2 49 PATHODA 1 49 BAZYAFT 1 JAMONIA KHAJURIYA KALAN(PANDAG 50 KASAM 2 50 RAMNAGAR 1 50 AON 1 51 KURLI KALAN 2 51 SATAR 1 51 JHAGAR 1 52 MAINA 2 52 SOMALWADA 1 52 JHALI 1 53 MAINAKHEDI 2 53 JHIRNIYA 1 54 MOLU KHEDI 2 54 KHANPURA 1 55 MORUKHEDI 2 55 KHARSANIA 1 56 PARDI KHEDI 2 56 KOSMI 1 PATARIYA 57 GOYAL 2 57 KOTRA PIPALYA 1 58 RASULPURA 2 58 KUMANTAL 1 59 RUPA KHEDA 2 59 MALAJPUR 1 MANDI 60 RUPETA 2 60 (MANDHI) 1 61 SIDDIQUEGANJ 2 61 MUHAI 1 62 AHMADPUR 1 62 NIMNAGAON 1 63 AMKHEDI 1 63 SATDEV 1 64 ARNIYA JOHRI 1 64 SHYAMPUR 1 65 ARNIYA RAM 1 65 SOHAN KHEDI 1 66 AROLIYA 1 66 TILADIA 1 67 BADKHOLA 1 68 BAGDAWADA 1 69 BAIJNATH 1 BAMULIYA 70 RAIMAL 1 71 BAPCHA 1 72 BARKHEDA 1 73 BEDA KHEDI 1 74 BHANA KHEDI 1 BHAVRI KALAN (BHAURI 75 KALAN) 1 76 BHERUPUR 1 77 CHANCHARSI 1 78 CHHAPRI 1
113 Assessment of ERS Performance in Madhya Pradesh Final Report
No. No. No.
Village of Village of Village of
S.No S.No S.No EMs EMs EMs
79 DUKA 1 80 GAJNA 1 81 GOPALPUR 1 GURADIYA 82 KALAN 1 83 GWALA 1 HUSAINPUR 84 KHEDI 1 85 JAFRABAD 1 86 JHILELA 1 87 KABIR KHEDI 1 88 KAJI KHEDI 1 KAMALPURKH 89 EDI 1 90 KANDA KHEDI 1 KARMAN 91 KHEDI 1 92 KESHOPUR 1 KHAMKHEDA 93 ASHTA 1 KILERAMA (FATEHPUR 94 KILERAMA) 1 95 LAKHIYA 1 96 LAKHMIPUR 1 97 LAKHU KHEDI 1 LASUDIYA 98 KHAS 1 99 LASUDIYA PAR 1 100 LORAS KALAN 1 101 LORAS KHURD 1 102 MAGAR KHEDI 1 103 MALI KHEDI 1 104 MALIPURA 1 105 MANA KHEDI 1 MOONDLA 106 MOHABA 1 107 MUNDLA 1 108 MURAWAR 1 109 NEELBAD 1 110 NIMAWARA 1 111 NOGAON 1
114 Assessment of ERS Performance in Madhya Pradesh Final Report
No. No. No.
Village of Village of Village of
S.No S.No S.No EMs EMs EMs
112 PAGARIYA HAT 1 113 SAMARDA 1 114 SANDO KHEDI 1 115 SHIV KHEDI 1 116 SINGARCHORI 1 117 SOBHA KHEDI 1 118 TANDA 1 119 TIGARIYA 1 120 UMARPUR 1
115 Assessment of ERS Performance in Madhya Pradesh Final Report
Annexure 8.2 List of interviews conducted (village-wise)
Gwalior District
Village Category Users/Attendants Non-Users ASHA/PRI Gwalior Rural Girwai Frequent 4 Purani Chavani Frequent 8 Gigsoli Frequent 8 Ajaypur Frequent 2 11 Kulat Frequent 6 Veerpur Infrequent 8 Jalalpur Infrequent 8 Gwalior Urban DH Murar 16 GRMC 5 22 12 GH Birla 11 Gwalior Bitarwar Karhiya Frequent 9 Rahi Frequent 4 Chinour Frequent 5 Mohangarh Frequent 7 17 Bhagwai Frequent 4 Shyampur Frequent 2 Adampore Infrequent 7 Maigaon Infrequent 8 TOTAL 91 53 40
Sagar District
Village Category Users/Attendants Non-Users ASHA/PRI Garhakota Kumrai Frequent 9 Ron Frequent 9 Chanauva Bujurg Frequent 8 12 Chorai Frequent 9 Parasiya Infrequent 8 Kajrawan Infrequent 8 Sagar Urban District Hospital Sagar 31 16 12 Banda Chhapri Frequent 8 Sorai Frequent 9 12 Ganyari Frequent 10
116 Assessment of ERS Performance in Madhya Pradesh Final Report
Village Category Users/Attendants Non-Users ASHA/PRI Fatehpur Frequent 11 Dilakhedi Infrequent 9 Ricchai Infrequent 8 TOTAL 104 49 36
Sehore district
Village Category Users/Attendants Non-Users ASHA/PRI Ashta Hakimabad Frequent 8 Mundikhedi Frequent 9 Pagariya Ram Frequent 8 12 Jatakheda Frequent 8 Kilerama Infrequent 8 Sonda Infrequent 8 Nasrullahganj Chidgaon Frequent 9 Ladkui Frequent 9 Gopalpur Frequent 9 12 Agra Frequent 6 Baisad Infrequent 6 Chapri Infrequent 8 Budhni Bayan Frequent 8 TaalPura Frequent 10 Bori Frequent 5 Salkanpur Frequent 4 12 Jahajpur Frequent 11 Pandado Infrequent 8 Pilikarar Infrequent 8 TOTAL 104 46 36
117 Assessment of ERS Performance in Madhya Pradesh Final Report
Annexure 8.3 – Comparison of 108 ambulances as per international norms
1. As depicted in the table below equipment (marked in green) are currently available in the BLS ambulances. Names of equipment not available in the BLS ambulances are marked in red and further categorised as; For B.L.S., For A.L.S. and Not Relevant.
