Service Operations & Management Studio 2020- Covid-19 by Urban Managers

COVID 19 COVID 19 Service Operations and Management Studio

Master of Urban Management Monsoon Semester 2020 CEPT University Service Operations and Management Studio 2020

Students: Aakanksha Gupte (PG190001) Apeksha Agarwal (PG190166) Apoorvi Gupta (PG190172) Dhairya Chopra (PG190262) Karanbir Singh (PG190439) Shantanu Bane (PG190889) Snigdha Kanta (PG190961)

Course: UM4002 Service Operations Management Studio: Unit-B Studio Instructor: Dr. Gayatri Doctor: Associate Professor, CEPT University

Teaching Fellow: Himadri Panchal

Booklet and Graphic Designer Apeksha Agarwal

Editor Snigdha Kanta & Shantanu Bane

Compilator Karanbir Singh

COPYRIGHT @ CEPT University, Ahmedabad All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, trasmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of the publishers.

Service Operations and Management Studio 2020 CEPT University

Table of Contents Acknowledgement

Abstract

Abbrevations

List of Figures

List of tables

Executive Summary

Introduction to Studio

Introduction to Pandemic at Global and National Level

A- Faridabad

B- Hapur

C- Lucknow

D- Ahmedabad

E- Vasai Virar

F- Navi Mumbai

G- Gulbarga

112

City Learning

131

References

136

Appendix

138 CEPT University Service Operations and Management Studio 2020

Acknowledgement

We are grateful to CEPT University and the Faculty of Management for making it possible for us to undertake the study. We express our sincere gratitude to Dr. Gayatri Doctor and Dr. Mercy Samuel and are grateful for their guidance, encouragement and support. Their meticulous scrutiny and scholarly advice has helped us accomplish our task.We are extremely grateful to the Dean of our department, Prof. Chirayu Bhatt for his insights, expertise and constant support throughout. We pay our deep sense of gratitude to Prof. Chinubai and Prof. Chinmay Jain whose valuable guidance helped us shape our work throughout the course. We are indebted to our Teaching Assistant (TA), Ms. Himadri Panchal for her constant guidance to accomplish our work and reach our targets on time. We are grateful to all the seniors and guest faculty throughout the semester, who with their thoughtful comments gave the project a new dimension at every stage. I would also like to take this opportunity to thank the various officials at our respective city’s Municipal Corporation who during the quest of data collection, helped us get through the investigation process productively. Last but not the least; we would like to thank our fellow classmates for their constant support and coordination.

Service Operations and Management Studio 2020 CEPT University

Abstract

Service organizations respond to the requirements of users to satisfy some needs and leave certain experiences in the minds of the users through a service delivery system. This studio addressed the design, operational and strategic aspects of managing service systems. It was designed in a way that helped us equip tools and techniques for understanding the management of urban services and their effective delivery in their respective cities. It also guided us to develop efficient techniques to prepare a service operation plan which strengthened our skills to develop strategies, methods, and implementation tools for managing complex urban delivery systems. As the semester was conducted online, the scope of exploration was our respective hometowns. In this process, we learnt about the technical, financial, social, and other processes involved in managing urban areas in COVID- ‘19. It helped us gain an in-depth understanding of the current scenario vis-à-vis their performance and user interface, prepare a plan to augment the area by identifying the scope of improvement. Identification of the most optimal solution was outlined. The report comprises a detailed study of seven cities of India on their respective COVID scenarios and the unique ways and techniques followed by each to combat the pandemic respectively and finally a comparison to decipher the key learning from each. This was done with the help of various management tools like Swimlane, RACI, Service Quality, and FMEA only to name a few. The study was done over three major categories namely: Identification and Testing, Treatment, Monitoring, and Surveillance. The ultimate the deliverable was to create a Service Audit Profile illustrating the existing and the recommended service concept thus identifying the gap in each parameter. These recommendations if incorporated can improve the efficiency and effectiveness of the operation of services and finally assess the drawbacks in existing urban services. In the process, we also learnt data visualization techniques in the form of charts, graphs, lines, and others to represent the findings.

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Abbrevations MCF: Municipal Corporation of Faridabad DC: District Commissioner CMO: Chief Medical Officer MO: Medical Officer IGI Airport: Indira Gandhi International Airport DCHC: Dedicated COVID Health Centres DCH: Dedicated COVID Hospitals CCC: COVID Control Centre SOP: Standard Operating Procedure FMEA: Failure Mode and Effect Analysis RPN: Risk Priority Number C2G: Citizen to Government G2G: Government to Government IEC: Information Education Communication NGO: Non-Government Organization GNM-General Nursing & midwifery GP - General Physician CCC- COVID Care Centre) DCHC- Dedicated COVID Healthcare Centres DCH- Dedicated COVID Hospital AMC- Ahmedabad Municipal Corporation GMC - Gulbarga Municipal Corporation CCC - COVID care Committee HWC - Healthcare workers PPE: Personal Protective gear FMEA: Failure Mode and Effect Analysis RPN: Risk Priority Number CMO: Chief Medical Officer DM: District Megistrate NMMC – Navi Mumbai Municipal Corporation MMR – Mumbai Metropolitan Region PMC – Panvel Municipal Corporation LMC- Lucknow Municipal Corporation 6

CPCB Central Pollution Control Board MT – Metric Tonnes TSDF - Treatment, Storage and Disposal Facilities

Service Operations and Management Studio 2020 CEPT University

List of Figures Figure 1: Timeline of Studio Figure 2: Map depicting the population and confirmed cased as of 31st October 2020, of the 7 cities studied in the report. Figure 3: Sample of Process profile worksheet Figure 4: Sample of RACI Chart Figure 5: Sample scoring criteria in FMEA Figure 6: Worldwide confirmed COVID19 cases visualization Figure 7: Average tests per million per day week wise

Figure B2 Hapur District COVID19 Status Timeline Figure B3 COVID19 status of districts in Uttar Pradesh (As of October 31, 2020) Figure B4 Government laboratory mapping for Covid 19 diagnosis Figure B5 Treatment facilities mapping for Covid 19 mapping Figure B6 Hapur District website accessed on 12.08.2020 Figure B7 Scoring based proforma for Identification process Figure B8 Illustration for depicting type of Figure A1 Map of Faridabad with its adjoining corona virus testing cities Figure B9 Illustration for COVID19 treatment Figure A2 Timeline Figure B10 Images of Hapur city during Figure A3 Types of Quarantine Facilities in the sanitization process City Figure B11 Road with Barricades for containing Figure A4 Vector Image depicting the visual of the locality Identification and Testing Figure B12 Survey Demographics Figure A5 Vector Image depicting the visual of Figure B13 SERVQUAL Analysis for Hospital Treatment Identification Process Figure A6 Vector Image depicting the visual of Figure B14 SERVQUAL Analysis for Testing Prevention Process Figure A7 Gap Analysis for Mobile Testing Figure B15 SERVQUAL Analysis for Monitoring Figure A8 Gap Analysis for Helpline Assistance and Surveillance Process Figure A9 Gap Analysis for Sanitization Figure B16 Audit Profile Figure A10 Service Audit Profile Figure A11 Actions being taken by the Figure C1 Lucknow Graphical Representation Government of Faridabad Figure C2 City Organization Chart Figure C3 Timeline Figure B1 Division of 36 wards with population Figure C4 Lucknow Covid Control Room density in Hapur City (Inside)

Figure C5 Lucknow Covid Control Room (Exterior) Figure C6 Uttar Pradesh Home Isolation Application user interface Figure C7 Vector Image depicting the visual of COVID Patient Figure C8 Vector Image depicting the visual of facilities to quarantined patients Figure C9 Vector Image depicting the visual of COVID Testing Figure C10 Vector Image depicting the visual of ICCC Monitoring desk Figure C11 Vector Image depicting the visual of Sanitization Figure C12 Chief Minister Yogi Adityanath monitoring the ICCC activities Figure C13 P-E Gap Analysis (Identification & Testing) Figure C14 P-E Gap Analysis (Quarantine & Treatment) Figure C15 Rater Analysis (Identification & Testing) Figure C16 Rater Analysis (Quarantine & Treatment) Figure C17 P-E Gap Analysis (Monitoring) Figure C18 Overall Process Rater Average Figure C19 Rater Analysis (Monitoring) Figure C20 Composite Rater Analysis Figure C21 Hello Doctor E-OPD For Lucknow Citizens Figure C22 Lucknow’s own COVID19 Mobile Application Figure C23 Initiative to encourage social

CEPT University Service Operations and Management Studio 2020

List of Figures distancing by Lucknow Smart City Figure D1 Administrative structure of Ahmedabad Municipal Corporation Figure D2 Zone wise Active Cases of COVID19 in Ahmedabad City Figure D3 Timeline Figure D4 Newspaper article regarding identification strategy in Ahmedabad Figure D5 Testing Labs in Ahmedabad City Figure D6 COVID Case status in Ahmedabad City Figure D7 104 Emergency Helpline vehicle Figure D8 Kiosk for Rapid antigen testing at CG Road, Ahmedabad, Gujarat Figure D9 Containment zone barricading Figure D10 Relaxing zone in one of the Quarantine Centers in Ahmedabad Figure D11 Robotic drone being used in walled city area of Ahmedabad Figure D12 Chalaans being issued for not wearing masks Figure D13 Area sanitized by fire department team during sanitization operation Figure D14 Sanitisation done in Public and private spaces by dedicated teams Figure D14 Advertisement promoting usage of mask Figure D15 Dhanvantri Rath Figure D16 Contact Tracing Team Figure D17 Swab Collection Figure D18 ICCC Figure D19 People waiting in line for Rapid Antigen Test

Figure D20 Paramedical Staff Figure D21 COVID CARE CENTRE Figure D22 Sanitizing activity outside a house Figure D23 Marking Home Quarantine Figure D24 Quarantine Facility in Ahmedabad City Figure D26 Age group of respondents Figure D27 P-E gap for Identification and Testing Figure D28 P-E gap for Treatment Figure D29 P-E gap for Monitoring & Surveillance Figure D30 Composite Rater Analysis Figure D31 Composite Process Analysis Figure D32 Advertisement promoting Do’s in COVID times Figure D33 Advertisement promoting benefits of mask Figure D34 Advertisement for behavior change Figure D35 Advertisement for behavior change Figure D36 Service Audit Profile Figure D37 Advertisement discouraging spitting in public spaces. Figure D38 Advertisement for COVID friendly greeting styles Figure D39 Advertisement for CORONA SANTVANA ( Mental Helpline Number ) Figure D40 Poster for mask awareness Figure E1 Vasai Virar Municipal Corporation, Palghar District, Maharashtra Figure E2 Timeline of COVID cases

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Figure E3 Infrastructure and staff set up for COVID management Figure E4 Survey participants details Figure E5 Service rating for various parameters Figure E6 Services with highest positive gap Figure E7 Services with highest negative gap Figure E8 RPN of failures and risks Figure E9 Impact of recommended action on RPN of failures Figure E10 Service Audit Profile Figure F1 Map of MMR with districts and Municipal Corporations Figure F2 Zones and wards in NMMC Figure F3 Zones and wards in NMMC Figure F4 COVID cases in various wards Figure F5 COVID Timeline Figure F6 Response time of NMMC after being tested positive Figure F7 RATER analysis for Reliability Figure F8 RATER analysis for Assurance Figure F9 RATER for tangibility of the service Figure F10 RATER for Empathy of the service Figure F11 RATER for responsiveness of the service Figure F12 Composite RATER ANALYSIS. Figure F13 Service Audit Profile Figure G1 Location of Gulbarga city in Karnataka state Figure G2 Dashboard of COVID-19 cases in Gulbarga city (as of 8 th Sept) Figure G3 Number of COVID cases with age

List of Figures and gender Figure G4 Map showing the location of COVID hospitals in Gulbarga city Figure G5 Timeline Figure G6 Showing the images of Home quarantine sticker and form Figure G7 Showing the images of isolation beds of COVID care centers and hospitals in Gulbarga city Figure G8 Showing images of containment strategies in Gulbarga city Figure G9 Showing the demographics of survey Figure G10 Showing the composite RATER analysis of Testing Figure G11 Showing the composite RATER analysis of Home quarantine Figure G12 Showing the composite RATER analysis of COVID care isolation Figure G13 Showing the newspaper clippings of COVID care isolation centers Figure G14 Showing the composite RATER analysis of Monitoring and Surveillance Figure G15 Showing the newspaper clipping of lack of contact tracing Figure G16 Showing the service audit profile of Gulbarga city Figure G17 Showing the interface of Corona Watch App initiated by Karnataka Government

visualization Figure 9. Process wise RATER analysis Figure 10. RATER Analysis of city’s COVID Management Services Figure 11 Unique features of the cities. Figure 12 Process of COVID waste management

Figure 8 Worldwide confirmed COVID19 cases CEPT University Service Operations and Management Studio 2020

List of Tables Table A1 Process: Process Identification Table A2 Process: Identification and Testing Table A3 Process: Treatment: Quarantine Table A4 Process: Treatment: Hospital Table A5 Process: Monitoring and Surveillance Table A6 RACI Chart depicting Roles and Responsibilities of all the Stakeholders Table A7 FMEA for Decentralized Treatment: Bed Allotment at Institutional Table A8 FMEA for Sanitization of the area Table B1 Process Identification sheet Table B2 Process Profile Worksheet for Identification Process Table B3 Process Profile Worksheet for Testing Table B4 Process Profile Worksheet for Quarantine and Treatment Table B5 Process Profile Worksheet for Monitoring and Surveillance Process Table B6 RACI diagram for COVID19 service processes Table B7 FMEA for Identification process Table B8 FMEA for Testing process Table B9 FMEA for Monitoring and Surveillance process Table C1. Covid Identification Process Table C2 Profile worksheet for Identification Table C3 Profile worksheet for Quarantine Table C4 Profile worksheet for Treatment Table C5 Profile worksheet for Monitoring Table C6 RACI Diagram Table C7 FMEA 10

Table C8 Service Audit Profile

Table G1 Showing the administration of Gulbarga city Table D1 Containment zones in Ahmedabad Table G2 Showing the processes of COVID (zonewise data) management in Gulbarga city Table D2 Process identification worksheet Table G3 Showing the process profile Table D3 Process: Identification and Testing worksheet of Self reporting and Table D4 Process: Treatment: Identification Table D5 Process: Monitoring and Surveillance Table G4 Showing the process profile Table D6 RACI Chart depicting Roles and worksheet of Home quarantine and Responsibilities of all the Stakeholders Monitoring Table D7 FMEA Analysis Table G5 Showing the process profile worksheet of COVID care isolation Table E1 Process Identification Sheet and Monitoring Table E2 Process profile worksheet - Table G6 Showing the process profile Identification & testing worksheet of Containment and Table E3 Process profile worksheet - Treatment Surveillance strategies in Gulbarga Table E4 Process profile worksheet city Monitoring & surveillance Table G7 Showing the RACI chart Table E5 RACI Diagram Table G8 Showing the SERVQUAL analysis of Table E6 FMEA table testing process Table E7 FMEA: RPN of recommended actions Table G9 Showing SERVQUAL analysis of Table E8 Identified service concept Home quarantine process Table G10 Showing SERVQUAL analysis of Table F1 Process Identification Worksheet COVID care isolation process Table F2 Process Profile Worksheet for Table G11 Showing SERVQUAL analysis of identification process Monitoring ans Surveillance Table F3 Process Profile Worksheet for Table G12 Showing the FMEA of containment Treatment process strategies in Gulbarga city Table F4 Process Profile Worksheet for Monitoring and Surveillance process Table 1. RATER Analysis of various services Table F5 FMEA carried out in the city as a part of Table F6 FMEA - Difference in new RPN COVID management

Service Operations and Management Studio 2020 CEPT University

Executive Summary Service Operations Management in pandemic focuses on how Municipal Corporations are engaged in service delivery during these hard times. Service operations management can streamline their operations for efficiency and citizen satisfaction in turn contributing to a better quality of life. The novel Coronavirus also known as COVID-19 has affected worldwide to a greater extent where millions have lost their lives. It is important at this stage for the government to manage the services efficiently with the ease of services for the betterment of citizens. This report consists of profiles of seven cities of India which details out the COVID scenario in the city, with the confirmed cases, recovered cases and the deceased cases along with the number of COVID tests done. The other details such as isolation/ wards management with the number of beds are studied with respect to the population of the city. Overall COVID management is studied using various tools and a detailed analysis has been done for the same, further in the report. Various tools have been used for the COVID management study which helps to know how efficiently a city is managing the ongoing pandemic. The tools that we have used in the study are: • Process Identification worksheet, which shows the trigger events and the processes. The study has been conducted with respect to the three major processes in the COVID management and they are: Identification and testing - This process involves

identifying the symptomatic patients/ suspects and analysing the samples based on various COVID tests conducted in the cities. Treatment - This process involves treatment and monitoring of the patients under home quarantine/ isolation centers/ dedicated COVID hospitals Monitoring and Surveillance - This process involves monitoring and surveillance of containment areas in the city to restrict the further spread of virus to a greater extent. • SWIMLANE, which shows the responsible stakeholders and the activities with respect to time,that delineates who does what in the process of COVID management. • Process profile worksheet, which helps in capturing important data about a particular process in COVID management. The worksheet template highlights the Service risks and its Key controls along with Measure of Success of the COVID management processes. • RACI chart, which is a responsibility assignment matrix, also known as RACI matrix or linear responsibility chart, describes participation by various roles/ stakeholders in completing the tasks or deliverables for a COVID management process. • SERVQUAL, which is a multi-dimensional research instrument designed to capture responder’s expectation and perception of COVID management in the city along the five dimensions, which are Reliability, Assurance,

Tangibles, Empathy and Responsiveness, that are believed to represent service quality. • FMEA, which is Failure Mode and Effects Analysis (FMEA) is a structured approach to discovering potential failures that may exist in the COVID management process of our cities. FMEA is evaluated based on the criteria of frequency of threat occurrence, probability of threat detection and threat severity from which the Risk Priority Number (RPN) is assessed. Using all the above tools the cities have been analysed with regard to the COVID management and a service audit profile is created which shows the existing services that are given by the government in the city and the recommendations for the efficient working of those services.

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Introduction to Studio

The Service Operations Studio is intended to Objectives: access the Urban Service Concept and plot 1. To understand Service Operations the graph on Service Audit Profile that the Management Concept. service can achieve after imbibing the possible solutions suggested. To suggest improvements, 2. To recommend possible solutions for the service risks are identified with the help of improving efficiency and effectiveness of suitable tools, techniques and systems. the operation of services

Operations Management.