Availability S. No. International Checklist for BLS Status 1 Stethoscope – adult and paediatric 2 Thermometer with low temperature capability 3 Blood pressure device – automatic / manual, with paediatric and adult cuffs 4 Pulse oxymeter with paediatric and adult probes 5 Portable and fixed suction apparatus with a regulator 6 Glucometer Portable and fixed oxygen supply equipment, capable of metered flow with 7 adequate tubing 8 Nebulizer 9 Atomizers for administration of intranasal medications Not Relevant 10 Laryngoscope handle – paediatric and adult For ALS 11 Laryngoscope blades, sizes ( sizes 1–4, curved – Macintosh) For ALS 12 Bag-valve mask (manual resuscitator) – adult and infant Portable, battery-operated monitor/defibrillator (with paediatric capabilities – 13 For ALS child- sized pads and cables or dose attenuator with adult pads). 14 Transcutaneous cardiac pacemaker, including paediatric pads and cables Not Relevant 15 Blood glucose test strips 16 Intravenous catheters 14G –24G 17 Intraosseous needles or devices appropriate for children and adults Not Relevant 18 Venous tourniquet, rubber bands 19 Syringes of various sizes 20 Needles, various sizes (one at least 1 ½” for IM injections) 21 Intravenous administration sets (microdrip and macrodrip) 22 Intravenous arm boards, adult and paediatric Not Relevant Large bore needle (should be at least 3.25” in length for needle chest 23 For ALS decompression in large adults) 24 Blood sample tubes, adult and paediatric For ALS Endotracheal tubes (if ALS service scope of practice includes tracheal 25 intubation) sizes 2.5 –5.5 mm cuffed and/or un cuffed and 6 – 8 mm cuffed (1 each), other sizes optional 26 Infant oxygen mask For ALS Alternative airway devices (for example, a rescue airway device such as the 27 ETDLA [esophageal-tracheal double lumen airway], laryngeal tube, or laryngeal mask airway) Nasogastric tubes, paediatric feeding tube sizes 5F and 8F, sump tube sizes 8F– 28 For ALS 16F 29 3.5 –5.5 mm cuffed endotracheal tubes, with stylettes For ALS 30 Topical haemostatic agent/bandage For ALS
118 Assessment of ERS Performance in Madhya Pradesh Final Report
Availability S. No. International Checklist for BLS Status 31 Emesis bags or basins 32 Elastic bandages 33 Needle cricothyrotomy capability and/or cricothyrotomy capability Not Relevant Burn kit (sterile burn sheets, bandages, dressings, gauze rolls, occlusive dressing 34 or equivalent, adhesive tape, arterial tourniquet, heavy bandage or paramedic scissors for cutting clothing, belts, and boots). 35 Obstetric Kit 36 IV pole or roof hook A length based paediatric dosing tape or appropriate reference material that 37 converts length to estimated ideal body weight in kilograms for paediatric drug Not Relevant dosing and equipment sizing 38 Wheeled cot / Folding stretcher 39 Stair chair or carry chair 40 Long Spinal Board complete with head immobilizer and Security Straps Impervious backboards (long, short; radiolucent preferred) and extrication 41 Not Relevant device 42 Paediatric backboard and extremity splints For ALS 43 Femur traction device (adult and child sizes) Not Relevant 44 Cervical collars 45 Head immobilization device (not sandbags) 46 Pelvic immobilization device Not Relevant 47 Upper and lower extremity immobilization devices Not Relevant 48 Vacuum Mattress Not Relevant 49 Bedpan 50 Urinal 51 Blankets 52 Flashlights (2) with extra batteries and bulbs 53 Sheets, linen or paper, and pillows 54 Towels 55 Triage tags Not Relevant 56 Protective helmet/ jackets or coats/ pants/ boots Not Relevant 57 Fire extinguisher 58 Cellular phone Appropriate CBRNE PPE (chemical, biological, radiological, nuclear, explosive 59 personal protective equipment), including respiratory and body protection Applicable chemical antidote auto injectors (at a minimum for crew members’ 60 protection; additional for victim treatment; appropriate for adults and children) 61 Cold packs For BLS 62 Hazardous material reference guide For BLS 63 Patient care protocols For BLS Source: http://www.nasemso.org/Councils/PEDS/documents/AmbulanceEquipmentGuidelinesJune2012.pdf
Item available in EMRI – BLS Ambulances Item not-available in EMRI – BLS Ambulances
119 Assessment of ERS Performance in Madhya Pradesh Final Report
2. The equipment which are not currently available but could be part of a Basic Life Support Ambulance are categorised as ‘For BLS’, those which could be part of the planned 50 Advanced Life Support ambulances are marked as ‘For ALS’ and those which are not relevant in the Indian setting or are not required at the level of care provided in the ambulances are marked as ‘Not relevant’.