Week one and two of the studio focused on studying service concept and audit profiles for multiple online services and understanding the local government’s response to the COVID pandemic. The primary focus in weeks three and four Aim: 3. To assess the existing urban services and was to understand the process analysis To understand key aspects of the service and to identify issues with the help of tools, tools to describe a pizza delivery service and access the improvements. techniques, and systems used for Service understanding COVID management of our

Figure 1: Timeline of Studio Source: Primary

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respective cities. Data visualization on new software called Tableau was taught in the following week. The population and the number of cases in each city was evaluated using the Swimlane tool which is a type of flowchart that delineates who does what in the process of COVID management. It provides clarity and accountability by placing process steps within horizontal or vertical “SWIMLANES” of a

RACI matrix which is the responsibility assignment matrix that maps out every task, milestone, or key decision involved in completing a project and assigns which roles are Responsible for each action item, which personnel are Accountable, and, where appropriate, who needs to be Consulted or Informed along the five dimensions that are believed to represent service quality and they are: Reliability, Assurance, Tangibles, Empathy,

Figure: 3: Sample of Process profile worksheet Soruce: Primary

Figure 2: Map depicting the population and confirmed cased as of 31st October 2020, of the 7 cities studied in the report. Source: Primary

particular department. Coming to the Process Profile Worksheet which helps capture the important data about a particular process in COVID management. It helps us the various Service risks and its Key controls along with the Measure of Success of the COVID management processes.

and Responsiveness. Further, a SERVQUAL analysis was done which is a multidimensional research instrument, designed to measure the service quality by capturing respondents’ expectations and perceptions along the five dimensions of service quality. Furthermore, Failure Mode and Effect

Figure: 4: Sample of RACI Chart Soruce: Primary

CEPT University Service Operations and Management Studio 2020 13

Analysis also called the FMEA is a structured tool used to detect the possible risk assessment for each service risk identified previously and their corresponding recommendations. A parameter of 480 was set wherein any Risk Priority Number (RPN) that is above it shall be considered unacceptable.

Service Audit Profile with the respective recommendations was charted out to suggest areas of improvement which if managed carefully can help in the effective management of the various cities and India as a whole and ultimately help us contain the virus. There are majorly 3 main processes that have been studied throughout the report for the COVID-19 management of the 7 cities namely: • Identification and Testing: This process involves identifying the symptomatic patients/ suspects and analyzing the samples based on various COVID tests conducted in the cities. • Treatment: This process involves treatment and monitoring of the patients under home quarantine/ isolation centers/ dedicated COVID hospitals. • Monitoring And Surveillance: This process involves monitoring and surveillance of containment areas as well as Contact Tracing of the suspects who might have been in contact with the positive patient for the last 14 days to restrict the further spread of a virus to a greater extent.

Criteria and weights for threat severity (S): Potential threat effects

Scoring

Occurrence

Extremely dangerous

Dangerous

Very serious

Serious

Moderate

Very little

Harmless

Function No door to door testing

Quarantine & Treatment

Inadequate infrastructure (bed)

Probability

Scoring

Nearly impossible

0.3

Every hour

Very often

Every day

Very little

0.5

Often

Every 2 days

Negligible

0.7

Moderately often

Every week

Very low

0.8

Average

Every 2 weeks

Low

0.9

Seldom

Every month

Average

0.95

Very seldom

Every 2 months

Medium high

0.98

Slight

Every 6 months

High

0.99

Very slight

Every year

Very high

0.999

Almost impossible

Never

Almost certain

>=0.9999

Potential Cause of Failure Inadequate manpower Distance between labs / long travel time Inaccurate assessment & forecasting of requirements

Delayed response time (testing team)

No contact tracing

Inadequate manpower

Old

New

Difference

Percentage

Score

378

314

83.06%

160

120

75.31%

729

717

98.35%

140

65.70%

552

95.83 %

Inefficient sanitization

Incompetent human resources and inappropriate resource management

576

Improper demarcation of containment zone

Unauthorized movement

270

189

70.00%

No complaint redressal system

Staff not trained regarding technology

168

46.42%

Monitoring

Service Operations and Management Studio 2020 CEPT University

Detectability

Almost certain

Parameter

Identification & Testing

Percentage Range

Scoring

Almost nil

Scoring

Frequency estimation

0-15

16-30

Figure:5: Sample scoring criteria in FMEA Source: Primary

Criteria and weights for frequency Criteria and weights for probability of threat detection (D): of threat occurrence (O):

3 31-45

46-60

61-75

76-90

91& above

Introduction to Pandemic at Global and National Level The novel coronavirus also known as COVID19 pandemic has already affected over 51,808,319 people all over the world as of 31st October 2020 (WHO Country Office for India, 2020). The most cases were reported in United States of America, India, Brazil and Russia. As of 31st October 2020 the total number of confirmed COVID19 deaths around the world is 1,278,715 with highest in United States, Brazil and India. Though if considered corona deaths per million population, the situation is worse in South American countries and the US while it is much lower in tally in India with a fatality rate of 1.52% only.

The very first case of COVID19 in India was reported on 30th January, 2020 which came through a student who returned from China, Wuhan. Only two cases were reported by the month of February in India while the count of affected people worldwide was 71,429. India jumped from 3rd place to 2nd place in the world with 81,37,119 confirmed cases as of 31st October 2020. India sought an increase of nearly 590,000 new cases of COVID19 in first week of September. The increased surge in number of cases could be due to sudden increased number of tests done. Tests per million population has increased from 6,396 on 1st July to 43,888 as of

31st October with a cumulative tests surpassing the 5 crore mark as per Union Health Ministry. Guidelines provided by WHO on “Public Health Criteria to Adjust Public Health and Social Measures in the Context of COVID-19”, has advised countries to conduct 140 tests per day per million population for detection of corona virus in suspected citizens. As shown in figure2, India has shown a continuous rise in the number of tests done per million per day week wise. According to Ministry of Health and Family Welfare (MoHFW), majority of confirmed cases were reported from the state of Maharashtra, Andhra Pradesh, Tamil

Figure 1 Worldwide confirmed COVID19 cases visualisation Source: WHO official website accessed from https://covid19.who.int/table

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Nadu, Karnataka and Uttar Pradesh. MoHFW also revealed in a report. India with a population of 1 billion people and high population density of 382 person per sq. km which is almost 3 times that of China, poor healthcare resources and social economic conditions could become a new epicentre of COVID19. World Health Organisation (WHO) has also stated that the “future of the pandemic will depend on how India handles it”. Therefore this report is an attempt to study COVID19 management in Indian cities. After months of managing the crisis while doing the everyday work of government, cities are opening up again without knowing how long this period of co-existence with the virus will last. Months of lockdown period has ended and ctiy governments are creating new strategies to tackel the corona virus. The study focuses on analysing their service delivery models and the scope of improvements to make cities perform better and more efficient.

4,85,609

17,00,000

8,30,731 8,32,396 16,87,784 1,21,641 7,31,942

81,37,119 76,41,109

Figure 2 Average tests per million per day week wise Source: Mint article accessed from https://www.livemint.com/news/india/ covid-19-india-scales-a-new-peak-as-total-number-of-tests-cross-5-croremark-11599554858565.html

Figure 3 Number of confirmed cases in Indian states as of 31st October 2020 Source: https://www.facebook.com/IndiaToday/photos/?ref=page_internal

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FARIDABAD 18

Service Operations and Management Studio 2020 CEPT University

Apoorvi Gupta PG190172

A1. About the City

The city of Faridabad lies in the South-eastern part of the state HARYANA and is also situated in the NATIONAL CAPITAL REGION bordering the Indian Capital New Delhi. It is one of the major satellite cities of Delhi (25kms) and is located 284 kilometres south of the state capital Chandigarh. It is an essential Industrial Hub for Haryana and a prominent stakeholder for driving the economy of the state. Around 50% of the income tax collected in Haryana is from Faridabad and Gurgaon. The city is also famous for henna production from the agricultural sector, while tractors, motorcycles, switch gears, refrigerators, shoes and tyres constitute its primary industrial products. It was included it in the fast track list of Round 1 of Smart Cities Mission on 24May,2016 by the Government of India.

A1.1. City Demographics

The city shares its boundaries with New Delhi to the north, Noida to the east, Palwal to the south and Gurugram to the west. Delhi-Mathura National Highway No. 2 (SherShah Suri Marg) passes through the middle of district/city. Longitude: 77°18’28” E Latitude: 28°25’16” N The city has an area of 741 sq km with a population nearly about 18,09,733 (Census 2011). Density/km2 is 2,442 with a projected population growth rate of 32.54%. Migration Influx for the state: 8Lakh (registered) with majority of them belonging from Uttar Pradesh, Madhya Pradesh and Bihar. Altitude: 198 metres above sea level STD Code: 0129

A1.2. Organizational Capability

During COVID, apart from the Corporation of Faridabad, various other segments amalgamated for a successful management of the pandemic within the city, namely: 1. COVID Control Room Responsible for public assistance with a 24*7 helpline number and Co-ordinating with the other segments 2. MCF Control Room Sanitization of the City, Dead Body Management, COVID Medical Waste Management and Identification of cases. 3. CMO Control Room Collecting and Monitoring Data, maintaining and updating data, Reporting the status to DC Office everyday and Assisting the people. 4. Police Control Room Maintaining law and order within the city and monitoring the follow up of norms and strategies

A2. Current COVID19 Scenario in the City

Figure A1 Map of Faridabad with it’s adjoining cities Source: https://bharatmaps.gov.in/map.aspx?dtcode=088

The first case in the city was registered on 20th March 2020 and ever since then Faridabad has been the highest affected city in Haryana. As of 31st October,2020 the city had 25,297 Confirmed cases, 1,258 Active cases, 23,793 Recovered cases and 246 Deceased cases. The active and recovered ratio are 4.9% and 94% respectively. The city reached its peak by the mid of Unlock phase 1 or Lockdown 5.0 and had started decreasing in terms of confirmed and active cases, but a second wave of the virus can be seen taking over the city. Post unlock phase 3, wherein the majority of activities were back to their course of action; an increase in the number of cases is visible, requiring some change in actions and strategies.

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Sealing of the borders, Issuing of the movement pass for moving inter as well as intra city, Rapid testing, demarcating the containment zones (160 approx.), IEC Activities to spread awareness and persuade people to come forward and get tested. Apart from that, Section 144 was implemented throughout the city and movement for non-essential items within the city was “strictly prohibited” between 7PM to 7 AM. A COVID mitigation plan was set up by the city. Gathering was restricted to a total number of 50 people and sanitization of public spaces took place on regular bases. Cinema halls, shopping malls, gymnasiums, sports complexes, swimming pools, entertainment parks, theatres, bars, and auditoriums were shut down.

A2.1.2. During Unlock Phases Figure A2 Timeline Source: https://www.covid19india.org/state/HR

A2.1. Strategies

To combat the pandemic various strategies were implemented in the city both during the lockdown and unlock phases, namely:

A2.1.1. During Lockdown Phases

• Essential Services (did not shutdown): Firstly, all the Kirana shops, petrol pumps, street vendors, milk shops; were allowed to function between 11AM to 5PM every day except on Sundays. Wholesale vegetable and fruit markets were allotted a time slot form 6AM to 11AM. Secondly, all Hospitals, Banks, Telephone services, Media, IT Services etc, were granted the permission to operate for whole day. Services like petrol pumps, LPG stations and chemist shops were allowed to function throughout the day. Lastly, all government offices related to providing services such as: Sanitation, Water Supply, Sewerage, Electricity were permitted to function without any restrictions. 20

• Labourers and the poor To restrict the movement of unwanted labourers, accommodation to the same was arranged ensuring social distancing norms at community centres, dharmshalas, schools, colleges etc where proper arrangement of toilets and drinking water exits. It was mandatory that they should be provided two meals a day in form of cooked food packets or dry ration, and the expenditure for the same could be booked to State Disaster Relief fund for which an amount of Rs, 1 Crore has already been sanctioned to each district. Other than this a list of 47 NGO’s was listed down for each ward which is responsible for supplying the essentials to poor and needy people. • Mandatory Restrictions A lot of activities and services went through mandatory restrictions and boundations, in order to prevent the outbreak and control the cases. Few of them were:

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The unlock phase 1.0 throughout the state initiated from 1st June,2020, wherein for Faridabad, the city being demarcated as a red zone, it was more of Lockdown5.0. The actual unlocking commenced from 1st July,2020 with opening up of few services and with a motive to bring back the city on the track. Few of the activities that opened post Lockdown5.0 are: Firstly, all government offices opened in full capacity, interstate movement of goods and people were permitted (no e-permit required) and sporting activities could now start from 5AM instead of 7AM. Secondly, hotels, restaurants, malls, salons, beauty parlours reopened in accordance with a defined SOP, ensuring social distancing and sanitisation of focal points. (Timing: 9AM to 8PM) (Visitors >65 and <10 years of age not permitted). Lastly, wearing of masks became compulsory throughout the city and challans were filed in case not found wearing. Gyms came into functioning from 5th August,2020 and various other public spaces like temples also reopened

A3. Overview Of the COVID19 Management in the City

The city can be classified into three major aspects for management, starting from identification to prevention.

A3.1. Identification and Testing

Identifying can be described as the process of recognizing the people who have been a victim of COVID19. It comprises of locating, examining and testing the patient/suspect, and on the basis of the result, carrying on the further process of quarantining, treatment and finally discharging. Faridabad abides by the rules and regulations laid down by the state government of Haryana. According to the COVID19 Management Plan for the city, there are two ways of identifying and surveying the suspect: 1. Active Surveillance 2. Passive Surveillance The city follows SOP’s for molecular testing, i.e., RTPCR, Rapid Antigen and CB-NAAT/True NAAT. The cost of the testing at government labs is borne by the government, wherein for the authorised private labs it has been fixed to a maximum rate of Rs. 2200. Post testing, the case is classified into four categories, i.e., • Asymptomatic or very mild symptoms (Fever) • Mild Case (Fever) • Moderate Case (Pneumonia with no sign of severe disease) • Severe Case (Having Respiratory issues and requires to be on ventilators)

A3.2. Treatment

(A) Quarantine The process initiates when, either the person has a travel history, or the person has been tested positive or if the person came in contact with a positive tested patient and is taking precautionary measures

to prevent it from spreading further. Apart from this, quarantine can be defined as the separation of people and restriction on the movement with a purpose of preventing transmission. People with very mild or mild symptoms (Stage 1 and 2) are quarantined. On testing positive with very mild or mild symptoms, the person is mandatorily advised to home isolate or get admitted to an institutional based facility depending on the grade of infection. In Faridabad there are a total of 17 non-medical government COVID Care Centres, 3 medical government COVID Care centres and 33 private COVID Care centres.

oxygen supply] depending on the grade of the symptoms. Treatment Costing: The cost of treatment at the Government dedicated hospitals is free of charge including medicines, food and other services Dead Body Management: In case the person dies during the COVID process, the dead body is managed by the Municipal Corporation. The Corporation has 4 teams in total that are responsible for carrying the body till the cremation ground while abiding by the laid down norms. The Corporation needs to make sure that not more than 20 people are allowed to be at the cremation ground.

A3.3. Monitoring and Surveillance

Figure A3 Types of Quarantine Facilities in the City Source: Primary

(B) Hospital Moderate and Severe case patients (Stage 3 and 4) are admitted to Dedicated COVID Health Centres (DCHC) [they are basically hospitals or separate blocks in hospital having beds with oxygen supply] OR Dedicated COVID Hospital (DCH) [they are hospitals with fully equipped ICU, ventilators and

To prevent the outbreak of the of the pandemic within the city, the government took various measures, including: 1. Imposing of Strategies 2. Sanitization of the City -The sanitization of the public spaces is done by the Corporation of Faridabad. The corporation has: • 6 Vehicles (Fire Tenders, Road Sweeping Machine having spray facility) • 70 non-motorized manual back loading machines • 6 motorized back loading machines A positive tested citizen can also avail the sanitization facility by placing a call at the corporation, free of charge. Private sanitization starts at a cost of Rs. 200 according to the house area 3. Barricading the Containment Area The police are responsible for barricading the red zones/ containment zones and keeping a surveillance over the same. 4. Penalization on Violation The police department is responsible for imposing the challans and penalties over the ciizens to oppose following of the norms and the guidelines.

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A4. COVID19 Management Process Analysis A4.1. SWIMLANE Diagram

Inferences: The swimlane tool helps understand the process flow and how the activities are connected to one another. It swimlane gives an intricate detailing of how the process works in the city, starting from the feeling of the symptoms to the patient finally being recovered. In Faridabad the process initiates from

Suspect Or Patient

The person having ILI/SARI symptoms or Travelling inter-state/city On call consultation with the doctor and receiving medication

Doctor Medical Officer at IGI Airport Priavte Or Government Technician

Symptoms still prevailing

Received at the Airport by Medical Team and asked about travel history Seeking assistance from control room for the further procedure

COVID Control room Supervisor

Going to a government lab for RT-PCR testing

Going to a private lab for RT-PCR testing

Civil Dispensary MO/ANM Worker

Directed towards nearest civil dispensary for rapid antigen testing

Day 4

Institutional Facility Supervisor

Dedicated COVID Hospital MO

Chief Medical Officer: CMO (ESIC Team) Timeline

Day 1

Day 2

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Day 4

Result Awaited

identification and testing, to the patient being quarantined or admitted to an institutional facility or the hospital based on their grade of infection and ultimately recovering. People over the age of 60 are mandated to be admitted to the hospital irrespective of them having any grade of symptoms. Corporation Employees, Police Officers, Health Workers, Medical Officers, Lab Technicians and DC are the few major stakeholders in the process of managing COVID within the city. Recovered Patient

Negative Very Mild/Mild Moderate Severe

The ANM worker puts a sticker and demarcates the property

Home Quarantine

Non-Medical Govt. CCC Private CCC

Admitted to hospital depending on the grade of infection

Day 6

Information of daily cases updated, collected and monitored at CMO Room

Reporting to DC

Day 7

Day 6-20

Call received for next 14 days

Notified for re-testing

Day 20

Day 22

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A4.2. Process Identification

Inferences: After understanding the process via swimlane, the COVID19 management within the city can be bifurcated into three major categories, namely, Identification, Treatment and Monitoring and Surveillance.