EQUIPMENT For BLS For ALS Not Relevant Cold packs Laryngoscope handle – paediatric Atomizers for administration of and adult intranasal medications Hazardous material reference Laryngoscope blades, sizes ( sizes Transcutaneous cardiac guide 1–4, curved – Macintosh) pacemaker, including pediatric pads and cables Patient care protocols Portable, battery-operated Intra osseous needles or devices monitor/defibrillator (with pediatric appropriate for children and capabilities – child- sized pads and adults cables or dose attenuator with adult pads). Large bore needle (should be at Intravenous arm boards, adult least 3.25” in length for needle and pediatric chest decompression in large adults) Blood sample tubes, adult and Needle cricothyrotomy pediatric capability and/or cricothyrotomy capability Infant oxygen mask A length based pediatric dosing tape or appropriate reference material that converts length to estimated ideal body weight in kilograms for pediatric drug dosing and equipment sizing Nasogastric tubes, pediatric feeding Impervious backboards (long, tube sizes 5F and 8F, sump tube short; radiolucent preferred) and sizes 8F–16F extrication device
3.5 –5.5 mm cuffed endotracheal Femur traction device (adult tubes, with stylettes and child sizes)
Topical hemostatic agent/bandage Pelvic immobilization device Pediatric backboard and extremity Upper and lower extremity splints immobilization devices Vacuum Mattress Triage tags Protective helmet/ jackets or coats/ pants/ boots
120 Assessment of ERS Performance in Madhya Pradesh Final Report
Annexure 8.4 – Roles and Responsibilities of key stakeholders involved in carrying out field operations
Key Stakeholder Responsibility Program Responsible for adherence of regional performance to decide service level Managers parameters of the state (PM) Monitoring and supervising EMEs for each district Managing the field operations at the state level Liasoning with other support teams such as quality team for Ambulance go live audits Emergency Managing Operations Management Monitoring and supervising EMTs and Pilots in the district Executive Rostering and scheduling of field staff `(EME) Planning and conducting district events such as EMT day, Pilot day etc. Adding and updating data on health facilities in H.I.S. and syncing it same with the Sense team Liaising with other support function teams such as quality team, sense team etc. Responsible for ambulance fund management Conducting periodic ambulance audits on regular intervals Marketing Create awareness of EMRI services in the district such as conducting demos Liaising Liaising with the district committees for quarterly meetings Vendor management at district level Liaising with media Collecting information on health facilities and maintaining hospital relations within the district Emergency Care Management Receiving calls from the Emergency Response Centre (ERC) and the caller to Technician reach the emergency site and providing case closure reports to the ERC (EMT) Providing emergency pre-hospitalization care to the patient. The EMT is required to speak with the ERCP before administering any medicine to the patient Recording vitals of patients and filling out Patient Care Records and getting forms signed by the MO on duty at the health facility Filling of PCR form and hand over one copy of PCR to the hospital with the attending doctor signature Administration Submission of PCRs to state office Periodic medicines indenting and equipment repair Conduct demos as planned with the EME Maintain medicine, care and demo related registers Pilot Providing transport services to the patients Assisting Emergency Medical Technicians (EMTs) in victim shifting and scene management. Assisting EMTs during demos Maintaining log books and recording number of kilometers covered in each trip. Ensure complete documentation in cases of accidents Coordinate with fleet department for scheduled service maintenance
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Annexure 8.5 – Launch Details of Ambulances and Population Coverage per district
Coverage No. of Ambulance (Population per
ambulance)
Population
District (Census
S.No. 2011)
Dec '12 May'13
As on As on As
Dec'12
Jan‘13
Feb ‘13
May'13
Apr Apr ‘13
Mar ‘13 May ‘13
1 Bhopal 1,843,510 15 15 122,901 122,901 2 Jabalpur 2,151,203 14 1 15 153,657 143,414 3 Gwalior 1,632,109 12 1 13 136,009 125,547 4 Indore 2,465,827 15 15 164,388 164,388 5 Rewa 1,973,306 15 15 131,554 131,554 6 Sagar 2,021,987 17 17 118,940 118,940 7 Datia 628,240 3 5 8 209,413 78,530 8 Damoh 1,083,949 3 4 7 361,316 154,850 9 Sehore 1,078,912 5 7 12 215,782 89,909 10 Hosanagabad 1,084,265 3 5 8 361,422 135,533 11 Raisen 1,125,154 9 9 125,017 12 Dhar 1,740,329 13 13 133,871 13 Katni 1,064,167 8 8 133,021 14 Shajapur 1,290,685 9 9 143,409 15 Morena 1,592,714 9 9 176,968 16 Rajgarh 1,254,085 8 8 156,761 17 Sidhi 1,831,152 6 6 305,192 18 Sheopur 559,495 5 5 111,899 19 Shivpuri 1,441,950 10 10 144,195 20 Shahdol 1,575,303 7 7 225,043 21 Umariya 515,963 6 6 85,994 22 Dindori 580,730 6 6 96,788 23 Singroli 1,178,132 6 6 196,355 24 Anuppur 749,521 6 6 124,920 25 Harda 474,416 5 5 94,883 26 Satna 1,870,104 6 7 13 143,854 27 Betul 1,395,175 5 5 10 139,518 28 Vidisha 1,214,857 8 8 151,857 29 Bhind 1,428,559 9 9 158,729 30 Ashok nagar 844,979 6 6 140,830 31 Guna 1,666,767 8 8 208,346 32 Chinddwara 1,849,283 12 12 154,107 33 Mandla 894,236 9 9 99,360 34 Khargone 1,872,413 10 10 187,241
122 Assessment of ERS Performance in Madhya Pradesh Final Report
Coverage No. of Ambulance (Population per
ambulance)
Population
District (Census
S.No. 2011)
Dec '12 May'13
As on As on As
Dec'12
Jan‘13
Feb ‘13
May'13
Apr Apr ‘13
Mar ‘13 May ‘13
35 Panna 856,558 8 8 107,070 36 Narsinghpur 957,646 6 6 159,608 37 Seoni 1,166,608 9 9 129,623 38 Tikamgarh 1,202,998 9 9 133,666 39 Chhatarpur 1,474,723 11 11 134,066 40 Balaghat 1,497,968 10 10 149,797 41 Jhabua 1,394,561 7 7 199,223 42 Alirajpur 728,677 6 6 121,446 43 Dewas 1,308,223 8 8 163,528 44 Ratlam 1,215,393 8 8 151,924 45 Mandsaur 1,183,724 8 8 147,966 46 Badwani 1,081,441 9 9 120,160 47 Khandwa 1,309,443 8 8 163,680 48 Neemuch 726,070 6 6 121,012 49 Burhanpur 756,993 6 6 126,166 50 Ujjain 1,710,982 12 12 142,582
TOTAL 64,545,485 102 454 632,799 142,171 *Population per ambulance is expected to reduce to 1, 07,218 with the launch of 150 ambulances
123 Assessment of ERS Performance in Madhya Pradesh Final Report
Annexure 8.6 – Facility Feedback
District Ambulance Facility Comments/Feed back Sometimes EMTs leave patients without attendants at JAH medical casualty without informing the receiving doctors on College - Gwalior history and location of pick up. Level of care could be better for example in wound Gwalior City care and inserting intra cath line in patients. Centre PCR copy not handed over directly to attending Maheshwari Private doctors as a practice. Attending doctor never seen Hospital* PCR copy. Gwalior Overall service is good and response time is fast. Care provided on ERCP advice (I/v and O2) was not CHC Bhittarwar Bhittarwar Block required in a specific case. Ambulance JAH medical Overall satisfactory care provided by EMT. College - Gwalior Response time is fast. DH Morar Timely response provided by 108. Purani Chavni Sufficient care provided at the level of EMT. Ambulance Birla Nagar Maternity Home Good advice provided by ERCP DH Sagar Good response time maintained by 108 service Sagar Police Good management of cases and quality of care Control Room Daffrin Hospital satisfactory. (DH Sagar) Adequate documentation done by EMT. Good response time maintained by 108 service. Garhakota Good management of cases and quality of care Sagar CHC Garhakota Ambulance satisfactory. Adequate documentation done by EMT. Good quality of care at the EMT level. Banda CHC Banda Advice from ERCP useful. Ambulance Documentation is adequate. Timely response provided CHC Budni Correct care provided by EMT. Budni Police Services found useful especially since large number of Chowki DH Hoshangabad trauma cases transported to facility by 108. Sometimes serious cases not transferred to Bhopal. Care provided is adequate as per level of EMTs Sehore Traffic DH Sehore however services could be better. Thana Sehore ERCP advice is useful and correct. Good response time maintained. Adequate pre-hospital care not provided. PCR forms sometimes not properly filled. Ashta Police CHC Ashta ERCP advice inadequate at times. Chowki Good care of pregnancy related cases. Useful and sufficient documentation. Service quality better than JEY. * Maheshwari hospital is a private health facility and no doctors were available for interview.