Key Process Area: COVID19 management services Trigger Event Process Name The person falling sick and feeling symptoms such as: fever, cough, sore throat etc. The person tested positive with mild symptoms The person tested positive with moderate or severe symptoms Patient mandatorily asked to Quarantine

Table A1 Process Identification

A-Identification and Testing B-Treatment: Quarantine B-Treatment: Hospital C-Monitoring and Surveillance

A4.3. Process Profile Worksheets A4.3.1. Identification and Testing

Inferences: The process profile worksheet for Identification focuses on identifying th positive cases in the city with its major service risks being: Unavailability of a doctor, Miscommunication, Error with the reports and shortage of antigen kits; to which the corresponding key controls identified are: having a contact information of more than one doctor, reconfirming what was communicated, Trained and skilled staff and maintaining and inventory. 24

Process Name – Number Identification and Testing Identifying the positive cases in the city

Process Owner Civil Dispensary Medical Officer Description

Triggers Event beginning The person falling sick and feeling symptoms such as: fever, soar throat, body ache, etc. Event ending Confirming the result post COVID testing Additional events Calling the doctor, Receiving the medication, Seeking assistance regarding the nearest authorized civil dispensary, Providing information on the recent whereabouts and travel history, Going for the test. Inputs – Items and Sources Call(Suspect), Information on Travel History(Suspect), Assistance with locating of dispensary(COVID Control Room Supervisor), Submitting the sample(Suspect) Outputs – Items and Customers Test Result(Civil Dispensary Medical Officer) Process Units Process Unit Owners Placing a Call Suspect Assistance with locating of dispensary COVID Control Room Supervisor Conducting the test ANM Worker Service Objective(s) Service Risks Miscommunication/Lack of understanding To identify the maximum number of people in Shortage of rapid antigen testing kits the city with utmost accuracy Unprofessional Sample Collection Error with the Report Key Controls Measure of Success Re confirming what was communicated No. of people assisted by the control room via Maintaining an inventory calls (Reaching out to max. people) Properly trained and skilled team Number of Positive Feedbacks (Assistance) SOP for sample collection and testing Maximum no. of samples collected and tested Table A2 Process: Identification and Testing

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Process Name – Number Treatment: Quarantine

Process Owner CMO Control Room Description The patient asked to self quarantine or admitted to an institutional non medical government COVID Care Centre according to the grade of infection Triggers Event beginning The person tested positive with mild symptoms Event ending Patient Recovery Additional events Informing the patient, Monitoring the patient and having a daily status update, Notifying for a retest post 14 days, Co-ordinating with CMO Control Room Inputs – Items and Sources Call(Civil Dispensary Medical Officer), Quarantine Facility(Civil Dispensary Medical Officer), Call(CM Office Employee) Outputs – Items and Customers Recovery(Patient) Process Units Process Unit Owners Informing the patient Civil Dispensary Medical Officer Quarantining at Institutional Facility Institutional Facility Supervisor Monitoring patient’s health status CMO Employee Service Objective(s) Service Risks Untidy Environment To inform the patient and provide with the Degraded Food Quality further medical assistance till the person is Patient avoiding getting retested recovered Error with the new report Key Controls Measure of Success SOP for maintaining hygiene Maximum Number of Recovered Patients Regular Food Quality Check Positive Feedback/Rating received for the Keeping a regular check on the patient Institutional Facility SOP for testing Table A3 Process: Treatment: Quarantine

A4.3.2. Treatment: Quarantine Inferences: The process profile worksheet for Quarantine focuses on asking the patient to self quarantine or admit to an institutional non medical government COVID Care Centre according to the grade of infection with its major service risks being: Untidy Environment, Degraded Food Quality, Meals not provided timely, Patient avoiding getting retested or Error with the new report; to which the corresponding key controls identified are: SOP for maintaining hygiene, Regular Food Quality Check, Management plan for food distribution indicating duties and responsibilities, Keeping a regular check on the patient (till proven negative), Properly trained and skilled Team and SOP for testing.

Figure A4 Vector Image depicting the visual of Identification and Testing Source: https://pngtree.com/

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Process Name – Number Treatment: Hospital

Process Owner Dedicated COVID Health Medical Officer Description The patient admitted to a hospital due to high grade infection Triggers Event beginning The person tested positive with moderate or severe symptoms Event ending Patient Recovery Additional events Informing the patient, Admitting the patient, Providing the suitable treatment, Monitoring the patient and having a daily status update, Notifying for a retest post 14 days, Coordinating with CMO Control Room, Death (If unable to recover) Inputs – Items and Sources Call (Civil Dispensary MO), Hospital (Dedicated COVID Health Medical Officer, Call (CMO) Outputs – Items and Customers Recovery/Death (Patient) Process Units Process Unit Owners Admitting the patient to the hospital Dedicated COVID Health Medical Officer Monitoring patient’s health status CMO Employee Co-ordinating with the CMO Control Room Dedicated COVID Health Medical Officer Service Objective(s) Service Risks Shortage/Miscommunication regarding beds To inform the patient and provide with the Shortage of medicines, medical equipments further medical assistance till the person is Patient avoiding getting retested recovered Untidy Environment Key Controls Measure of Success Centralized bed management system Maximum Number of Recovered Patients Positive Feedback/Rating received for the Having an inventory for both Hospital Keeping a regular check on the patient SOP for maintaining hygiene Table A4 Process: Treatment: Hospital

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A4.3.3. Treatment: Hospital Inferences: The process profile worksheet for Hospital Treat focuses on making sure that the patient is admitted to the dedicated hospital facility due to his/her high grade infection, with its major service risks being: Unavailability of the beds, Shortage of required medicines and medical equipments, Untidy Environment, Patient avoiding getting retested, Error with the new report, Dead body mismanagement; to which the corresponding key controls identified are: Co-ordinating with the increasing cases and laying new facility if required, Maintaining an inventory both for medicines and medical equipments, SOP for maintaining hygiene, Keeping a regular check on the patient (till proven negative), Properly trained and skilled Team and SOP for dead body management.

Figure A5 Vector Image depicting the visual of Hospital Treatment Source: https://pngtree.com/

Process Name – Number Monitoring and Surveillance

Process Owner Government Description Prohibiting further spread of the symptoms in the area due to a COVID positive tested patients Triggers Event beginning Patient tested positive and mandatorily asked to quarantine Event ending No new cases suspected Additional events Demarcating the house, Sanitizing the area, Restricting the movement outside the house, Barricading the Containment areas, Ensuring following up of the norms Inputs – Items and Sources Sticker outside patient’s house(ANM worker), Sanitization(MCF), Barrication (Police Officer) Outputs – Items and Customers Abridgment of the symptoms(Government) Process Units Process Unit Owners Demarcating the property ANM Worker Sanitizing the house and the surroundings MCF Employee Penalising for violation Police Officer Service Objective(s) Service Risks Unavailability/Breakdown of the Sanitizing Vehicle/Equipment People removing the stickers To prevent further spread of the disease People violating the norms Negligence towards Contact Tracing Key Controls Measure of Success A checklist ensuring proper maintenance and availability of the Vehicle No new cases suspected in the area Daily surveillance on the demarcated houses Timely Monitoring Heavy Penalty for violation SOP for Contact Tracing Table A5 Process: Monitoring and Surveillance

A4.3.4. Monitoring and Surveillance Inferences: The process profile worksheet for Monitoring and Surveillance focuses on prohibiting the further spread of the symptoms in the area due to a COVID positive tested patients with its major service risks being: Unavailability of the Sanitizing Vehicle/Equipment, Breakdown of the vehicle, Negligence towards Demarcating the house, People removing the stickers, People violating the norms, Negligence towards Contact Tracing, Lack of monitoring, Internal Staff miscommunication; to which the corresponding key controls identified are: A checklist ensuring proper maintenance and availability of the Vehicle, Daily surveillance on the demarcated houses, Heavy Penalty for violation, SOP for Contact Tracing, Rapid Response Team, Monitoring the monitoring team and a Proper laid out monitoring plan.

Figure A6 Vector Image depicting the visual of Prevention Source: https://pngtree.com/

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A4.4. RACI Diagram Process Name Identification and Testing Treatment: Quarantine Treatment: Hospital Monitoring and Surveillance

Doctor

Medical Officer at IGI

Private/Govt. Technician

CCC Supervisor

Civil Dispensary MO/ANM

Institutional Facility Supervisor

Patient/ Suspect R

Table A6 RACI Chart depicting Roles and Responsibilities of all the Stakeholders

DCH Medical Officer

CMO (ESIC Team)

Inference: The RACI Diagram shows the various stakeholders, i.e., the patient, doctor, medical officer at IGI Airport, Government and private lab technicians, COVID Control Centre Supervisor, Civil Dispensary Medical Officer, ANM Team, Institutional facility Supervisor, DCH Medical Officer, Cheif Medical Officer and District Commissioner who are Responsible, accountable, consulted and informed respectively in all the processes that are followed in the COVID-19 management in the city. The above chart infers that all the tasks require involvement of the dispensary MO of every ward and DC is informed at every stage.

A4.5. Servqual: RATER Analysis

Servqual Tool helps digging into the depthness of an issue by supporting it with the help of citizen’s opinion. For the city of Faridabad, a survey was conducted on 3 parameters, namely: Mobile Testing, Helpline Assistance and Sanitization. The survey contained the expectation and the perception for each service and was floated among the citizens, wherein the citizens were asked to rate each of them on a scale of 1 to 7, where: 1 meant Highly Disagree and, 7 meant Highly Agree A total of 25 questions were framed, euqually distributed among the 5 aspects of RATER, i.e., Reliability, Assurance, Tangible, Empathy and Responsiveness. The questions that received the maximum P-E gap were established as the areas of improvement within the city while the ones that has the minimum gap were benchmarked as good practices for other cities. 28

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A4.5.1. Mobile Testing Inferences: Good Points: 1. The sample collection team in the city wears proper medical gears abiding by the norms. 2. A new kit is unpacked prior to every new test. 3. The FLW is polite and trained enough to explain the procedure before testing and assist the patients throughout the process 4. The result of the report comes within the promised timeframe. Areas of Improvement: 1. The city lacks the facility of government based door to door testing, which can be an area to improve for a better and an efficient management.

A4.5.2. Helpline Assistance Inferences: Good Points: 1. The staff is polite and patient enough to answer to all the queries being asked, making them empathetic towards their citizens. Areas of Improvement: 1. There is no proper awareness and display of respective control room numbers for the citizens on any platform. 2. There is a lack of system that reconfirms the citizens about their issues being administered or not. Also, no complaint redressal service is available to cater to the problems being faced by the citizens within the city.

A4.5.3. Sanitization Inferences: Areas of Improvement: 1. Majority of people lack awareness about the facility of sanitization being provided by the government, of which few who know, are unaware of whom to reach to. 2. Of those who manage to reach out to the concerned authority, are unsatisfied with the service not being provided on time. 3. No initiation can be seen from the government end in terms of sanitizing the house/area of the affected person. An integrated internal communication system seems to be lacking within the government segments.

Figure A7 Gap Analysis for Mobile Testing Source: Primary

Figure A8 Gap Analysis for Helpline Assistance Source: Primary

Figure A9 Gap Analysis for Sanitization Source: Primary

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A4.6. FMEA

2. Sanitization of the area RPN over here is calculated based on the score of severity, frequency of the occurance and probability of detectability. RPN: S*O*D The criteria for risk assessment: RPN < 64 - Tolerable risk 64 < RPN < 480 - Controlled risk RPN > 480 – Unacceptable risk, needs to be priorotised and modified immediately.

Table A7 FMEA for Decentralized Treatment: Bed Allotment at Institutional facility

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Inference: From the FMEA for Decentralized Treatment: Bed Allotment at Institutional Facility, it can be inferred that the potential failure mode is improper data being provided by the authorities. Internal Miscommunication within the segments and Misrepresentation os data are the key causes of failure. The RPN Scoring of 512 depicts that this parameter needs to be catered on priority basis and a recommendation in it can make the system more organised and efficient.

The key recommendation would be introducing a centralized bed allotment system, wherein for all the hopitals in the city, a common live dashboard would exist, which shall be managed by the team of CMO and the team shall be responsible for updating and managing the status of bed availibility in the hospitals everyday. Such a system will influx transperancy within the management and people will be more inclined towards the efforts being made by the government.

Inference: From the FMEA for Sanitization of the area, it can be inferred that the potential failure modes are both long waiting period and Inefficient Sanitization. Lack of a proper communication channel for and on time service (C2G) and Lack of internal communication (G2G) are the key causes of failure. With a RPN Scoring OF 648 and 630 respectively, both the parameters need to be administered paralelly in order to have a system that is seamless, userfriendly and structured.

The key recommendations would be introducing a one call service system, wherein the citizen needs to make a single call, and the responsible authority shows up within the promised timeframe. Other than that, another solution can be a centralized portal, wherein all the responsible segments for COVID management are integrated on one single platform and are automatically updated with the everyday cases and perform their duties accordingly without creating any chaos.

Table A8 FMEA for Sanitization of the area

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A5. Service Concept

A6. Service Audit Profile

Service Received: • Quality and timely treatment • Regular and responsible monitoring • On call services through helpline numbers • Provision of safety gears • Sanitized and safe surroundings • Free Testing

Figure A10 Service Audit Profile Source: Primary

Organization: Government of Faridabad. Organizing Idea: To incessantly cater the people of the city, while minimalizing their movement, providing services to look after their health and nurturing their needs during the pandemic. Service Concept: The service concept is centered around creating an ecosystem that serves to the needs of its citizens by providing healthcare, food, shelter and a secured environment –all available at one place. It also focuses on spreading awareness about the measures to be taken to prevent it from spreading further, i.e., mandatory masks, sanitizing and social distancing. Service Provided: • Screening and monitoring • COVID Care Centres • Demarcation of Containment Zones • Rapid Testing • 24*7 Helpline Numbers • Isolation Check • Provision of PPE kits • Medical Supplies to the first respondents • Shelter homes for migrant workers • Relaxation in paying bills/taxes • Online App integrating essential services • Listing down of NGO’s for providing food to the poor • IEC to create awareness • Defining SOP’s for opening and monitoring of public amenities

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A7. Conclusion

recommendations based on survey, analysis and case studies, the city can clearly unlock another level of management and become more organised, seamless and reliant.

Figure A11 Actions being taken by the Government of Faridabad Source: https://www.instagram.com/p/CGAgJ7VFhAP/?igshid=xlkclrddmse3

After an elaborate study of the existing scenario of COVID Management in the city of Faridabad via various management tools and also by analysing benchamarks of the cities across the country, it can be conlcuded that Faridabad has both good services and few areas of improvements. The trained and skilled staff, the delivery of test results within the set timeframe, the security of FLW’s, the following up of guidelines by both citizens and government authorities, segregagtion of treatment facilities, etc are a few key takeaways from the city. The city is performing well on an overall factor of assurance, tangiblity and empathy. On the other hand, there are certain loopholes and areas of improvement that can be administered such as lack of: one call serivce for efficient and immediate sanitization, live dashboard for maintaining a transparent information system for bed allotment and an integrrated portal for internal G2G communication. Implementing these CEPT University Service Operations and Management Studio 2020 33

HAPUR 34

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Apeksha Agarwal PG190166

B1. About the City

Hapur is a city in, as well as the headquarters of, Hapur district, in western Uttar Pradesh and a part of the National Capital Region (NCR). The city is situated at a distance of 65 Km from Delhi towards the east. Hapur district was carved out from the Ghaziabad district in 2011 with a population of 13,38,000 (District Administration, 2020). It is governed by Municipality (Hapur Nagar Palika Parishad) which was established in 1982. The river Ganga passes through the eastern boundary of the district and is home to the sacred place known as Garhmukteshwar where lakhs of people come every year for pilgrimage.

B1.1. Administrative Setup

There are three Tehsil, four Kshetra panchayats, three Nagar Palika Parishad, and one Nagar panchayat in Hapur district. The division of three tehsils in the district is as shown in figure B2 from left to right namely Dhaulana Tehsil, Hapur Tehsil,

Hapur District Figure B 1 Division of 36 wards with population density in Hapur City Source: http://dcmsme.gov.in/dips/2016-17/DIP%20Hapur.pdf

and Gargh Mukhteshwar Tehsil. Within the Hapur Tehsil is the Hapur city and headquarters of the district. The district is headed by District Magistrate. It has ADM also. Tehsils called Hapur, Dhaulana, and GarhMukteshwar are headed by SDM and Tehsildars. The Hapur city has an ASP police to deal with law and order situations and assisted by CO police for the town called Babugarh, Hapur, Pilkhuwa, and GarhMukteshwar. To address and manage the covid scenario, various departments from state government and city government are working in collaboration namely: • Directorate of Medical & Health Services, Uttar Pradesh responsible for conducting tests and providing treatment and headed by Chief Medical Officer (CMO). • The municipality (Hapur Nagar Palika Parishad) responsible for creating awareness, sanitation, marking of containment zones, and headed by the Executive Officer. • Hapur Police Department was responsible for monitoring and guarding containment areas and

Hapur City

headed by the Superintendent of Police. • Response Team (Crisis Management) was responsible for creating strategies for Covid Management and headed by District Magistrate.

B1.2. Economic Activities

Hapur is a major industrial town in the Nation Capital Region area of western Uttar Pradesh. There are approximately 965 Registered Industrial Units in the District. It is noted as a manufacturing hub for making Stainless Steel Pipes and Tubes. Hapur is also famous for papads, home furnishing Industries, Steel Industries, Paper Industries, Laminated Products, Rice & sugar Mill (ODOP Cell, Uttar Pradesh, 2019).

B2. Current COVID19 Scenario in the City

In Hapur, the first case was detected on April 2, 2020, during the first lockdown phase as shown in figure B2. As of October 31, 2020, (Covid19 India, 2019) the total number of: • Confirmed cases= 3296 • Recovered Cases= 2078 • Deceased Cases= 57 • Total number of tests done= 16767 In Hapur city, on the identification of any positive case in the locality, a radius of 250 meters was considered as the containment area around the locality as per state government guidelines. Later with an increase in the number of positive cases in the city, the containment area radius was increased to 750 meters. Therefore by the end of the lockdown phase and initiation of the unlock phase, half of the city was under containment zones and nothing different from the previous lockdown period. Later as per government guidelines, a weekend lockdown period for a specific number of hours was implemented and commercial and

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Figure B2 Hapur District COVID19 Status Timeline as of 31st October 2020 Source: WHO official website accessed from https://covid19.who.int/table

business markets started operating by the end of August during unlocking phase 3. The containment area radius is also reduced accordingly. To understand the severity of the situation in Hapur city better, a comparison analysis was made concerning other districts of the Uttar Pradesh state as shown in figure B3. On analyzing the statistics for Hapur district and Uttar Pradesh state as of September 8, 2020, it was observed that firstly, the affected population percentage in the district is approximately similar to the Uttar Pradesh with a value of 0.14% and 0.13%

respectively. Secondly, the fatality rate for the district came out to be greater than the state with the values of 1.7% and 1.45%. Thirdly, the percentage for cases among the total tests conducted for Hapur is 11% whereas 4% for the state.