124 Assessment of ERS Performance in Madhya Pradesh Final Report
Annexure 8.7 – Minimum qualifications and recruitment process for EMTs, Pilots and ERO
1. The minimum qualifications and recruitment process for EMTs, Pilots and EROs is presented below:
Employee Minimum Qualifications Recruitment Process EMT Science Graduate (preferably with Biology) Written test Max age at entry- 32 years Technical interview Also accepts 2 year Science diplomas like Training BEMS, BHMS etc. Examination after training Pilot Class 10 appearance (pass/fail) Written test HTV/LTV/Commercial vehicle driving Interview license Medical test 5 years driving experience Driving test Max age at entry- 38 years ERO Graduate in any discipline Typing speed of 30 words per minute (after undergoing training) Max age at entry- 35 years
125 Assessment of ERS Performance in Madhya Pradesh Final Report
Annexure 8.8 – Assessment parameters and tool used for EMT assessment
Technical Knowledge 1. The EMT was assessed on the knowledge level and soundness of understanding of clinical conditions, their associated signs and symptoms and their management protocols. The common emergencies handled were segregated into four sub categories for a detailed understanding of each category. The sub categories were general orders, medical, trauma and pregnancy. General Orders- This section focussed on basic protocols on initial patient assessment, areas to investigate for the same and overall history taking and physical examination procedures for all types of cases and standard protocols on BLS, AVPU, CPR etc. Medical Emergencies- This section focussed on specific medical conditions other than trauma and pregnancy related cases like anaphylaxis, altered mental status, cardiac arrest, stroke and seizures etc. Trauma-Vehicular and Non Vehicular emergencies- This section focussed on cases like injuries due to RTA, suicidal cases, severe pain and amputations Pregnancy related emergencies- This section focusses on emergency cases related to pregnancy and child birth complications.
Questions from the section on General Orders and questions from two of the other three sections were administered to all EMTs.
Practical knowledge (Skill and Direct Handling of cases) 2. The EMT was assessed on the ability to practically put to use his/her technical knowledge in direct handling of an emergency case. This was done by the expert by way of qualitative discussions (captured at relevant areas in the tool) when administering the tool and on direct observation. The expert travelled with the EMT in the ambulance where ever possible to observe the level of skill and direct patient handling among EMTs in real time.
Systems knowledge 3. As part of their responsibilities the EMTs are mandated to follow certain standard processes once the central call centre directs a caller to the nearest ambulance to the time they are transferred to the nearest health facility. These include details on processes involved in receiving the call by the EMT to recording the case ID, connecting with the patient, confirming the choice of the health facility, recording the details to handing over the patient at the facility and closing the case. The EMTs were assessed in their knowledge of these mandated processes.
Documentation 4. EMTs are expected to maintain several formats/ registers, based on the services provided and for program management purposes. The following registers are mandated to be maintained by the EMT in the ambulance: Patient Data Register Prehospital Care Record forms Against Medical Advice Form Inter Facility Transfer Form Handing Over Register Storage of medicines Bio Medical Waste Handover Register Daily checklist Complaint Register Attendance Record 5. These documents were checked for availability and completeness, and EMTs’ understanding of what information is required to be maintained in these documents.
126 Assessment of ERS Performance in Madhya Pradesh Final Report
Assessment tool for EMT
1. EMT Details 2. Name of the EMT 3. Educational qualification 4. Total years of experience 5. Years of service with EMRI 6. Trainings received from EMRI till date 7. Duty timings
Process Related 8. What is the process followed once you receive a call from the ERO at the call centre? 9. What are the SOPs you follow while handling various types of emergencies? Please share* 10. During an EM call, who decides the health facility? You or the patient? Where is the patient taken to - with EMRI tie-ups only or any facility? 11. What are the records you are required to maintain? Observe 1-2filled PCR Forms 12. In case of off duty hour emergencies, who is responsible for attending that emergency? 13. Has it ever happened that the patient/caller has refused the service once you reached the site of emergency? What is procedure followed in such a situation? 14. What is the case closing procedure followed after the patient has been handed over at the health facility?
Monitoring and Supervision 15. Did you receive any further training / refresher from EMRI (on updated equipment, medication, protocols etc.)? Please detail if any? Do these trainings happen at regular intervals? 16. Is there any monitoring activity undertaken by GVK EMRI? 17. What are the major issues that you face in ensuring smooth functioning of operations in relation to your roles and responsibilities? Is there a grievance redressal system for employees at GVK EMRI? 18. Do you have any suggestions for improvement of services?
EMT Assessment (To be carried out by the technical expert) On pre hospital care given to the patient on reaching the site of emergency 19. What interventions constitute the Initial Patient Assessment? 20. What are the components of history taking and physical examination in medical and trauma cases? 21. Under what conditions will you call for medical directions in emergency cases? 22. What constitutes the BLS protocol? In what condition will you start BLS protocol? Please specify for adult and pediatric age group. 23. What are the components of the TRIAGE protocol? 24. What is the AVPU protocol? 25. What is GCS? When is it used? When did you use it last? 26. What is the CPR Protocol? Please enumerate steps
Medical Emergencies 27. What is the management protocol for a patient with altered mental status? What is GRBS and what is the normal value for it? What is the BP check which is crucial? 28. What is an anaphylactic reaction? What is the treatment protocol to be followed in cases of anaphylaxis? What are crucial observations which are required in such cases? 29. What are crucial signs and the treatment protocol for cases of breathing difficulty?
127 Assessment of ERS Performance in Madhya Pradesh Final Report
30. What are the crucial standing orders for a case of chest pain? What is the treatment protocol for the same? 31. What are treatment protocols for a case of cardiac arrest? (Check if mentions BLS protocol) 32. What are the management protocols in a case of stroke? 33. Please enumerate key seizure management protocols. Check for position knowledge in seizure management. 34. Will you take history in a case of cardiac arrest?
Trauma (Vehicular/Non Vehicular) and Suicidal Cases 35. What are the general standing orders in cases of trauma? 36. What are the key areas of physical examination in cases of abdominal injury? Please enumerate 5 key steps of management for the same. 37. What is the management and treatment protocol for cases with Burn injuries? What actions are contraindicated in the same? 38. What are the key management protocols in cases of external bleeding/injury and amputations? What is to be done with amputated parts if any? What are the other protocols to be kept in mind in such cases? What is contraindicated in amputations? 39. Please enumerate key examination areas and shock management protocols. 40. What are the key areas for physical examination in cases of head injury? Also point out 4 key management protocols. 41. What are the treatment protocols for a case of hanging? What is a crucial contraindication in such cases? 42. What is the kind of information to be sought from the patient and the management protocols in cases of poisoning? 43. What is a major contraindication in cases of hypothermia/drowning?
Pregnancy Related 44. What is the first action as per SOP which you will undertake in an emergency child birth case? What all will constitute in the initial history taking of such cases? 45. What are the signs and symptoms which you will observe initially in such a case? 46. What are the key management protocols for such a case? 47. Once the baby is delivered (in the ambulance) safely what steps are to be taken as per the SOP? 48. What is the Apgar score? What is considered as a normal score and what is a critical score? 49. What are the important steps in placenta management once the woman has delivered? 50. What are the key management protocols in spontaneous abortion cases? Enumerate key steps. 51. What are the presenting signs and symptoms in the condition ‘Prolapsed Cord’ 52. What are the key management protocols for the same?(Don’ts important here) 53. What are the presenting signs and symptoms in a breech presentation and what are the key management protocols for this condition? 54. What are the presenting signs and symptoms of mild pre eclampsia, moderate and eclamptic condition in a pregnant woman? 55. What are the key management protocols in a case of pre eclampsia/eclampsia? 56. What is PPH and what are its key management protocols?
EMT Assessment form
The interviewer is expected to document observations based on his/her interview with the EMT on following parameters –
128 Assessment of ERS Performance in Madhya Pradesh Final Report
1. Process Understanding 2. PCR Documentation (Completeness and Correctness) 3. Theoretical Knowledge on management protocols and standing orders(understanding of terminology and technical language used) 4. Direct Handling of Cases (correct identification of signs and symptoms) Direct Observation where applicable 5. Overall Impression
129 Assessment of ERS Performance in Madhya Pradesh Final Report
Annexure 8.9– List of consumables and equipment present in sample ambulances assessed
Gwalior Sagar Sehore
Consumables & Equipment
S.no
Ruralblock
2: Ruralblock 3: Ruralblock 1: 2: Ruralblock 3: Ruralblock
2:Urbanblock 1:Urbanblock
1:Urbanblock 3: Ruralblock 1. Pulse Oxymeter 0 0 1 1 1 1 1 1 1 2. Manual BP Apparatus 0 1 1 1 1 1 1 1 1 3. Glucometer 1 1 1 1 1 1 1 1 1 4. Thermometer- Digital 1 0 1 1 1 1 1 1 1 5. Suction Device (Automatic and Manual) 1 0 1 1 1 1 1 1 1 6. Needle and Syringe Destroyer 0 1 0 1 1 1 1 1 1 7. Nebulizer Machine 1 1 1 1 1 1 1 1 1 8. Humidifier 1 1 1 1 1 1 1 1 1 9. Stethoscope 1 1 1 1 1 1 1 1 1 10. Oxygen Cylinder (+ Flow Meter, Pressure 1 1 1 1 1 1 1 1 1 gauge, Volume gauge) 11. Disposable Gloves 1 1 1 1 1 1 1 1 1 12. Disposable Masks 1 1 1 1 1 1 1 1 1 13. Disposable Delivery Kit 1 0 1 1 1 1 1 1 1 14. Pediatric Kit 0 0 0 0 0 0 1 1 1 15. Oropharyngeal Airway Size 0,1,2,3,4 1 1 1 1 1 1 1 1 1 16. Nasopharyngeal Airway Size 6.5,7,7.5,8,8.5 1 1 1 1 1 1 1 1 1