B2.1. COVID19 Care Centre and Laboratory

The government has devised a three-tier system to deal with suspected and positive cases of COVID19 in the district (Khandelwal, 2020) and have identified different health centers for Hapur under as L1 level

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for non-critical COVID19 patient, L2 level, and L3 level for complicated and critical cases. A total number of 1720 beds are available in the district with the count of 30 available on L1 (CHC Hapur), 230 available in L2 level COVID19 care center, and 1240 available in L2 level hospitals (Directorate of Medical & Health Services, Uttar Pradesh, 2020) as marked in figure B3. Using data from the National Health Profile–2019, it can be observed that there are 7, 13,986 total government hospital beds available in India. This amounts to 0.55 beds per 1000 population. In the case of the

Figure B4 Government laboratory mapping for Covid 19 diagnosis Source: WHO official website accessed from https://covid19.who. int/table

Figure B3 COVID19 status of districts in Uttar Pradesh (As of October 31, 2020) Source: https://public.tableau.com/profile/apeksha.agarwal#!/vizhome/ Assignment-8_16002624284870/Story1

Hapur district, this amounts to 1.2 beds per 1000 population which could be considered sufficient. Government laboratory for COVID19 Diagnosis is not available in the Hapur district as shown in figure B5. Though one lab is available in the proximity of 31.3 km at Meerut district which is being used for conducting tests for Hapur also. Also, static booths are installed at ULB’s administration office for testing in the entire district. In the city, a prescription from a doctor is not necessary to get the test done. Anyone having the desire to get tested can approach the static booths for the testing and get it done on the provision of an AADHAR card.

Figure B5 Treatment facilities mapping for Covid 19 mapping Source: WHO official website accessed from https://covid19.who. int/tablwho.int/table

B3. Overview Of the COVID19 Management in the City

On detection of the very first case of COVID 19 in the district, the government started working for spreading awareness about the virus and the city went down in lockdown mode for a month. Following measures were taken to tackle the COVID19 virus attack within the district: • Notice released in newspapers: Notices were circulated through newspapers and digital formats requesting people to inform the authorities themselves if they visited Tablighi Jamaat organized

in Delhi. • Sanitation and cleanliness: All public areas, residential areas, and roads were being spray sanitized every alternate day. A supervisor tasked to ensure the covering of all marked hotspots. The supervisor clicked the pictures as proof by automatically geotagging it with date, time, and location as shown in the photograph above. • Distribution of pamphlets to create awareness: The counselors of each ward were generating awareness by distributing pamphlets to each household. The pamphlets include pictures describing the symptoms of COVID19, How to avoid exposure to the virus, the process of How to wash hands effectively, and a toll-free number provided by UP state to report any cases, symptoms, or travel history. • Markings to promote social distancing: The markings were provided in the front of ration distributing outlets to promote social distancing. • Distribution of Food Packets: The food packets were being provided to daily wage workers and below poverty line people. • Restriction on Businesses without E-pass/ Pass: All essential businesses were also required to apply for the pass for working permissions during lockdown within UP. The helpline number provided on the website of the city helped in creating a point of contact with authorities for getting more information and guidance regarding the COVID19 virus.

Figure B6 Hapur District website accessed on 12.08.2020 Source: https://hapur.nic.in

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B4. COVID19 Management Process Analysis B4.1. SWIMLANE Diagram

Inferences: As shown in figure swimlane diagram, it was observed that due to unavailability of testing labs within the district created a point of delay for getting results and confirmation of corona virus-positive patients. In the scenario of any symptomatic traveler or a passenger entering the city from any other state were

Citizen

Incoming Traveler

Symptoms?

Response Team

Asymptomatic Mild Symptoms

Symptoms? Symptomatic

Resident came in contact with Covid +ve patient

Screening Proforma

Block Survey

Self Control Room Inform

Screening Proforma

Location wise Contact Tracing

Data Processing

Repeat Block Survey

Municipality Hapur Police Nearest Consultant

Clinical Staff

Testing

RT-PCR Rapid Testing

Specimen Collection Specimen Collection

Shipment Time D

Report Sent

Chief Medical Officer Treatment Facility Timeline 38

5-14 Days

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15 Minutes

1-3 Days

5 Minutes

1 Day

asked to quarantine themselves for 14 to 20 days and details of these travelers were not documented or shared with other stakeholders like municipality and Hapur police to monitor the completion of the successful quarantine period.

Asymptomatic

Put barricades and sanitize house and neighborhood

Testing Recommended

Symptoms? Mild Symptoms

Choice

Provide Essentials

Trace contact history

End

Call History

Medium?

GPS History

Put barricades and sanitize house and neighborhood Provide Essentials Guard the Barricaded Zones Shipment to Meerut

Testing Repeats Report Receival D

Test Results

Negative Positive

End

Patient Details

Active and Recovered Case Count

State Portal Update and AArogya Setu App

State Portal Update

End

L1,L2,L3 Isolation facility as per condition of patient

1-4 Hours

2-5 Days

1 Day

14-20 Days

1 Day

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B4. Process Identification

Inferences: With the help of the Swimlane diagram, four major processes with their trigger events were identified as identification, testing, quarantine and treatment, monitoring, and surveillance.

Key Process Area: COVID19 management services Trigger Event Process Name Coming in contact with A-Identification COVID19positive person Corona Virus Symptoms B-Testing identified Patient confirmed with Treatment COVID19 virus Number of cases increases Monitoring and Surveillance

Table B1 Process Identification sheet

B4.3. Process Profile Worksheets B4.3.1. Identification

Inferences: The process profile worksheet for Identification process focuses on identifying the symptoms and suspects with the probability of infected with coronavirus. The major service risk identified was missing coronavirus carrier especially in case of incoming travelers to the city, late identification due to delay in results, a healthy person suspected, and symptoms neglected by the citizen.

Process Name – Number

Process Owner

Identification

CMO -Health Department (Hapur District) Description

The process of identifying the possible corona patients Triggers Event beginning Event ending Additional events

identifying the presence of symptoms Getting tested Contacting control room helpline, Survey filling, Contacting nearest health care facility Inputs – Items and Sources

Survey form (Response Team), Location wise Healthcare facilities (Response Team) Outputs – Items and Customers Suspects (corona patient), Identified hotspots Process Units

Process Unit Owners

Attend Call center Helpline Ask survey questions Data processing location wise Service Objective(s)

Response team Response team Response team Service Risks

Identify possible corona virus carriers

Key Controls Screen at the point of entry (City boundary)

Figure B7 Scoring based proforma for Identification process

Careful monitoring of the calls received at the source itself (control room)

Table B2 Process Profile Worksheet for Identification Process

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Missed corona virus carrier (Incoming travelers) Late identification (due to delay in results) Healthy person suspected Symptoms neglected by the citizen Measure of Success

Number of people identified for testing

Process Name – Number Testing

B4.3.2. Testing

Process Owner

CMO -Health Department (Hapur District) Description

The process of confirming the corona virus infected patients Triggers Event beginning Event ending Additional events

Presence of Symptoms Test Results Specimen collection, Shipment of specimen, Result declaration, Documentation Inputs – Items and Sources

Static Booths (ULB healthcare facility), Testing lab (Health Department), Collected specimen, Citizen details (AADHAR Card) Outputs – Items and Customers Result of test Process Units

Process Unit Owners

Decide the type of test Collect specimen Transport specimen to lab

Citizen Clinical Staff Clinical Staff

Declare Result

Chief Medical Officer

Service Objective(s)

Service Risks

Test the specimen and confirm corona virus carriers

Incorrect test results Improper sample collection Shortage of testing facility (kit, lab, staff)

Key Controls Test the specimen and confirm corona virus carriers Table B3 Process Profile Worksheet for Testing Process

Inferences: There are two types of tests taking place in the city. The RT-PCR test detects the virus’s RNA and tells whether or not someone has the infection very early on. The results are false negative in about 30 percent of cases of RT-PCR tests. The other one is the Rapid Antigen test, it seeks to detect the virus rather than the antibodies produced by the body and has a false negative in about 40 percent of cases. The testing process on Hapur city is entirely free for its citizens. Though when compared with the statistics of the Uttar Pradesh state, the number of tests done was very less. Only people with the utmost possibility of being a corona carrier are being tested. The process profile worksheet for testing focuses on confirming the identified suspects with a probability of a corona virus-infected person with its major service risks being in-correct test results, improper sample collection, and shortage of testing facilities like availability of testing kit, lab, and staff.

Measure of Success

Incorrect test results Improper sample collection

Shortage of testing facility (kit, lab, staff)

Figure B8 Illustration for depicting type of corona virus testing Source: WHO official website accessed from https://covid19.who.int/table

CEPT University Service Operations and Management Studio 2020 41

B4.3.3. Treatment

Inferences: There are three types of quarantine and treatment facilities available. Based on the condition of the patient, availability of space at home, and budget of the patient, the facility for the isolation period can be decided. There are three types of treatment facilities namely, L1 for non-critical cases, L2, and L3 for critical cases. People getting treated at home are supposed to update their daily vitals like blood pressure, oxygen levels, and fever temperature on a WhatsApp group specially created for all home quarantined patients with doctors added in it. The process profile worksheet for quarantine and treatment focuses on treating a confirmed corona virus-infected person with its major service risks being unhygienic quarantine facility, the passage of virus to frontline workers, and unavailability of quarantine facility.

Process Name – Number Treatment

Process Owner CMO -Health Department (Hapur District) Description

The process of isolating and treating the corona virus infected patients Triggers Event beginning Event ending Additional events

Confirmed corona virus infected patient Monitoring and Surveillance Home/ Institutional/ or Treatment facility provision as per patient condition and budget Inputs – Items and Sources

Home quarantine with separate room (Citizen), Treatment facility (Hospital), Un-operational building for Institutional quarantine Outputs – Items and Customers Corona virus free citizen Process Units

Process Unit Owners

Home quarantine Monitor the quarantine Provide essentials to the home quarantined Service Objective(s)

Citizen Hapur Police Municipality Service Risks

Complete recovery from virus Key Controls

Unhygienic quarantine facility Passage of virus to frontline workers Unavailability of quarantine facility Measure of Success

Maintain cleanliness and sanitized surroundings Follow social distancing norms and quarantine Good Recovery rate guidelines Figure B9 Illustration for COVID19 treatment Source: https://www.freepik.com/collection/coronavirus-vector/674671

Look for vacant buildings for converting into quarantine facility Table B4 Process Profile Worksheet for Treatment Process

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Process Name – Number

B4.3.4. Monitoring and Surveillance

Process Owner

Monitoring and Surveillance

CMO -Health Department (Hapur District) Description

The process of monitoring and tracing the corona virus spread Triggers Event beginning Event ending Additional events

Number of positive cases Containment of hotspots Sanitization, Containment of area with positive cases, Tracing the contact history, current movement surveillance of patient Inputs – Items and Sources

Inferences: The process profile worksheet for monitoring and surveillance focuses on monitoring the patients in quarantine or isolation facilities. It can be considered as support services required to ensure the suppression of virus spread to other healthy citizens with its major service risks being patients might not fulfill the 14-days quarantine criteria, community-level virus spread due to improper monitoring, and patients not disclosing complete information.

Details of travel history (Citizen), Spatial data for number of confirmed cases Outputs – Items and Customers Containment of corona virus spread Process Units

Process Unit Owners

Collect travel details of active cases Monitor completion of quarantine period Sanitization of house and neighborhood Service Objective(s)

Response Team Hapur Police Municipality Service Risks

Figure B10 Images of Hapur city during sanitization process Source: Twitter account of Sabhasad

Key Controls

Patient fulfilling the 14 day quarantine criteria Community level virus spread due to improper monitoring Patient not disclosing complete information Measure of Success

Rapid response strategies and rapid testing in hotspot areas Monitor current movement of patients especially in home quarantine

Recovery rate greater than active and deceased cases

Confine and suppress corona virus spread

Use of technology to track past movements Table B5 Process Profile Worksheet for Monitoring and Surveillance Process

Figure B11 Road with Baricades for containing the locality Source: Primary

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B4.4. RACI Diagram Process Name

Identification Testing Treatment Monitoring and Surveillance

Table B6 RACI Chart

Citizen

Response Team R C R C

Where, R is Responsible, A is Accountable, C is Consulted, I is Informed Inferences: The RACI tool helped to identify the roles and responsibilities of all the stakeholders involved in COVID19 management of a city. In table B6, it was observed that the Chief Medical Officer (CMO) is accountable for the majority of processes except for the monitoring and surveillance process. Also, many stakeholders are working as doers (responsible) in a single process of monitoring and surveillance.

R I I

I R C

Chief Medical Officer (CMO)

B4.5. Servqual: RATER Analysis

Service Operations and Management Studio 2020 CEPT University

Hapur Police

Municipality

A A A

Servqual Tool helps to dig into the depths of an issue by supporting it with the help of citizen’s opinions. For the city of Hapur, a survey was conducted on three parameters, namely: Identification, Testing, and Treatment especially for people in-home quarantine, and monitoring. The survey contained the expectation and the perception for each service, wherein the citizens were asked to rate each of them on a scale of 1 to 7, where: 1 meant Highly Disagree and, 7 meant Highly Agree A total of 25 questions were framed, equally

Figure B12 Survey Demographics Source: Primary

Clinical staff

Treatment Facility R I

distributed among the five aspects of RATER, i.e., Reliability, Assurance, Tangibles, Empathy, and Responsiveness. The questions recieving the maximum P-E gap were established as the areas of improvement within the city while the ones that had the minimum gap were benchmarked as good practices for other cities. The respondents approached for the survey, all went through the process of testing and had experienced the services first hand. The sample size of the respondents was 20, out of which 12 were males and 8 were females and 90% of them got tested from a government facility.

B4.5.1. Identification

Inferences: Good Points: •It was easy to connect with authorities if symptoms identified Areas of Improvement: • Tracking is not done efficiently for those who came in contact with a coronavirus positive patient • Control room helpline numbers were well received. Though the staff found out be not very helpful easy to connect with authorities on identification of symptoms

-0.7

tested if came in contact with coronavirus positive patient Control room helpline staff helpful Neighbourhood survey to track the asymptomatic patients

-1 -2 -3

Figure B13 SERVQUAL Analysis for Identification Process Source: Primary

In the Identification process, as per the respondent’s answers, it was observed that only a few localities were identified for the neighborhood surveys despite having a large number of positive cases in other colonies. This indicates the lack of coordination with the bottom-up approach. Sabasadhs or councilors are more approachable and might have detailed knowledge of their respective neighborhoods. Also, respondents felt that it was easy to connect with authorities by helpline numbers provided but the staff was not able to deliver satisfactory answers to their queries, leaving citizens in a state of confusion and helplessness. The respondents with positive test results were not inquired for their places of visit in the last three days as required for contact tracing.

B4.5.2. Testing

Inferences: Good Points: • Staff members found to be approachable in testing centers • Staff members trained and experienced to cater to the queries of people Areas of Improvement: • There was no platform provided to file the complaints regarding the reports • Social distancing guidelines were not implemented at the testing centers receive the reports in the promised time Queries were attended efficiently during the testing ample waiting space to maintain social distancing norms staff visible working with personal protective gears staff approachable during the visit different platforms to lodge complaints Acknowledge the receipt of complaints timely

-1.2 -0.4 -2.5 -1 -0.1 -3 -2

Figure B14 SERVQUAL Analysis for Testing Process Source: Primary

In the testing process, as per the respondent’s answers, it was observed that during the neighborhood surveys, all the residents were tested in the locality as assured by the government but the staff dedicated to carrying out testing were not equipped with PPE protective gears. Indicating the safety procedures are not being followed during testing. Those who went to the testing centers for the testing found poor conditions of waiting areas in terms of comfort and social distancing guidelines. Also, respondents felt the medium to lodge such complaints with the government was missing.

B4.5.3. Monitoring and Surveillance

Inferences: Good Points: • Respondents were satisfied with the doctor consultation during the quarantine period • Containment of the neighborhood was taking place as per the guidelines Areas of Improvement: • Regular sanitization of the neighborhood area was not happening • Sanitation requests were not acknowledged within 24 hours Provision of essential services during quarantine Residential & neighbourhood sanitization Regular sanitization of surroundings acc. to guidelines Containment of surroundings during quarantine Doctor consultation during quarantine period 250 meters neighbourhood area will be contained for every positive patient identified Sanitisation will be done within 24 hours after request received

-0.9 -1.2 -1 -0.3 0 -0.7 -1.9

Figure B15 SERVQUAL Analysis for Monitoring and Surveillance Process Source: Primary

In the Monitoring and Surveillance process, the respondents were found to be unhappy with the on-call sanitization facility as the actions were not being taken in the promised time. The sanitization was undertaken very casually and the residents of coronavirus positive patients were left unsanitized for more than 24 hours.

CEPT University Service Operations and Management Studio 2020 45

B4.6. FMEA

The FMEA (Failure Mode and Effect Analysis) Tool helps in root cause analysis of an issue. The RPN (Risk Priority Number) defines the most critical aspect of the parameter. FMEA identifies the potential effects of failure and its causes. The higher the RPN value, the higher is the risk. For Hapur city, the FMEA was done for the three functions having the SERVQUAL Rater P-E gap score of more than -2 value. RPN over here is calculated based on the score of severity, frequency of the occurrence, and the POTENTIA FUNCTION L FAILURE MODE Neighbour hood survey to track the asympto matic patients

POTENTIAL EFFECTS OF FAILURE

Surge in virus spread

Asymptomatic Cases not identified

SEV.

POTENTIAL CAUSE OF FAILURE

Hotspots not identified efficiently

No immediate action taken if positive case identified

Identification

Control room helpline staff not helpful

Confused citizens

Aarogya Setu app data not updated

probability of detectability. RPN: S*O*D The criteria for risk assessment: RPN < 64 - Tolerable risk 64 < RPN < 480 - Controlled risk RPN > 480 – Unacceptable risk, needs to be prioritized and modified immediately. Inferences: From the FMEA for the Identification process, neighborhood survey and control room helpline were taken as the failure modes due to their more negative P-E gape score. Various potential

OCC.

Do not know what to reply

Credibility loss

Number of confirmed cases in locality

No proper SOP to follow

All positive patients data linked with AADHAR

Lack of seriousness towards queries

DET.

RESPONSIBILITY RECOMMENDED AND TARGET RPN ACTION TAKEN ACTION COMPLETION DATE 168

Spatial analysis to be done for better understanding

Control command center

Updation of the hourly basis citizen testings on the arogya setu app

Response Team

150

SOP defined with timelines and steps detail

Explaining the ICMR guidelines to follow at test centers

160

Constant updation of activities on arogya setu app

Control command center in collaboration with zonal team

Efficient updation of data to regain the trust of citizens for safe testing

Standard question type depending on the symptoms of the citizen should be created

Medical health officer

Frequently asked should be devised

Training should be given to the staff

Medical health officer

None

Table B7 FMEA for Identification process Source: Primary

CURRENT PROCESS CONTROLS

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Less calls at helpline numbers

causes for the inefficient neighborhood survey were identified as due to the ineffective selection of hotspots due to lack of data, late actions to get the data documented and updated, or data not being uploaded on the portals like Arogya Setu and Uttar Pradesh State portal. The RPN value of 168 signifies that it is a controlled risk and needs to be updated to make the process better. The key recommendation could be to update the results of positive cases on an hourly basis on Arogya Setu App so that the spatial interface of the app can

160

128

A feedback should be taken at the last

SEV.