17. Oxygen Masks- Adult and Child 1 1 1 1 1 1 1 1 1 18. Nebulizer Mask- Adult 1 1 1 1 1 1 1 1 1 19. Mucus sucker 1 1 1 0 1 0 0 1 1 20. Macintosh Rubber Sheet 1 1 1 1 1 1 1 1 1 21. Non Breather masks- Adult and Child 0 1 0 0 0 0 1 1 1 22. Nasal Cannula- Adult and Child 1 1 1 1 1 1 1 1 1 23. Suction Catheter 0 1 1 1 1 0 1 0 1 24. Drip Sets 1 1 1 1 1 1 1 1 1 25. Cervical collar- Hard (all sizes) 0 1 1 0 1 1 1 1 1 26. Ambu Bag (silicon)- Adult and Child 1 1 1 1 1 1 1 1 1 27. Sputum cup 1 1 1 1 1 1 1 1 1 28. Bed pan 1 1 1 1 1 1 1 1 1 29. Urine pan 1 1 1 1 1 1 1 0 1 30. Kidney tray 1 1 1 1 1 1 1 1 1 31. Liquid Hand wash 1 1 1 1 1 1 1 1 1
130 Assessment of ERS Performance in Madhya Pradesh Final Report
Gwalior Sagar Sehore
Consumables & Equipment
S.no
Ruralblock
2: Ruralblock 3: Ruralblock 1: 2: Ruralblock 3: Ruralblock
2:Urbanblock 1:Urbanblock
1:Urbanblock 3: Ruralblock 32. Adjustable wrench 1 1 1 1 1 1 1 1 1 33. Screw Driver- Flat and Star 1 1 1 1 1 1 1 1 1 34. Hacksaw with blades 1 1 1 1 1 1 1 1 1 35. Vise grip pliers 1 1 1 1 1 1 1 1 1 36. Large Hammer 1 1 1 1 1 1 1 1 1 37. Fire Axe 1 1 1 1 1 1 1 1 1 38. Wrecking Bar 1 1 1 1 1 1 1 1 1 39. Crowbar 1 1 1 1 1 1 1 1 1 40. Shovel 1 1 1 1 1 1 1 1 1 41. Tin Snips 1 1 1 1 1 1 1 1 1 42. Leather Gloves 1 1 1 1 1 1 1 0 1 43. Reserve Blanket (2) 1 1 1 1 1 1 1 1 1 44. Ropes 1 1 1 1 1 1 1 1 1 45. Mastic Knife 1 1 1 1 1 1 0 1 1 46. Centre punch 1 1 1 1 1 1 1 1 1 47. Pruning Saw 1 1 1 1 1 1 1 1 1 48. Luminous warning torch 1 1 1 1 1 1 1 1 1 49. Fire extinguisher 1 1 1 1 1 0 1 1 1 50. Ambulance Tool Kit 1 1 1 1 1 1 1 1 1 51. Rain Coats 1 1 1 1 1 1 1 1 1 1 – Available; 0 – Not Available
131 Assessment of ERS Performance in Madhya Pradesh Final Report
Annexure 8.10 – Comparison of cases handled by 108 and Janani Express Yojana (JEY) in Sagar District
1. As suggested by GoMP during the state level evaluation of ERS in MP, Deloitte conducted a brief comparison of pregnancy cases handled by JEY in comparison to 108 in the high focus district of Sagar.
Introduction JEY in Sagar 2. The JEY service was launched in Sagar District in Jan 2011 and currently operates 14 vehicles. This helpline number serves to the entire district providing home to facility and facility to home drop service to pregnant women. Under this scheme, the Sagar DH has a dedicated phone line with a 24 X 7 attendant answering calls made on the helpline.
108 in Sagar 3. The 108 service was launched in Sagar District in November, 2010 with a fleet size of 17 BLS ambulances. The service provides integrated emergency care for medical, police and fire emergencies.
Objective 4. The objective of this comparison was to get an understanding of the share of pregnancy cases handled by JEY and 108. The comparison was done based on the no. of home to facility cases handled by 108 and JEY for the month of May 2013, as 108 covers only home to facility and does not handle drop back.
Data Limitations 5. Irregular functioning of JEY in 2012: While the services were launched in the district in Jan, 2011 the services were not functional in 2012 due to contractual and systemic delays. Since the service resumed in January 2013, data from February 2013 was being captured and submitted to the district administration. 6. Unavailability of home to facility data: An analysis of JEY reports for the period Feb – May 2013 indicated that, for the months of Feb, Mar and Apr, only consolidated number of pregnant cases handled was available. Classification of data into home to facility and facility to home drop was available only for the month of May. Therefore the comparison between 108 and JEY was done only for the month of May 2013.