OCC.

DET.

RPN

be used more effectively to identify the hotspots without confusion. Such an update will make the surveys transparent and unquestionable. Inferences: From the FMEA for Testing, waiting conditions at the test centers were taken into consideration. The RPN value of 288 indicated that the risk is controllable and can be modified to make the process better and efficient. The major potential cause of these issues as per the calculated RPN is POTENTIA POTENTIAL FUNCTION L FAILURE EFFECTS OF MODE FAILURE Increased waiting time at the test center

Poor implemen tation of social distancing norms

Crowd accumulatio n

High exposure to virus

Losing trust in service provider

Testing

No standardiz ed testing procedure

Hard to analyse the statistics to take action

Credibility loss in test results

POTENTIAL CAUSE OF FAILURE

SEV.

the lack of availability of space. Since the testing centers were created in the form of static booths at the Tehsil office (administrative office) and existing primary health care centers, the availability of space and furniture required for waiting was lacking. The key recommendations could be to train the staff at the testing center for executing social distancing as per ICMR guidelines in waiting areas. This will help in decreasing the fear amongst them of coming in CURRENT PROCESS CONTROLS

OCC.

6 Lack of space availability

No efficient monitoring staff

Upto the citizens to decide the testing procedure

People choosing rapid test as it consumes less time

Present UCHC and hospitals are used as testing centers

No proper SOP to follow

Monitoring staff should be present at the center

DET.

RESPONSIBILITY RECOMMENDED AND TARGET RPN ACTION COMPLETION DATE

270

288

216

No proper SOP to follow 7

Availability of 2 kinds of testing

contact with the coronavirus at the testing centers. Inferences: From the FMEA for Monitoring and Surveillance, an RPN value of 280 was achieved for both lack of feedback of system and contact tracing due to a shortage of staff. The key recommendation could be to add a feedback extension within the helpline numbers provided. The feedback can be taken after the call as well an extension could be provided specifically for feedbacks.

120

Limiting citizen testings on hourly basis

Control command center

Training staff for efficient monitoring

ACTION TAKEN

SEV.

OCC.

DET.

RPN

Updation of the hourly basis citizen testings on the arogya setu app

Zonal monitoring team

Explaining the ICMR guidelines to follow at test centers

Constant updation of activities on arogya setu app

Control command center in collaboration with zonal team

Efficient updation of data to regain the trust of citizens for safe testing

Standardizing the test type depending on the symptoms of the citizen

Medical health officer

Detailing out the symptoms for both the kind of testings available and standardizing each

Structuring a SOP for testing to be followed pan city

Medical health officer

Following the norms acc. to guidelines

Table B8 FMEA for Testing process Source: Primary

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POTENTIAL FUNCTION FAILURE MODE

POTENTIAL EFFECTS OF FAILURE

No feedback system available

No improvement to the drawbacks in the service quality

Only immediate family contacts are considered for contact tracing

Loss in the credibility of government services

Surveillance and Monitoring

Scope of virus affected citizens movement pan city further spreading the virus Insufficient awareness spread pan city

People becoming reluctant towards the seriousness of the pandemic

SEV.

POTENTIAL CAUSE OF FAILURE

OCC.

No SOP in place

No specific medium of contact between the citizens & service provider

Covid command center

Covid care helpline should be have an extension for feedback at the end of queries

180

People who were within 6 feet of the infected person for at least 10 minutes or so should be contacted

Covid command center in collaboration with zonal monitoring team

Automated texts should be sent to people if they came in contact with an infected patient in last 3 days

Recruit & train staff to trace the contact efficiently

Zonal monitoring team

Staff should be divided to work in batches and then quarantined for 14 days

Levy fine system in case of any violation of social distancing norms

Police department

Standardize fines & spread awareness about the seriousness of the issue.

None 8

No strict monitoring in the neighborhoods towards following the norms

280

SOP manual (Feedback system from testing to treatment)

Only immediate family members are contacted

Shortage of staff 7

DET.

RESPONSIBILIT RECOMMENDE Y AND TARGET RPN ACTION TAKEN D ACTION COMPLETION DATE

None 7

CURRENT PROCESS CONTROLS

The police department is incharge in monitoring the citizens to follow the norms

280

252

SEV.

OCC.

DET.

RPN

Table B7 FMEA for Monitoring and Surveillance process

B5. Service Concept

Organisation: Hapur Government Organizing Idea: Suppressing the Covid 19 virus spread with constant track, treat and trace process Service concept: Maintaining essential health services with accurate diagnosis and effective isolation Service Provided: • 24/7 COVID Helpline control room • Static Booths for testing • Quarantine facilities 48

• Monitoring of Home quarantined citizens • Sanitization facilities • Essential services for the poor and needy • Free ration for citizens below poverty line • Shelter homes • PPE kits • Baricadding containment zones Service Provided • Helpline Services • Free testing

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• • •

Sanitized surroundings Shelter & food for people in need Essentials in contained zones

B6. Service Audit Profile RELIABILITY Easy to connect with authorities Testing results are received timely Error free reports are provided 250 meters neighbourhood area containment Sanitisation done within 24 hours ASSURANCE Contact Tracing The testing lab will have trained staff Queries were attended efficiently during the testing The sanitation at government approved rates TANGIBLE Use of safety & protective gear by frontline workers Monitoring of social distancing Availability of waiting area before getting tested Availability of basic amenities at the test center Regular sanitization of surroundings Use of new testing kits while testing Containment of surroundings during quarantine EMPATHY Gentle & caring staff Approachable staff Personal attention will be given to everyone RESPONSIVENESS Waiting period before testing Time taken to issue the test result Doctor consultation during quarantine period Feedback system

-5 -4 -3 -2 -1 0

RELIABILITY Rapid Antigen to be done for every RT-PCR tested person Sample taking procedure to be included in training ASSURANCE Set of question with answers to be provided

TANGIBLE Mandatory protective gears for frontline workers Explaining the ICMR guidelines to follow at test centers Demarcation of distance as per guidelines

Internal streets to be mapped in containment areas EMPATHY Training to be given for patient handling RESPONSIVENESS Hourly updation of test results on the arogya setu app Testing lab availability for RT-PCR test Feedback extension added with the helpline number

Figure B16 Audit Profile Source: Primary

B7. Conclusion

After an elaborate study of the existing scenario of COVID Management in the city of Hapur via various management tools and also by analyzing benchmarks of the cities across the country, it can be concluded that Hapur has both good services and a few areas of improvement. The delivery time of the RT-PCR test can be improved with the additional infrastructure placement in

the city. It will help to prepare the city for future health related issues also. The city is doing well on the overall factor of Reliability and Assurance. The city has been able to control the number of cases despite sharing the boundaries with Meerut and Gautam Budh Nagar having a very high number of confirmed cases. The strategies and actions at the starting of the lockdown phase were effectively

implemented and have been successful till now.

CEPT University Service Operations and Management Studio 2020 49

LUCKNOW 50

Service Operations and Management Studio 2020 CEPT University

Dhairya Chopra PG190262

C1. About the City

The city of Lucknow is the elegant capital city of the state of India that is Uttar Pradesh. It is situated in the heart of the Gangetic Plain. The river Gomti flows through the city from North-West towards South-East direction. Lying in the northern hinterlands of the country, is home to the remains of one of the most sophisticated and celebrated cultures of the Indian subcontinent, the kingdom of Awadh. Standing at the cusp of a bygone era and a developing metropolis, back in the 1990’s the city saw an unprecedented shuffle of power between its symbolic Dalit leaders which led it to a spree of manic development bursting at its seams. Eventually, this unplanned growth and commercialization of the city drained it of its inherent character. Lucknow is ranked 1st in the fast track list of Round 1 of Smart City Mission as on 24th May, 2016. The city shares its adjoining boundaries with Barabanki district to the east, Unnao on the West Raebareli on the south, Sitapur and Hardoi district on the north. Three national highways and five provincial highways along with a good number of local highway serves the region. The two railway corridors of North Eastern Railway and of Northern Railway pass through the whole city. These linkages give rise to the tendency of interaction between the central and adjoining areas. The expansion of municipal limits of Lucknow means that a larger population of the district shall now avail urban amenities provided by civic agencies like Lucknow Municipal Corporation and Lucknow Develoment Authority. The total increase in Urban Area is 56%. The growth rate of population in last 10 years is 25%. The migrant influx is 38lac people post COVID ‘19. Master Plan 2021 estimates that Lucknow covers an area of 16,270 hectares in 2004-05 and the trend in residential use has grown dramatically.The major

C1.1. Administrative Setup

The longitude and longitude of the city are 26° 30’27° 10’ N and 80° 30’- 81°13’ E respectively. The total district area of the city is 2,528 sq. km. with the total population of 28,17,105 (city) and 45,89,838 (district). The projected population growth of the city is 2.53% with a population density of 1,816 per sq. km. (district). There are a total of 05 tehsils, 08 blocks, 961 villages in the city and a total of 43 police stations. The medical demographics are 11 corona hospitals, 6,900 beds, 500 intensive care units and 200 ventilators.

C1.2. Organizational Capability

Figure C1 Lucknow Graphical Representation Source: www.maps0995623.lucknow.com

types of businesses are steel, plastic, terracotta and chikan with the business objectives of 12 percent per annum growth rate, doubling the export from the state, generating maximum output, a qualitative development through export infrastructure development scheme, cluster development scheme and technical upgradation scheme and ultimately the promotion and protection of handicrafts.

The major governing authority in the city being the Lucknow Municipal Corporation, the structure of the corporation is such that it is headed by the municipal commissioner with seven major departments working in equal co-ordination namely, house tax department, health, accounting, engineering, publicity, property and forest department. During COVID Lucknow Municipal Corporation was the major department working along with other 5 deparment which are elaborated further in the report.

The major focal nodes or points of activity center or an area where traffic, money or information flows in the city are Husainganj, Chowk, Alambagh, Aminabad, Hazratganj and Bhoothnath. The Chief Minister of the state is Mr. Yogi Adityanath, while the city Commissioner is Mr. A.K. Dwivedi with the Mayor of the city being Miss. Sanyukta Bhatia. Figure C2 City Organisation Chart Source: Primary

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Figure C3 Timeline Source: Primary

C2. Current COVID19 Scenario in the City

A 35-year-old Canada-based female doctor was admitted on March 8 in King George’s Medical University and was the first case of COVID-19 reported in the city.

C2.1. Timeline

Above mentioned are the graphical representations of the COVID statistics in the state and city respectively as on October 31st , 2020 with the total number of confirmed cases of 63,262; active being 3,150; recovered cases being 59,234; deceased 878 while the number of cases tested are 8,02,632. The timeline clearly shows how the number of cases have eventually increased.

C2.2. Guidlines

The guidelines and the mandatory actions practiced in the city are:

Figure C4 Lucknow Covid Control Room (Inside) Source: Primary

Mandatory Actions • Article 144 was enforced in the city and people were not allowed to move outside the containment zone. Proper demarcation the containment zones was done. People above the age of 65 and below 10 were prohibited from movement. • As per the lockdown guidelines markets, temples, schools and colleges were closed. • Gathering restricted to 50 people. • IEC practice was done. ULB Delivery Strategies • The LMC workers were giving the responsibility of providing food and ration to the poor. Approved List: For the smooth working of the city during pandemic 7 collection centres were established with 34 laboratories, 10 CHCs and one separate covid control centre which is used for data record and monitoring via DSO portal.

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Figure C5 Lucknow Covid Control Room (Exterior) Source: Primary

C2.3. Strategies

• It has opened community kitchen centers to provide food to more than 4,000 people amid lockdown in the wake of the novel coronavirus outbreak. • 112 helplines have been implemented which was previously for police has been directed for Covid19. • LMC also plans to use drones for disinfection with a carrying capacity of 7-10 liters which can

be operated through a transmitter, mobile or computer. • RT – PCR application for sample collection (for technicians) and UP Home Isolation application.

C2.4. COVID Managment Department

The COVID control centre is the main department which works in co ordination with five other departments:

C3. COVID Management: Process Analysis

C3.2. Quarantine

The city has been classified into four major steps for the process of managing COVID in the city of Lucknow.

C3.1. Idetification

Identifying is process of recognizing the people who have been in contact/ travelled and are now witnessing symptoms. It comprises of locating, 1. CM Control Room examining and testing the suspects. The process of • Overall reporting and monitoring being the identification is done on the basis of people having representative body ILI (patient with Influenza Like Illness: an acute respiratory infection with fever more than 38C and 2. CMO Control Room cough) or SARI symptoms. Post testing, the case is • Assisting people classified into four categories i.e: • Advising home/ facility quarantine based on the symptoms of patients • Asymptomatic or very mild (fever) • Regular check of patients via phone calls • Mild case (fever) • Moderate case (pneumonia with no sign of severe disease) 3. Lucknow Municipal Corporation • Severe case (having respiratory issues and • Creating containment / de containment requires to be on ventilators) zones (Barricading areas) • Sanitizing the city • Survey the containment zones • COVID medical waste management

4. DM Control Room • Administrating the other departments.

Quarantine can be defined as the separation of people and restriction on the movement with a purpose of preventing transmission. As soon as a person is tested positive for Coronavirus he/she is home or facility quarantined for a period of 14days to prevent the spread of coronavirus. STATISTICS: 100 isolation beds, 10 CHC and home isolation only if there is a provision of one bedroom and toilet per person. The process of quarantine is necessary for separating contacts of COVID patients from the community, monitoring contacts with a sign of developing symptoms of COVID and segregation of COVID suspects as early as possible from among other quarantined people. On testing positive with very mild or mild symptoms, the person is mandatorily advised to home isolate or get admitted to an institutional based facility depending on the grade of infection.

C3.3. Treatment

Patients with moderate and severe symptoms are facility quarantined at COVID Healthcare Centres (equipped with ICU units, ventilators and beds with oxygen supply).The ambulance is assigned from the nearest COVID healthcare facility. The cost of treatment at the Government dedicated hospitals is free of charge including medicines, food and other services

C3.4. Monitoring

Monitoring including: • Keeping a check on home quarantined patients (Police department) • Containment strategies (LMC) • Sanitizing the affected areas (LMC)

5. Police Control Room • Monitoring movement in containment area • Dead body management Figure C6: Uttar Pradesh Home Isolation Application user interface Source: https://play.google.com/store/apps/details?id=com.covid19. dgmup&hl=en_IN&gl=US

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C4. COVID Management Process Analysis C4.1. SWIMLANE Diagram

Inferences: The swimlane tool helps understand the process flow of all the activities and how they are connected to one another. The swimlane helps us picture the entire process in detail starting from the patient falling ill to finally being recovered. In Lucknow the process goes from identification, to the patient eventually

Role

Activities

Patient/ Home Exposure By Coming In Conatct With A Covid Positive Patient

-ve

Suspicion Of Influenza Like Illness (Ili) Or Severe Acute Respiratory Infections (Sari) Sympotms

COVID – ve confirmed

Syptoms Prevail

+ve

Asympto-matic

 L1- Not critical patients, where home quarantined is not possible  L2- Complicated patients  L3- Critical patients

Doctors Information Received And Patients Consulted Offline/ Online

Treatment No

Test Lab And Chc Rapid On Spot Testing Facility With Rt- Pcr

Test Result Yes

Covid Control Room

Timeline 54

Registration Of Data On The District Surveillance Office Portal

5-14 days

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5- days

2-3 days

 Information Call To:  Police  Municipal Corporation  Patient

15-30 minutes

being quarantined or admitted and ultimately being treated.

Role

Activities

Covid Control Room

 Patient

Detection Of Mild, Moderate Or Severe By Doctors

Incase Of Moderate/ Severe Corona: Facility Based Quarantine

Rapid Response Team

Timeline

* Death

L2 – District Government. Hospital L3 – Government Medical College

Incase Of Mild Corona: Home Quarantine (Separate Room & Toilet)

Municipal Corporation

L1 - CHC

Ambulance Assigned From The Nearest Covid Healthcare Facility

The Patient Is Made To Download The Up Home Isolation Application

Municipal Corporation Marks The House For Home Quarantine

Recovery

Information Call To The Municipal Coroporation

Updation Of Data On The Distric Surveillance Office Portal

Information Call To The Police

Regular Check Up Of Patients For 14days Until Fully Recovered Via Call From Cmo Office

SURVEY & MARKING THE CONTAINMENT AREAS (100m RADIUS)

Sanitizing The Containment Areas

 Contact Tracing Of  Primary – Family Members  Secondary – All The People The Patient Visited In The Last 14 Days (Example: Office Colleague, Friends And The Others)

14 days

Decontainment Strategies

Positive Testing Done By Rapid Response Team

Negative

(Process Repeats)

1 day

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C4.2. Process Identification Worksheet

Inferences: The COVID19 management within the city can be bifurcated into four major categories namely, identification, quarantine, treatment and monitoring with their respective trigger events.

Key Process Area: COVID19 Identification Process Trigger Event Process Name Person develops symptoms Identifying like Influenza Like Illness (ILI) or Severe Acute Respiratory Infections (SARI) and gets a test done and is detected positive The corona positive patient Quarantine is either home or facility quarantined depending upon mild, moderate or severe symptoms The patient is quarantined, Treatment given proper medication and monitored Monitoring and tracking Monitoring the spread of Coronavirus (containment strategies, sanitizing, contact tracing)

Table C1. Covid Identification Process

C4.3. Process Profile Worksheets C4.3.1. Process Identification

Inferences: The process profile worksheets for the below-mentioned process helps in analysing the service risks and the key controls to mitigate them.

Process Name

Test lab and CHC

Description

Person develops symptoms like Influenza Like Illness (ILI) or Severe Acute Respiratory Infections (SARI) and gets a test done and is detected positive

Triggers

Event beginning Event ending Additional events

Person gets sick Patient detects corona positive Patient goes to the test lab after preliminary treatment and provides the details of the travel history/ contact with any suspect, gets himself tested with RT-PCR rapid, receives medication, co ordination with the COVID control room.

Inputs – Items and Sources

Contacting the test lab (patient), information on travel history (patient), submitting the sample (patient)

Outputs – Items and Customers

Getting the COVID -19 report (test lab)

Process Units

Process Unit Owners

Service Objective(s)

Service Risks

Consulting the doctor for preliminary treatment Getting tested for COVID 19 Collecting and sending out samples To provide the primary medication and treat the patient; corona treatment only if symptoms prevail. Accurate diagnosis of the report with utmost care and accuracy in order to identify maximum number of people in the city, safeguard the health of the employees

Key Controls

Upgradation of helpline numbers if changed, highly trained doctors, SOP for sample collection and generating test report, maintaining an inventory of equipments, penalization when required Table C2 Profile worksheet for Identification

Process Owner

Identification

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Doctor Test lab Rapid response team

Wrong helpline number, unavailability of doctors, insufficient number of rapid antigen testing kits/ team, incorrect / delayed diagnosis, negligence towards maintain hygiene, sample not labelled accurately

Measure of Success Number of recommendations for both test lab and CHC, number of positive feedbacks, correct/ early diagnosis, number of people identified for testing.