Observation 7. In the month of May 2013, the total no. of institutional deliveries in Sagar district was 254932, pregnancy cases carried by JEY were 54933 and by 108 were 117334. The key finding is that due to irregular functioning of JEY 108, continues to carry pregnancy related cases to hospitals. 8. However, drop back is done only by JEY. For the month of May, JEY dropped back 414 cases from facility to home, constituting about 43% of total trips done by the JEY vehicles
32 Monthly District report provided by CMHO, Sagar District 33 Monthly District Report of JEY 34 Information provided by EMRI’s district EME of Sagar District
132 Assessment of ERS Performance in Madhya Pradesh Final Report
Annexure 8.11 – Financial data submitted by EMRI
Apr-12 to Jan-13 to Apr-13 to 09-10 10-11 11- Financial Year Dec-12 March-13 Jun-13 (YTD) (YTD) 12(YTD) (YTD) (YTD) (YTD) Capital Expenditure
102,839,61 Ambulance 44,981,280 84,758,367 84,758,367 84,758,367 8,434,000 1 Equipments 9,973,518 14,630,497 14,671,591 14,685,941 3,133,999 23,559,599 Infrastructure 12,978,541 13,962,863 14,185,975 14,389,659 315,985 14,916,718 IT Infrastructure
Hardware 12,722,691 12,976,346 13,017,961 13,037,061 64,260 13,131,321 Software 262,401 283,596 283,596 287,853 - 287,853 Telecom 8,837,781 8,956,482 8,956,482 8,956,482 - 8,956,482 163,691,58 Total (Capex) 89,756,212 135,568,151 135,873,972 136,115,363 11,948,244 4 Operational Expenditure Fleet
Repairs 880,510 3,527,578 4,886,225 5,697,555 1,985,013 3,779,622
Fuel 5,962,079 17,270,747 21,229,723 15,184,944 14,434,384 16,743,919 Tyre 187,814 1,302,103 2,568,797 1,787,301 1,151,200 840,200 Insurance 154,047 145,198 79,313 581,034 95,490 418,204 Others 10,259 208,595 66,720 17,097 81,500 - Equipment -
Repairs 4,483 14,411 118,963 129,924 19,683 - Calibration - - - - -
Maintenance - - - - -
Insurance - - - - -
Oxyzen 106,192 283,035 260,820 234,202 73,339 175,322 Drugs & Consumables 2,201,048 4,443,428 3,718,297 2,887,343 2,358,768 3,080,206 Communication
Telephone-Land line 1,290,619 1,743,830 1,175,688 798,540 159,931 350,104 Telephone-Mobiles 692,397 1,031,175 836,889 595,533 219,072 748,396 Internets 320,186 457,525 355,957 272,961 86,334 153,670 AMCs 1,975,657 483,596 2,040,636 1,422,911 158,408 31,404 License Renewal
Marketing 2,210,098 354,554 230,949 257,074 274,358 268,000 Administrative 6,531,974 11,395,486 7,966,238 6,148,895 4,520,272 4,322,851
133 Assessment of ERS Performance in Madhya Pradesh Final Report
Apr-12 to Jan-13 to Apr-13 to 09-10 10-11 11- Financial Year Dec-12 March-13 Jun-13 (YTD) (YTD) 12(YTD) (YTD) (YTD) (YTD) Office Maintenance - - - - -
Electricity and Water 1,118,458 1,885,303 1,885,640 1,650,295 460,113 1,002,823
Repairs and maintenance of office, 351,249 197,404 204,011 449,906 369,494 133,014 building and computer
Trainings 2,461,774 2,463,078 3,993,947 3,143,267 11,373,332 19,383,517 Security 242,844 405,655 533,116 432,412 471,196 243,934 Houskeeping 211,851 484,980 533,248 479,996 199,877 291,906 Courier 256,237 556,343 560,384 569,574 199,834 738,943 Stationery 490,642 592,605 1,032,590 899,004 585,184 1,021,839 Others 3,961 28,254 19,815 76,369 (44,640) -
Salary 29,565,936 57,080,117 71,817,566 56,468,057 54,042,067 24,329,379
Total (Opex) 57,230,313 97,450,222 106,354,999 126,115,529 100,184,194 73,881,239
134 Assessment of ERS Performance in Madhya Pradesh Final Report
Annexure 8.12 – Details of year wise parameters for costing ratios – no. of ambulances, emergencies handled and Kms travelled
Apr 13 Jul 09 - Mar 10 Apr 10 - Mar 11 Apr 11 - Mar 12 Apr 12 - Mar 13 - June Months 13 No. of Kms/ Total No. of Kms/ Total No. of Kms/ Total No. of Kms/ Total No. of ambys trip Ems ambys trip Ems ambys trip Ems ambys trip Ems ambys April 52 88 102 454 May 52 94 102 454
June 52 94 102 454 July 40 52 94 102 August 40 67 99 102 40 September 40 67 99 102 35.51 116,048 37.8 148,467 163,556 October 52 67 99 102 November 52 17.26 50,599 84 99 102
December 52 84 99 102 January 52 84 99 102 February 52 84 99 217 32.58 March 52 84 102 286 48 17.3 50,599 69 35.5 116,048 97 37.80 148,467 127 37.03 163,556 114
135 Assessment of ERS Performance in Madhya Pradesh Final Report
Annexure 8.13 – Year wise costing details
(Amount in Rs) Jul 09 to Apr to Dec Financial Year 10-11 11-12 Mar 10 2012 Ambulance Running and
Maintenance Fuel Cost of ambulance 5,962,079 17,270,747 21,229,723 15,184,944 Tyre Expenses 187,814 1,302,103 2,568,797 1,787,301 Ambulance repair, maintenance and 890,769 3,736,173 4,952,945 5,714,652 refurbishment Equipment repair & maintenance 110,675 297,446 379,783 364,126 Vehicle insurance 154,047 145,198 79,313 581,034 Medical consumables 2,201,048 4,443,428 3,718,297 2,887,343 HR Salary 29,565,936 57,080,117 71,817,566 56,468,057 Training 2,461,774 2,463,078 3,993,947 3,143,267 Communication and Tech Support Communication expenses 2,303,201 3,232,531 2,368,533 1,667,034 IT/Equipment maintenance and Tech 1,975,657 483,596 2,040,636 1,422,911 support Administration Administration and Travelling 9,207,215 15,546,029 12,735,041 10,661,811 Marketing IEC and Marketing 2,210,098 354,554 230,949 257,074 TOTAL 57,230,313 106,354,999 126,115,529 100,139,554
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