Process Name Quarantine

Figure C7: Vector Image depicting the visual of COVID Patient Source: https://pngtree.com/

The process profile worksheet for Identification focuses on identifying the positive cases in the city with its major service risks being: wrong helpline number, unavailability of doctors, insufficient number of rapid antigen testing kits/ team, incorrect / delayed diagnosis, negligence towards maintain hygiene, sample not labelled accurately.

Figure C8: Vector Image depicting the visual of facilities to quarantined patients Source: https://pngtree.com/

C4.3.2. Quarantine

The process profile worksheet for Quarantine focuses on asking the patient to self quarantine or admit to an institutional non medical government COVID Care Centre according to the grade of infection with its major service risks being: Unhygienic environment, low quality of food provided.

Process Owner COVID Control Room Description The corona positive patient is either home or facility quarantined depending upon mild, moderate or severe symptoms after registration on DSO portal Triggers Event beginning Patient is detected corona positive Event ending Patient starts getting treated Additional events Registration of data on DSO portal, information call to police, municipal corporation and patient, patient quarantined on the basis of mild (home quarantined), moderate and severe symptoms (facility quarantined), ambulance assigned Inputs – Items and Sources Information call to patient, police and municipal corporation by COVID Control Room Outputs – Items and Customers Recovered patient Process Units Process Unit Owners Registration of data on DSO portal COVID control room Information call to police, municipal COVID control room corporation and patient Detection of mild, moderate and sever Doctor symptoms Ambulance assigned COVID control room Ambulance assigned Service Risks To provide an isolated area to the patients to Unhygienic environment, low quality of food prevent the spread of the virus provided Key Controls Measure of Success Guidelines for hygienic and sanitized facility, Positive feedback for institutional facility regular food quality check, trained staff, follow social distancing norms and quarantine guidelines

Table C3 Profile worksheet for Quarantine

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C4.3.3. Treatment Inferences: The process profile worksheet for Hospital Treat focuses on making sure that the patient is admitted to the dedicated hospital facility due to his/her high grade infection, with its major service risks being: relapse of the virus, passage of virus to other people, shortage of medical equipments or facilities, error with the new report, unhygienic environment. The key controls for the service risks are strict monitoring over timely intake of medicines, proper care to the patients,, maintaining an inventory for the required medicines and medical equpments, maintaining hygiene as per the SOPs, dead body management as per the government specified guidelines, trained staff in particular domains. The measure of success in the process is the recovery rate.

Process Name – Number

Process Owner

Treatment

COVID Control Room Description The patient is quarantined, given proper medication and monitored Triggers Event beginning Patient is home/ facility quarantined Event ending Patient recovers Additional events Ambulance assigned from the nearest COVID healthcare facility, patient is made to download the UP home isolation application, patient is checked regularly via audio/video calls from CMO office and given proper medication

Inputs – Items and Sources

Medication, UP home isolation application (CMO office) Recovered patient

Outputs – Items and Customers

Process Units

Ambulance assigned Patient is asked to download the UP home isolation application Provision of medicines Monitored regularly via audio / video calls

Service Objective(s)

Proper care and monitoring

Key Controls

Figure C9: Vector Image depicting the visual of COVID Testing Source: https://pngtree.com/

Strict monitoring, timely intake of medicines, proper care to the patients, being updated covid development and laying new facilities accordingly, maintaining an inventory for the required medicines and medical equpments, maintaining hygiene as per the SOP, dead body management as per the gov. specified guidelines, trained staff

Table C4 Profile worksheet for Treatment

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Process Unit Owners CHC CMO office

Doctors at COVID control room Doctors at COVID control room

Service Risks

Relapse of the virus, passage of virus to other people, shortage of medical equipments or facilities, error with the new report, unhygienic environment

Measure of Success

Quick recovery rate

Process Name – Number

C4.3.3. Monitoring

Process Owner

Monitoring

Lucknow Municipal Corporation

Description

Monitoring and tracking the spread of Coronavirus

Triggers

Event beginning Event ending Additional events

Person is detected corona positive Patient recovers Area within a radius of 100m from the patient’s house is surveyed , the area is barricaded, sealed and sanitized and there is strict monitoring to ensure there is no movement in or out, primary ( family members) as well as secondary (office colleagues and friends) contacts (last 14days ) traced and and tested via door to door surveys

Inputs – Items and Sources

PP kits (surveyors from LMC), Spray machine (LMC), barricades (police), Information regarding the travel history, sample (patient)

Inference: There is no re testing of patients once they start witnessing a decline of symptoms that is incase the patient is asymptomatic necessary measures are not taken to curb the spread of virus.

Outputs – Items and Customers Containment of virus spread, Detailed analysis survey report (LMC) Process Units Process Unit Owners Survey (R: 100m), barricading, sealing and sanitizing area Strict monitoring to ensure zero movement, penalization

The process profile worksheet for Monitoring focuses on prohibiting the further spread of the symptoms in the area due to a COVID positive tested patients with its major service risks being: inaccurate survey report, lose barricades, less number of sanitizing vehicles and equipments, spread of virus, people violating norms i.e not being quarantined for 14 days, no strict monitoring to which the corresponding key controls would be: trained staff, daily surveillance of demarcated houses, penalty for violation of guidelines, checklist for maintaining adequate number of vehicles as per requirement, SOP followed to sanitize, frequency of sanitizing, monitoring plain as per SOP.

LMC

Police

Service Objective(s)

Service Risks

Key Controls

Measure of Success

Inaccurate survey report, lose barricades, less To analyze the exact number of positive patients, number of sanitizing vehicles and equipments, contain and barricade the area, prevent the spread spread of virus, people violating norms i.e not of virus, safeguard the health of employees being quarantined no strict monitoring Trained staff, daily surveillance of demarcated houses, penalty for violation, checklist for maintaining adequate number of vehicles as per requirement, SOP followed to sanitize, frequency of sanitizing, monitoring plain as per SOP

Table C5 Profile worksheet for Monitoring

Recovery rate greater than active/ deceased cases Figure C10: Vector Image depicting the visual of ICCC Monitoring desk Source: https://pngtree.com/

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C4.4. RACI Diagram Process Name

Patient

Identification Quarantine Treatment Monitoring

I R

Doctors C C R,C

Table C6 RACI Diagram

Where , R= Responsible A= Accountable C= Consulted I = Informed

Covid Control

CHC R R A

A A C

Lab Technician A

LMC

Rapid Response

R,A

Inference: The RACI chart identifies the various departments that are Responsible, Accountable, Consulted or Informed. The major players being the patients, doctors, COVID control room, CHC, lab technician, Lucknow Municipal Corporation and rapid response team.

C4.5 Servqual Analysis

C4.5.1 Demographic Study

70% People were tested from private operated labs

Even though the rapid response team monitors , the process is not very efficient. COVID Control room is further reports to Chief Minister’s office with the daily updated data for keeping State records inline. 35% People were tested corona positive

90% people were quarantined out of which 73% were home quarantined while others were facility quarantined

Figure C11: Vector Image depicting the visual of Sanitization Source: https://pngtree.com/

Figure C12: Chief Minister Yogi Adityanath monitoring the ICCC activities Source: https://timesofindia.indiatimes.com/city/lucknow/-modeleases-stress-on-lucknow-command-centre/articleshow/77441917.cms

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Servqual tool helps digging into the depth of an issue by supporting it with the help of citizen’s opinion.

C4.5.2 Identification

-0.24

-0.5

-0.4

-0.3

-0.2

-0.1

0.1

-0.70

0.2

Figure C13 P-E Gap Analysis (Identification & Testing) Source: Primary

Average Responsiveness

Telephone consultation services

0.07

-0.05

Average Tangible

0.19

Ambulance response time

-0.12

Average Assurance

-0.20

Average Reliability

Testing team response same day

-0.48

-0.33

0.30

Figure C15 Rater Analysis (Identification & Testing) Source: Primary

C4.5.3 Quarantine & Treatment

0.3

Figure C14 P-E Gap Analysis (Quarantine & Treatment) Source: Primary

-0.1

-0.05

Average Responsiveness

-0.15

-0.12

Average Empathy

-0.2

-0.14

Average Tangible

-0.25

-0.19

Average Assurance

Adequate number of beds at quarantine facility Quarantined patient comfotable with staff

-0.3

-0.05 -0.2

0.00

-0.19

Professional and patient staff

-0.7

Average Reliability

-0.29

0.05

Figure C16 Rater Analysis (Quarantine & Treatment) Source: Primary

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C4.5.4 Monitoring

-0.4

Figure C17 P-E Gap Analysis (Monitoring) Source: Primary

C4.5.5 Analysis

Furthermore, for the in depth analysis of issues, a Service Quality analysis was conducted for the citizens of Lucknow. The sample size was 22 people out of which 12 were male while the others were female and their age group varied from 20 years to 60 plus years. The result of the first step that is Identification and Testing; the major flaw was the response time of both ambulance and the testing team and Assurance being the poorest factor in RATER. While, the service of telephone consultancy was performing good in the city.

-0.3

-0.2

-0.1

Figure C19 Rater Analysis (Monitoring) Source: Primary

the points to be appreciated are: • The sample collection staff is well equipped with PPE kits • Uses a fresh kit for each test and • Are able to resolve the queries of the citizens on call.

Average Responsiveness Average Empathy Average Tangible

Likewise for Monitoring the sanitization service needs improvement in both efficiency and promptness with Reliability being the lease performing factor in RATER. The Composite RATER analysis depicts that Reliability and Responsiveness in terms of Monitoring are major areas of concern. While on the other hand 62

Average Assurance Average Reliability Figure C18 Overall Process Rater Average Source: Primary

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-0.70

-0.20 Figure C20 Composite Rater Analysis Source: Primary

-0.14 -0.12

-0.5

-0.7

Moni Treat Ident

-0.05 -0.19

-0.6

-0.19 Average Responsiveness

-0.7

-0.14 Average Empathy

-0.8

-0.02 Average Tangible

-0.9

-0.17 Average Assurance

Sanitization done within 24hours of the request received Sanitization as per SOP

-1

-0.50 -0.2

0.00

-0.90

Sanitization process conducted efficiently

Average Reliability

-0.33

0.3

0.30

C4.6 FMEA FUNCTION

Identification & Testing

Quarantine & Treatment

POTENTIAL FAILURE MODE

POTENTIAL EFFECTS OF FAILURE

S E V

POTENTIAL CAUSES OF FAILURE

O CURRENT C PROCESS C CONTROLS

D RPN E T

No door to door testing

False statistics on DSO portal

Inadequate manpower

378

Delayed response time (testing team)

Delay in proving immediate medical care and health deterioration

Distance between labs / long travel time

160

Inadequate infrastructure (bed)

Delayed treatment

Inaccurate assessment & forecasting of requirements

No contact tracing

Unidentified suspects

Inadequate manpower

Inefficient sanitization

Spread of coronavirus

Incompetent human resources and inappropriate resource management

Improper demarcation of containment zone

Increase in number of cases

Unauthorized movement

No complaint redressal system

Slow improvement in services

Staff not trained regarding technology

Monitoring

Table C7 FMEA Source: Primary

Inference: The failure Mode and Effect Analysis also called the FMEA was done wherein the possible risk assessment for each of these factors was done as a parameter set that any Risk Priority Number above 480 is unacceptable. Hence, after further analysis the major threats came down to be inefficiency in sanitization and inadequate number of beds. Furthermore, the corresponding recommended actions and new Risk Priority Number was calculated for each. Thereafter it was converted into a percentage and a score card

RECOMMENDED ACTION

RESPONSIBILITY

ACTION TAKEN

S E V

O D C E C T

RPN

Rapid Response Team

Hiring

Locating the nearest available test lab

LMC

Rapid response team should coordinate with COVID control room

729

Maintaining an asset inventory and centralized infrastructure allotment system

LMC

Real time bed availability status on centralized portal

140

Optimizing manpower

LMC

Assigning/ recruitment of skilled staff

576

Staff training and maintaining resource inventory, daily update to COVID control room

LMC

Monitoring and supervision

270

Strict monitoring and barricading

Police

Supervision and blocking with hard barricades

168

Development of training modules and SOP

COVID Control Centre

Staff training and complaint redressal system

Staff recruitment

was developed between 1-7 for the same. This score card helped us plot our recommendations on the Service Audit Profile between -7 to +7 depicting our recommendations. For example, in the case of Reliability – Door to Door testing is not taking place which is due to lack of manpower or their optimization hence staff recruitment is the most appropriate recommendation. Similarly, under Assurance staff training and maintaining a resource inventory is the optimum suggestion for inefficiency in sanitization. A

centralized bed allotment system and maintaining an asset inventory could tackle the issues of Tangibles. Lastly, developing a complaint redressal system shall not only improve the responsiveness among people but also help Government take suggestions and implement them.

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C5. Service Concept

Organisation: Government of Lucknow Organising Idea: ‘’Healthier, Together’’ Service concept: To serve the people of the city irrespective of their caste, creed, religion or economic strata in order to protect and nurture them by providing all the essential services like healthcare, food, shelter and a safe environment required with minimum movement. It also focuses on educating the citizens about the preventive measures to be taken during the pandemic like usage of masks, gloves and sanitizer and maintaining optimum social distance. Service Provided: • Identifying citizens with ILI/ SARI symptoms

• • • • • • • • • • •

• Guidelines for opening up public spaces • Mitigation strategies Service Received: • Quality treatment

• 24*7 helpline numbers • Provision of PPE kits to the employees and masks and gloves to the citizens • Sanitized and safe areas • treatment • Regular monitoring • Provision of food to the needy • Free COVID 19 tests • COVID Control Centre providing all services in co ordination with other departments A few initiatives by Lucknow Municipal Corporation:

•

Doctor’s consultation Rapid testing Quarantine centres Demarcation of containment areas Treatment by providing medical supplies Monitoring and screening COVID Control Room 24*7 helpline numbers Isolation checks Shelter homes for migrant workers Online applications for essential services, isolation and treatment Dead body management Surveying the containment areas Provision of PPE kits Relaxation in taxes and certain bills Provision of food to the needy via community kitchens and NGOs IEC program for prevention

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• • • • •

Figure C21 Hello Doctor E-OPD For Lucknow Citizens Source: https://twitter.com/LkoSmartCity/status/1326819551380725760

Figure C22 Lucknow’s own COVID19 Mobile Application Source: https://twitter.com/LkoSmartCity/status/1326442105309433856

Figure C23 Initiative to encourage social distancing by Lucknow Smart City Source: https://twitter.com/LkoSmartCity/status/1326442105309433856

C6. Service Audit Profile

Table C9 Service Audit Profile

Inference: The left side depicts the existing scenario whereas the right side are the suggestions for example in the case of reliability door to door testing is not taking place which is due to lack of man power or their optimization, hence staff recruitment is the suggested recommendation. Similarly under assurance staff training and maintaining a resource inventory is the most optimum suggestion for inefficieny in sanitization.

C7. Conclusion

After an elaborate study of the existing scenario of COVID Management in Lucknow using various management tools and studying the benchmarks of the cities across the country, it can be concluded that Lucknow has a few good services while there are certain areas that need improvement. Teleconsultation services, an integrated COVID control room, and a DSO portal for data record and maintenance are a few key takeaways from the city. The city is performing comparatively good in the Identification and Testing of COVID ‘19 patients

whereas lacks the Monitoring aspect. Certain areas of improvement that can be administered are inadequate infrastructure, inefficient sanitization, implementing door to door testing, and contact tracing. These aspects if taken care of, can help the smooth and efficient working of the city in such times without creating an atmosphere of panic among the citizens and also help curb the spread of Coronavirus in the city.

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AHMEDABAD 66

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Karanbir Singh PG190439

D1. About the City The city of Ahmedabad, now the seventh largest metropolis in India and the largest in the state of Gujarat, was founded in 1411 AD as a walled city on the eastern bank of the river Sabarmati. It is the home of several scientific and educational institutions of national, regional and global importance. The Municipal Corporation was formed in 1950. D1.1 Administrative Setup: The corporation is headed by a Municipal commissioner (Shri Mukesh Kumar), an IAS officer appointed by the government of Gujarat. The city is at present divided into 7 zones - central, east, west, north and south and new west zone. Each zone is further split into wards. There are at present total 48 wards (area 463 sq km and total population of

55,77,940 according to 2011 census). Each ward is represented by 4 corporators. The Mayor (Smt. Bijalben Patel) heads the party with the largest number of corporators elected. D1.2 Economic Activities: Ahmedabad has been one of the most important centres of trade and commerce in western India. Modern textile technology further oiled the Gujarati virtues in ‘reinventing’ Ahmedabad. Pharmaceuticals, Construction and Textiles are the main industries of Ahmedabad of today. The town contributes 14% of the total investments in all stock exchanges of India.

D2. Current COVID19 Scenario in the City

In Ahmedabad the first case was detected on March

19th , 2020 during the first lock down phase. As of 31st October 2020 (COVID19 India, 2019) the total number of: • Confirmed cases= 42,514 • Recovered Cases= 37,334 • Deceased Cases= 1,902 • Total number of tests done= 16,40,974

Figure D2 Zone wise Active Cases of COVID19 in Ahmedabad City Source: https://ahmedabadcity.gov.in/portal/jsp/Static_pages/corp_department.j

Figure D1 Administrative structutre of Ahmedabad Municipal Corporation Source: https://ahmedabadcity.gov.in/portal/jsp/Static_pages/corp_elec_intro.jsp

Ahmedabad Municipal Corporation was among the early birds who responded actively in containing the COVID19 pandemic. Ahmedabad municipal corporation, in comparison to other municipal corporation, was way ahead in taking immediate actions to cope up with crises situations. Learning from the situations in Italy, China and the United States of America, Ahmedabad city was able to take those measurements which were taken at a later stage to minimise the collateral damage. Even before anyone died or WHO declared Corona as a threat to the human race (30th January 2020), AMC called for an emergency meeting with the all the departments on 24th January 2020. The timeline highlights the 7 major phases in which Ahmedabad CEPT University Service Operations and Management Studio 2020 67

In Lockdown 4.0: During this period the positive cases started rising rapidly. To tackle this AMC monitored the super spreaders in 2 stages. 1st stage included the vegetable and fruit vendors. Red stickers were pasted outside on the gates of the houses of patients tested positive for COVID19, and the ones who have completed spending 14 days of quarantine, AMC is pasting green stickers outside their houses. AMC deployed 36 supermarkets (Big Bazar, D-mart, Reliance and Osia). In Unlock Phase 1 that is AMC has also started an initiative call #SponsorATest in which the donor organizations and individuals can sponsor tests In Unlock Phase 2.0– Educational institutions were reopend after consultation with local authorities In Unlock Phase 3.0 Permission for managing international travellers was the focus point with other relaxations in the protocols. Other spots of social gathering were given green flag to function at 50% capacity.

Figure D3 Timeline Source: https://ahmedabadcity.gov.in/portal/web?requestType=ApplicationRH&actionVal=loadCoronaRelatedDtls&queryType=Select&screenId=114#

Municipal Corporation took necessary steps to tackle to spread of COVID19 (as shown in Figure D3). In Lockdown 1.0: To tackle the immediate spread AMC conducted a Public space Sanitization drive in most vulnerable places of the city. The first order was to issue 3 lakh face masks and bulk orders for sanitizers and Personal Protection Kits to be provided to the Employees. Since Gujarat is well connected with china due to trade and business, it helped them to anticipate the kind of damage which could be caused in Indian cities. Due to this a lot of people were supposed to come back to India from China. AMC started screening of passengers at the Airport.

In lockdown 2.0: AMC launched the Door to door testing van called the Dhanvantri Rath along with Designated COVID treatment hospital with all facilities for a capacity of about 1800 patients. 68

Facility to quarantine up to 5000 patients was set up initially. AMC Started sanitizing AMTS and BRTS bust stands and 950 buses every day which carried 5 lakh people. The daily medical inspection was conducted for the people who were home quarantined after coming back from foreign visits. 17 floors of Sardar Vallabhbhai Patel Hospital were dedicated to the patients of coronavirus, each floor is of the size of a football field. Apart from the existing hospital facilities, different hotels and trains were utilised to accommodate at least 5,500 patients. In Lockdown 3.0: All the essential requirements of home quarantined people was delivered to them by AMC employees. About 6,000 people received food from good restaurants while being home quarantined. Essentials were delivered at the door step to the citizen with the help of E-rickshaws. During this period Cashless digital payments were made mandatory.

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In Unlock Phase 4.0: To ramp up the testing process AMC installed kiosks at various locations. Eventually movie theatres, parks and other social gathering areas are getting permission to fuction at full capacity.

Figure D4 Newspaper article regarding identification strategy in Ahmedabad Source: Source: https://ahmedabadcity.gov.in/portal FigurFigureFf

D3. Overview Of the COVID19 Management in the City

Ahmedabad Municipal Corporation along with Ahmedabad Urban Development Authority has set up a COVID war room at Paldi (ICCC office) where all the operations are handled in an integrated manner. Starting from identifying to bring in the patient for treatment in a hospital, everything is handled digitally with the help of a patient tracking system. The following strategies are the ones which have made this challenge doable: D3.1. Identification and Testing Identifying can be described as the process of recognizing the people who have been a victim of COVID19. It comprises of locating, examining and testing the patient/suspect, and on the basis of the result, carrying on the further process of

Figure D5 Testing Labs in Ahmedabad City Source: https://ahmedabadcity.gov.in/portal/jsp/Static_pages/corp_department.j

quarantining, treatment and finally discharging. On 15th May 2020, a medical van converted into miniclinic for rapid testing was launched by Ahmedabad Municipal Corporation called Dhanvantri Rath. It also provided non-COVID patients with the essential healthcare services to the doorsteps of the people in the city. Monsoon season at its edge, immediate care of symptoms, reference to UHC, with tests of malaria and dengue, was another motive for which this mobile testing van was launched (Corporation, 2020). If the patient is found COVID19 positive, he or she is made to fill up an online form. The van stays at a place for 2 hours at a spot, catering citizens living in the vicinity of up to 1 km radius. Oximeter are provided to the patient free of cost if home quarantined (Grewal & Jain, 2020). A team of AYUSH Doctor, paramedic and nursing staff along with local Medical Officer from Urban Health Centre of AMC are present in a Dhanvantri Rath van to provide necessary assistance to citizens. The civic authorities have also launched a Special helpline number – 155303 for senior citizens (Age > 60 years) to avail essential goods and can also complain about lack of services or improper civic work. Another initiative was 104 Helpline number which is a 24x7 helpline for people who feel like they want to get tested for COVID19. Antigen test helps in contact tracing. Test results in 15 minutes. The next step in identifying a patient about COVID19 symptoms after Rapid testing is a RT-PCR test (Reverse Transcription Polymerase Chain Reaction). Ahmedabad has 25 test labs where the testing process takes place. Out of these 25 labs, 16 are private labs and 9 are Government labs(as shown in Figure D5). For scaling up the testing numbers, kiosks (as shown in Figure D8) have been set up in 116 locations where anyone can come in and take a rapid antigen test free of cost. This has helped to ease off pressure of contact tracing.

Figure D6 COVID Case status in Ahmedabad City Source: https://ahmedabadcity.gov.in/portal/jsp/Static_pages/corp_department.j

Figure D7 104 Emergency vehicle in Ahmedabad City Source: https://ahmedabadcity.gov.in/portal/jsp/Static_pages/corp_department.j

Figure D8 Kiosk for Rapid antigen testing at CG Road, Ahmedabad, Gujarat Source: https://english.sakshi.com/photos/

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D3.2. Treatment Strategies: According to Ahmedabad Municipal Corporation, there is a guideline to provide separate medical facilities available to citizens in every zone (Division), 2020). Urban Health Centres (UHC) were the first point of contact for any medical assistance. A total of 77 UHC also know as COVID Health Centres now (DCHC)were converted into quarantine facilities. Apart from this, private hotels and malls were converted into quarantine centres in aid to help AMC provide the patients with isolation bed at the earliest. 17 COVID care centres(CCC) were made available for patients facing mild symptoms. 39 Dedicated COVID Hospitals (DCH) with a capacity of 1773 beds are available in the city. Every day a list of available beds is issued in the newspaper and also updated on the Ahmedabad COVID dashboard at 11:00 AM to navigate the incoming patients. At CCC, the Municipal corporation employees along with Sanjeevni workers assist the quarantined patients and also monitor their vitals and provide them with essential needs. At DCHC the paramedical staff along with AYUSH and MBBS students look after the quarantined patients (Welfare,

Figure D9 Containment zone barricading Source: https://www.youtube.com/watch?v=LHKjfYH2kDU

2020). At both CCC and DCHC, Medical officers visit every 2 days to every patient to do regular checkups in which body temperature, oxygen levels are the 2 prime areas of focus. At hospitals, a patient is first monitored in the triage area for a few days, and if the medical condition of a patient requires special assistance, separate ICU wards are there for it. These ICU wards have ventilator facility. At the quarantine centres the staff has put barricades and checkposts around the campus and within the facility so that

Figure D11 Robotic drone being used in walled city area of Ahmedabad Source: Source: https://ahmedabadcity.gov.in/portal

Figure D10 Relaxing zone in one of the Quarantine Centres in Ahmedabad Source: https://www.youtube.com/watch?v=LHKjfYH2kDU

exposure is kept at a minimum for those managing the facility and taking care of the patients. There are about three medical teams who work in shifts and each team consists of one doctor and one paramedic. A section of the facility has been cordoned off for health care professionals so that they can live within the facility. The medical team will also be tested every 14 days to ensure they haven’t contacted the infection. The facility is equipped with a yoga centre, an indoor game facility, free WiFi and a library that comprises over 1000+ books and magazines. Once a patient enters the facility, they are each provided with kits consisting of a bucket with soap and a toothbrush. The food for the patients is specially planned and prepared by the Nutrition department. It contains nutritious items like juices, khichri, dal, soup, vegetables, rotis among others.

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D3.3. Monitoring and Surveillance Strategies: Even after providing all top-notch medical infrastructure, there was a subsequent rise in the deceased cases. In initial days, the family of the patients were not allowed near the patient but with the help of technology, AMC is helping contain the spread of the virus as well as maintain social distancing. The first step taken towards this was ensuring Home quarantine patients are following the guideline. Sanjeevni Rath (CORONA Ghar Seva) were introduced for surveillance over home quarantine patients. Doctor and paramedic staff go and check every 3rd day to check social distancing and other guidelines (Grewal & Jain, 2020). The Integrated Command and Control Centre (ICCC) has played a crucial role in the proper patient monitoring system using a drone for sanitizing in walled city and surveillance over citizens to ensure Social distancing (as shown in Figure D11) . Another initiative has been taken by the authorities was ‘Vegetable-on-wheels’ to supply vegetables to the people at their doorstep. E-rickshaws are being used for the execution of the plan wherein the rickshaw visits the localities so that people do not need to get out of their houses and go to mandis. FlytNow

chemist department were involved in the operation (World, 2020).

A team from Municipal Corporation thoroughly sprayed disinfectant in every nook and corner of the house. They also inform DO’s and DON’T’s about the containment area (as shown in Figure D14).

Figure D12 Chalaans being issued for not wearing masks Source: Source: https://ahmedabadcity.gov.in/portal

developed drones which police authorities used to carry out live, remote drone operations to monitor the overall social situation through an operatorfriendly dashboard and take measures to monitor crowds and maintain public safety. Ahmedabad Police employed 200 local drone operators, to help authorities to identify crowded areas and intimating the police control rooms in real-time in order to take necessary action. This enabled the police to stream live multi-video feeds from multiple drones to their control room, thus providing situational awareness and enabling them to respond quickly to emergencies. The drones actually helped to control the havoc at a time without putting human helpers at risk of contracting the coronavirus. These drones also had loudspeakers, and sirens, serving as a public safety aid, sending a warning to people about the need to stay indoors, as well as potentially spraying disinfectants and the platform, can help the corona warriors do this safely from their homes. A silent campaign which turned out to be a failure though was MASK CAMPAIGN. Till

Figure D13 Area sanitized by fire department team during sanitization operation Source: Primary

Figure D14 Advertisement promoting usage of mask Source: https://twitter.com/AmdavadAMCjsp Figure D14 Sanitisation done in Public and private spaces by dedicated teams Source: https://ahmedabadcity.gov.in/portal

date, about 10,000 people are fined for not wearing a mask and authorities have collected about 1 Crore. Another initiative which was taken at a very early stage was Public place disinfectant drive on March 23rd 2020. For the execution of this plan, 18 vehicles were deployed. The department utilised 40,000 Litre sodium hypochlorite creating 4,00,00,000 Litre mist. The authorities made sure that they covered an area of about 100 sq km. For this BRTS corridor and bus stations, public places, 1000 buses, Riverfront was chosen, where the majority of the citizens usually use the public spaces. Fire health, engineer and

Table D1 Containment zones in Ahmedabad (zonewise data) Source: Source: https://ahmedabadcity.gov.in/portal

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B4. COVID19 Management Process Analysis B4.1. SWIMLANE Diagram

Inferences: As shown in figure swimlane diagram, it was observed that the testing process has been divided into 2 levels just to make the patient sure about his or her condition. As soon as the a patient is declared as COVID positive the contact tracing team tries to get in touch with those people who have been in contact

Patient

Symptoms (fever, cough, shortness of breath)

Doctor prescribes COVID19 test

Medical Staff Municipal Corporation

COVID19 negative confirmed

On call consultation

Call the helpline number

T SWAB collection

Laboratory

Timeline

COVID -ve

Rapid Antigent test Day 1 10 minutes

Figure D15 Dhanvantri Rath Source: https://www.youtube.com/watch?v=LHKjfYH2kDU

COVID -ve

Day 1 30 minutes

Patient identifies Contact located contacts for testing

COVID +ve COVID19 RT PCR positive HRCT scan confirmed test COVID +ve

Day 1 30 minutes

Figure D16 Contact Tracing Team Source: https://www.youtube.com/watch?v=LHKjfYH2kDU

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COVID19 positive intervied

Day 3 24 hours

Figure D17 Swab Collection Source: https://www.youtube.com/watch?v=LHKjfYH2kDU

B A

with the patient. On the other hand, same information is reported to ICCC where all the COVID19 related decisions take place. ICCC decides how to manage the requests of the testing process and send adequate workforce to different places. Marking and demarking of containment zones help with the help of ITIHAS application which is supporting the back end of Arogya Setu App. Content notified

Covid 19 negative confirmed

T Send Dhanvantri Rath

COVID-VE Swab Collection

Rapid Antigen Test Result COVID-VE

Quarantine centre

Contact assigned

Input from ICCC

Day-3

Figure D18 ICCC Source: https://www.youtube.com/watch?v=LHKjfYH2kDU

Day-3 (24 hours )

Figure D19 People waiting in line for Rapid Antigen Test Source: https://www.youtube.com/watch?v=LHKjfYH2kDU

Figure D20 Paramedical Staff Source: https://www.youtube.com/watch?v=LHKjfYH2kDU

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After is patient is confirmed as Positive, on the basis of conidition of the patient and availability of beds a patient’s quarantine location is decided. Home quarantine is for self isolating a person at home. DCHC(Dedicated COVID Healthcare Centres), CCC (COVID Care Centre) and DCH (Dedicated COVID Hospital) are the 3 instituitional quarantine facilities available in Ahmedabad. Sanitize residence and seal the floor

Follow home quarantine instruction for 14 days

Moderate symptom

Sent to DCHC

Discharged with certificate and suggested precautions Provide essentials to patient and monitor condition

Regular checkup every 3 days

Covid-ve Retest

Sent to DCH

Covid+ve

Yes Home quarantine available

A Covid-19 positive confirmed Day 4

Check symptom type

Mild symptom

Sent to CCC

Monitored by sanjeevni workers.

Severe symptoms

Symptomatic Asymptomatic

Day 6

Day 5 (30 minutes to 1 hour)

Figure D21 COVID CARE CENTRE Source: https://www.youtube.com/watch?v=LHKjfYH2kDU

Figure D22 Sanitizing activity outside a house Source: https://www.youtube.com/watch?v=LHKjfYH2kDU

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Day 20

Figure D23 Marking Home Quarantine Source: https://www.youtube.com/watch?v=LHKjfYH2kDU

D4.2. Process Identification

Inferences: After understanding the process with the help of swimlane, the COVID19 management in Ahmedabad City can be categorised into three processes; Identification & Testing, Treatment and Monitoring & Surveillance (as sh.

Key Process Area: COVID19 management services Trigger Event Process Name Person facing symptoms of COVID19 and getting himself tested. According to the grade of symptoms, the patient is allotted a quarantine facility. Sanitization of patient’s house and instructing self-isolation rules.

Identifying & Testing Treatment

Monitoring & Surveillance

Table D2 Process identification worksheet

D4.3. Process Profile Worksheets

This tool helps in listing down the trigger events, stakeholders, service risks, key controls and measures of success of different processes.

D4.3.1. Identification and Testing

Inferences: The process profile worksheet for Identification focuses on identifying the positive cases in the city with its major service risks being: Unavailability of a doctor, Miscommunication, Error with the reports and shortage of antigen kits; to which the corresponding key controls identified are: having a contact information of more than one doctor, reconfirming what was communicated, Trained and skilled staff and maintaining and inventory. Positive feedback was success measure.

Process Name Identification and Testing

Process Owner Ahmedabad Municipal Corporation Description Identifying the positive cases in the city from various places. Triggers Event beginning The person falls sick and experience symptoms such as fever, soar throat, body pain, etc. Event ending Confirming the RT-PCR Test result positive Additional events Informing the doctor, receiving the medication, contact tracing and surveillance, Taking testing sample Inputs – Items and Sources Call(Suspect), Information on Travel History(Suspect), Assistance with locating of dispensary(COVID Control Room Supervisor), Submitting the sample(Suspect) Outputs – Items and Customers Test Result (AYUSH Doctor) Process Units Process Unit Owners Informing about symptoms to a Doctor Suspect Assistance in taking antigen test COVID Control Room Supervisor Diagnosing the symptoms and providing ANM/ASHA worker/ Anganwadi workers/ NCC medication & Conducting the test cadets Service Objective(s) Service Risks Unavailability of the medical staff, To identify the maximum number of people in Inadequate PPE kits, the city with utmost accuracy Mishandled samples, Report errors, Error with the Report Key Controls Measure of Success Doctor’s contact details, Outreach(Reaching out to max. people) Number of samples collected and tested. Training protocol, Recommendations Back up Inventory , Positive feedback SOPs for testing Table D3 Process: Identification and Testing

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Process Name Treatment

Process Owner Ahmedabad Municipal Corporation Description The patient asked to home quarantine or admitted to COVID Care Centre, or Dedicated COVID Health Centre based on symptoms. Triggers Event beginning The person tested positive with mild or moderate symptoms Event ending Patient recovery Additional events Updating patient status, monitoring the patient’s vitals, Notifying for a retest post 14 days, coordinating with COVID19 war room Inputs – Items and Sources Call(Patient), Quarantine Facility (Medical officer), Call (ICCC Employee) Outputs – Items and Customers Recovery(Patient) Process Units Process Unit Owners Updating patient status Medical Officer Quarantining at institutional Facility AMC worker/Medical officer Monitoring patient’s health status Sanjeevni worker/Medical officer Service Objective(s) Service Risks Quality & Quantity of food served, Resistance from Patients, Faulty documentation To inform the patient and provide with the Degraded Food Quality further medical assistance till the person is recovered from COVID19 symptoms. Patient avoiding getting retested Error with the new report Key Controls Measure of Success SOP for maintaining, Food quality checkpoints, Recovered patient SOPs for Sanjeevni workers, Positive feedback/ Rating received for the SOP for testing institutional facility Table D4 Process: Treatment:

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D4.3.2. Treatment: Quarantine

Inferences: The process profile worksheet for Quarantine focuses on asking the patient to self quarantine or admit to an institutional non medical government COVID Care Centre according to the grade of infection with its major service risks being: Untidy Environment, Degraded Food Quality, Meals not provided timely, Patient avoiding getting retested or Error with the new report; to which the corresponding key controls identified are: SOP for maintaining hygiene, Regular Food Quality Check, Management plan for food distribution indicating duties and responsibilities, Keeping a regular check on the patient (till proven negative), Properly trained and skilled Team and SOP for testing. Measure of success of the profile were recovery of patient

Positive feedback for the institutional facility.

Figure D24 Quarantine Facility in Ahmedabad City Source: https://ahmedabadcity.gov.in/portal/web?requestType=ApplicationRH& actionVal=loadCoronaRelatedDtls&queryType=Select&screenId=114#

Process Name – Number Monitoring & Surveillance

Process Owner Ahmedabad Municipal Corporation Description Prohibiting further spread of the symptoms in the area due to a COVID positive tested patient Triggers Event beginning Patient tested positive and mandatorily asked to quarantine Event ending No cases suspected twice. Additional events Demarcating the house, Sanitizing the perimeter, Restricting the movement outside the house, Barricading in pink containment zones Inputs – Items and Sources Sticker outside patient’s house, Sanitization (AMC) , Barricading (Police officer) Outputs – Items and Customers Abridgement of the symptoms (Government ) Process Units Process Unit Owners Demarcating property & apprising the public AMC employee Sanitizing the house and the surrounding Police officer Barricading the area Fire department Service Objective(s) Service Risks Unavailability of the sanitizing vehicle/ equipment , Breakdown of the vehicle, To prevent spread of the COVID19 Virus Wrong address details, Social distancing defaulters Key Controls Measure of Success Centralized bed management system Maximum Number of Recovered Patients Positive Feedback/Rating received for the Having an inventory for both Hospital Keeping a regular check on the patient SOP for maintaining hygiene Table D5 Process: Monitoring and Surveillance

D4.3.3. Treatment: Hospital

Inferences: The process profile worksheet for Hospital Treat focuses on making sure that the patient is admitted to the dedicated hospital facility due to his/her high grade infection, with its major service risks being: Unavailability of the beds, Shortage of required medicines and medical equipments, Untidy Environment, Patient avoiding getting retested, Error with the new report, Dead body mismanagement; to which the corresponding key controls identified are: Co-ordinating with the increasing cases and laying new facility if required, Maintaining an inventory both for medicines and medical equipments, SOP for maintaining hygiene, Keeping a regular check on the patient (till proven negative), Properly trained and skilled Team and SOP for dead body management. Measure of success was the number of patients recovered.

Figure D25 COVID Hospital Facility in Ahmedabad city Source: https://ahmedabadcity.gov.in/portal/web?requestType=ApplicationRH& actionVal=loadCoronaRelatedDtls&queryType=Select&screenId=114#

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D4.4. RACI Diagram Process Name

Patient

Municipal Corporation A

Medical Staff

Identification & Testing Treatment

R I

Monitoring and Surveilance

Table D6 RACI Chart depicting Roles and Responsibilities of all the Stakeholders

Where R- Responsible A- Accountable C- Consulted I- Informed

Laboratory staff I A

Police

ICCC

and was floated among the citizens, wherein the citizens were asked to rate each of them on a scale of 1 to 7, where 1 meant Highly Disagree and, 7 meant Highly Agree. The analysis are as follows:

Figure D27 P-E gap for Identification and Testing Source: Primary

Inference: The RACI Diagram shows the various stakeholders, i.e., the patient, municipal corporation, medical staff, laboratory staff, police and ICCC who are Responsible, accountable, consulted and informed respectively in all the processes that are followed in the COVID-19 management in the city(as shown in Table D6).

D4.5. SERVQUAL Analysis

Servqual Tool helps in digging into the depth of an issue by supporting it with the help of customer’s opinion. For the city of Ahmedabad, a questionnaire was floated which had total 25 questions based on all the 3 parameters; Identifying & Testing (9), Treatment(9) and Monitorig & Surveillance(7). The questionnaire was sent to COVID positive patients who got in touch with Ahmedabad Municipal corporation and received various services according to the type of symptom they had. The survey was floated from 14th18th October 2020 and 30 responses were received. Out of the 30 responses, 19 were of male respondants and 11 were female. Majority of the responsants were in the age group of 20-30 years. The survey contained the expectation and the perception for each service 78

Figure D28 P-E gap for Treatment Source: Primary

Figure D26 Age group of respondants Source: Primary

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Figure D29 P-E gap for Monitoring & Surveillance Source: Primary

In the testing process the reliability in finding a testing facility had the highest gap (-0.40) and assurance of testing being conducted in a gentle manner had the lowest gap (-0.06). In the treatment process the responsiveness to conduct scheduled check-ups had the highest gap ( -0.43) and empathy of the staff to stay patient to answer all the queries had lowest gap (-0.21). In the monitoring and surveillance process the Assurance of sanitization happening thoughout the house had the highest gap (-0.93) and the tangibility of the frontline workers to wear in PPE kit before entering patient’s premises is the lowest gap (-0.5). According to Composite rater analysis states that monitoring and surveillance has the maximum gap(as shown in D30).

D4.6. FMEA

4.5.1 Areas of Improvement: Sanitation throughout the perimeter

Handling service requests for sanitizations

Unsatisfactory sanitization

RPN over here is calculated based on the score of severity, frequency of the occurance and probability of detectability. RPN: S*O*D The criteria for risk assessment: RPN < 64 - Tolerable risk 64 < RPN < 480 - Controlled risk RPN > 480 – Unacceptable risk, needs to be priorotised and modified immediately.

4.5.2 Good Points:

Figure D30 Composite Rater Analysis Source: Primary

Using new kit for Swab collection

Approachable medical staff whenever required

Politeness of medical staff to answer to patient’s queries. Figure D31 Composite Process Analysis Source: Primary

The FMEA (Failure Mode and Effect Analysis) Tool helps in root cause analysis of an issue. RPN (Risk Priority Number) defines the most critical aspect of the parameter. FMEA is used to identify the potential effects of failure and it’s causes. Higher th RPN value, higher is the risk. For the city of Ahmedabad, FMEA was performed highest 2 gap in each process: 1. Locating a testing facility 2. Difficulty in finding access to the helpline number 3.Difficulty in interacting with the Sanjeevni workers 4. Frontline workers not wearing PPE 5. Inefficient Sanitization 6. Delayed sanitization activities

Inference: From the FMEA we can understand that identification & testing had 2 potential failures. First one was locating a testing facility, potential effect to this mode was delay in identification of suspect and the potential cause leading to the failure was the travelling distance from a patient’s residence. Use of capturing patient’s GPS location while registering the complaint can be a recommended action for this which will significantly help in making the testing numbers better (as shown in Table D7). The second failure mode is difficulty in finding access to helpline number, to which the potential effect of failure is delay in reporting and testing

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of a case. This failure is being cause due to lack of awareness among people. If AMC can conduct some IEC programs regarding COVID19 virus then significatly testing process will become smooth. In the treatment process difficulty in interacting with sanjeevni workers was a failure mode. Due to rapid increase in COVID positive cases from 2nd to 6th month, Sanjeevni workers were not well trained enough to support the patient and respond in such a pandemic situation. This lead to a lot of discomfort to the patients. AMC needs to set up a

proper complaint redressal system with trained staff to supervise as well as train the Sanjeevni workers based on the feedback received by the patients. At times there were few cases in which Sanjeevni workers went to conduct scheduled checkups without wearing the PPE kit. In this situation AMC can impose some sort of penalization on the Sanjeevni works in order to ensure containment. GPS based Oxymeters can provided to home quarantined patients at nominal fee just for immediate help. In Monitoring & Sanitization the major failure

Table D7 FMEA Analysis Source: Primary

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modes were insufficient sanitization and delayed response of sanitization service provider. AMC can hire private sanitizing companies or make dedicated task force with the exisitng staff to sanitize houses of COVID positive patient within 24 hours of being declared. These recommendations can certainly affect the performance of the monitoring and surveillance teams which currently are not meeting their objectives due to lack of workforce and simultaneous increase in location to cater.

D5. Service Concept

Organization: Ahmedabad Municipal Corporation Organizing Idea: To instantly cater the people

of the city, while minimalizing their movement, providing services to look after their health nurturing their needs during the pandemic. Service Concept: Targeting on creating an secure environment that serves to the needs of its citizens by providing healthcare, food, shelter under one roof. It also focuses on spreading public awareness about the steps taken to prevent COVID19 Virus from spreading further i.e mandatory masks, sanitizing and social distancing.

Service Provided:

• Screening and monitoring • COVID Care Centres • Demarcation of Containment Zones • Rapid Testing • 24*7 Helpline Numbers •Isolation Check • Provision of PPE kits • Shelter homes for migrant workers • Relaxation in paying bills/taxes • NGO’s for providing food to the poor • IEC to create awareness •Defining SOP’s for functioning of public amenities • Online App integrating essential services

Figure D32 Advertisement promoting Do’s in COVID times Source: https://twitter.com/AmdavadAMC

Figure D34 Advertisement for behavior change Source: https://twitter.com/AmdavadAMC

Figure D33 Advertisement promoting benefits of mask Source: https://twitter.com/AmdavadAMC

Figure D35 Advertisement for behavior change Source: https://twitter.com/AmdavadAMC

Service Received:

Quality and timely treatment Regular and responsible monitoring On call services through helpline numbers Food for everyone Provision of safety gears • Provision of safety gears • Sanitized and safe surroundings • Free Testing • Integrated platform for all services

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D6. Service Audit Profile

Figure D36 Service Audit Profile Source: Primary

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Inferences: In the Service Audit profile, we can see the reflection of recommended action on the right. and towards the left is the existing scenario. The ratings received on the Serv Qual has been plotted on the service audit profile to understand each parameter and its efficiency(as shown in Figure D36) . The root cause analysis gave issues mentioned above and derived from that are the recomendations which are mentioned on the right side of the service audit profile. The dotted line on plot area shows the improvement in the overall rating after the recommneded actions are implemented. The inbetween area represents the service gap between the existing service delivery and the desired recomended service delivery.

D7. Conclusion

After using 6 managemnt tools to elaborate the existing scenario of COVID Management in the Ahmedabad city and also by analysing benchamarks of the cities across the country, it can be conlcuded that Ahmedabad has both good services and few areas of improvements. AMC has ramped up the very first step by taking over the control to the citizens themselves by making rapid antigen tests readily available free of cost. This has significatly reduced the workload of contact tracing domain in which various departments were integrated. But the fact cannot be denied that Ahmedabad is still facing the challenge in containing citizen at their homes, that too when the second wave of spread is just around the corner. Sanitization team needs to have a proper framework to monitor the hot spots as well as provide the same service to the people who have been quarantine on regular basis for better recovery rate. To cope up with the COVID times, citizens themselves need to get involved and join hands with AMC at every step to ensure the quality of services.

Figure D37 Advertisement discouraging spitting in public spaces. Source: https://twitter.com/AmdavadAMC

Figure D39 Advertisement for CORONA SANTVANA(Mental Helpline Number) Source: https://twitter.com/AmdavadAMC

Figure D38 Advertisement for COVID friendly greeting styles Source: https://twitter.com/AmdavadAMC

Figure D40 Poster for mask awareness Source: https://twitter.com/AmdavadAMC

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VASAI-VIRAR 84

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Shantanu Bane PG190889

E1. About the City

The city of Vasai-Virar of Palghar district lies in the western part of Maharashtra and is the southernmost part of the Mumbai Metropolitan Region (Greater Mumbai). The city, earlier a part of Thane district was added to the newly formed Palghar district in 2014. The Municipal Commissioner of Vasai-Virar Municipal Corporation (VVMC) during the time of study was Shri. Gangatharan D and the Mayor was Shri. Pravin Shetty. The region comes under the purview of Vasai-Virar Municipal Corporation (VVMC) and had a population of 12.2 lakhs in 2011. The projected population for the year 2020 is 19.8 lakhs. 5% of its population stays in rural areas and their main livelihood is Agriculture while Vasai-Virar being a satellite city to Mumbai region has a majority of population that travels daily to Mumbai for service. Economic activity in Vasai

Virar region is majorly agriculture, in industries and fishery. The area of Vasai Virar can be categorized as coastal area, internal area and the area near railway station connecting to Mumbai. The development has taken place close to the railway station and the ctitizens living in this area are majorly service class that commute to Mumbai for their jobs regularly. The people living in the coastal region are the native fisherman Koli community that practices fishery and sell their catch to the MMR region. The citizens living in the internal areas of Vasai majorly are into 2 occupations i.e farming and working at industries in Vasai. The farmers in this area mainly cultivate rice, betel, cotton, sugarcane, vegetables, bananas etc. The industries in Vasai mainly produce chemicals, electronics, pharmaceutical, plastic, printing press, spare parts, artificial fibres, textiles, paints, edible items.

E1.1. Administrative Setup

The existing organization structure has the Municipal Commissioner at the top with 2 Assistant Commissioners managing specific functions. Both the functions are supervised by the deputy Commisioner. The health department comes under the purview of Deputy Commissioner with Administrative Assistant Commissioner at the top followed by Health Officer and Sanitation Inspector. The organization structure is given in Figure 2. There are a total of 21 Primary Health Care Centres (PHC), 2 government hospitals, 3 Maternal Child Health Centre and 9 clinics in the Corporation.

Vasai-Virar, Palghar district

Figure E1 Vasai Virar Municipal Corporation, Palghar District, Maharashtra Source: Bharatmaps.com

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E2. Current COVID19 Scenario in the City E3. Overview Of the COVID19 Management in the City The first positive case of COVID was found in the city of Vasai-Virar on 23rd March 2020. The number of cases saw a steady growth for a period of one month and the cases rose to a number of 386 daily number of cases by 13th July 2020. The total confirmed cases in the region by that day were upto 4100. Since then the number of new cases have been gradually decreasing with daily number of new cases down to 144 on 8th September 2020 and confirmed cases seeing a slower growth at 18,165. The status of COVID cases and a timeline of various strategies adopted by VVMC during the pandemic

During the pandemic Mumbai Metropolitan region (MMR) had a huge surge of new cases in the initial days putting a pressure on health system in the region Many of the resources available in the satellite cities like Kalyan, Thane, Vasai-Virar, MiraBhayander, Bhiwandi were used to cater to Mumbai city. The lockdown took place on 22nd March and the local railway network of the region was shut and also vehicular movement within different regions of MMR was restricted. In VVMC, due to shut down of local shops a rationing helpline number was established on 27th

are shown are shown in figure no: E2.

Figure E2 Timeline of COVID cases Source: VVMC.in

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March to cater to the needs of people who were finding it difficult to avail food. Further on 18 April the Corporation launched a COVID dashboard website with information regarding precautionary measures, survey forms, containment zone lists, list of important contacts, details of COVID management Infrastructure and services. The dashboard also mentioned the number of daily new cases, active cases, total confirmed cases and deaths in the city. Vasai being Mumbai’s main railway junction for long distance trains moving from southwest region to Northern regions saw many migrant population in the city waiting for their Shramik special trains during the lockdown. To cater to their needs of

food and water, a makeshift facility was created for migrant population on 16th May. This was set up on an unused ground( earlier a saltpan). The workers halted in this facilty providing them shade during their waiting time and were transported to the railway station through a special bus service operating according to the train timings. On 5th June i.e after the unlocking process started, vehicular travel within the MMR region was opened up. The cases were still growing in VVMC area and 2 huge quarantine centres were opened in the first week of July. These quarantine centres were set up by acquiring an industry that was shut down years ago

Figure E3 Infrastructure and staff set up for COVID management Source: Primary

and a college campus in Vasai Gaon. Also a health audit team was formed later to keep a check on prices charged by private hospitals to treat COVID patients in the area. On 8th August ‘mission super 30’ was launched aiming rapid testing in the area. Though the Corporation received its first antigen testing kit in the second week of September. The infrastructure for management of COVID pandemic in the city is explained in the figure E3. A makeshift fever clinic was established in government schools. The set up was simply a school bench where the doctor and nurse would diagnose patients with an infrared thermometer and pulse-oximeter. The

people would stand in line in an open to sky space for their diagnosis maintianing social distancing norms. Once the patients were diagnosed at fever clinic they were recommended swab collection by the doctor. The fever clinic nurse sent the details of patient to government hospital for collection of swab. The swabs of the patients were collected at government hospital after confirmation of patients identity. After collection of swabs the swabs were delivered to JJ laboratory in Mumbai by 4:00 pm. These swabs were tested at laboratory and sent to the government hospital the next day. Also there was a Corona Control Unit set up as a helpline to citizens to provide necessary information regarding COVID management facilities and services to the citizens. Due to sudden rise in cases and lack of adequate staff, an invitation for volunteering at fever clinic was sent to general physicians (Henceforth GP) in the area on 10th May. The volunteering GP provided his/ her service at the fever clinic for specific hours weekly. The GP was assisted by a nurse who coordinated between patients, doctor, and hospital staff. The hospital staff was mainly involved in swab collection and attending patients at isolation centres. General Nursing and Midwifery (henceforth GNM) were assigned areawise. These GNM’s conducted surveys in containment zones and coordinated with VVMC staff for sanitization in case a positive case was found in the area. The VVMC staff was involved in sanitizing patients residence and society, and moving patients to quarantine facility. Also they updated areas as containment zones and informed police department to initiate the barricading procedure. The police department barricaded entry and exit points of containment zones and monitored the movement of people in and out of containment zones.

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E4. COVID19 Management Process Analysis E4.1. SWIMLANE Diagram

Inferences: The flow of responsibilities initiates from patients to volunteer GP to fever clinic staff. Further the swab collection is done by hospital staff and tested by laboratory staff. Once the reports are received the status of cases is updated. A delay was observed between the process steps of collection of swabs and

GNM Patient Volunteer GP

Patient observes symptoms

Visits fever / private clinic

Visit hospital Diagnose patient

Is there possibility of COVID

Prescription Recommend testing to hospital

Fever clinic nurse

Collect aadhar data

Hospital staff

Collect & deliver batch of swab

Send reports Conduct test & deliver reports to hospital

JJ laboratory

Update tested on dashboard

VVMC staff Police departent Timeline

10:00 Day 4

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10:10 Day 4

16:00 Day 4

18:00 - 20:00 Day 5

receiving of reports from testing laboratory. Once the identification process is completed the treatment and containment process initiates. In this procedure the decisions made by the GNM lead to the actions followed by the VVMC staff and police department. In terms of time taken for each step there is no delay in the quarantine and monitoring process Visit patient, inform reports

More cases in neighbourhood Is the symptoms mild/ severe

Conduct surveys in neighbourhood Monitor patients symptoms

Recommended home quarantine

Is home isolation possible

Buy home test equipment

Declare containment zone

Patients recovered

Send daily information to GNM

Institutional quarantine transfer Institutional isolation transfer Sanitize area Barricade area

10:00 Day 6

Symptoms getting worse

Patient recovered

Discharge patient

Delist neighbourhood Monitor movement

14:00 - 16:00 Day 6

Day 20

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E4.2. Process Identification

The processes adopted for COVID management by VVMC were identified as Identification & testing, treatment, and monitoring and surveillance. The following processes with their trigger events are shown below in table E1.

Key Process Area: COVID19 management services Trigger Event Process Name Patient is unwell and Identification & observes symptoms testing Patient is reported Treatment positive More than 25 cases in Monitoring and neighbourhood Surveillance Table E1 Process Identification Sheet

E4.3. Process Profile Worksheets E4.3.1. Process: Identification and testing

Inferences: The identification and testing involved processes from identification of symptomatic patients to receiving reports of the tested patient. The most critical risks involved in identification process were the delay in patient visiting the fever clinic/ private clinic and delay between collection of swab and informing the patient of his/her reports. The risk might lead to the virus spreading from the positive patient to his acqaintances. During the period of informing him. This identified risk of delay would further be quantified and studied in SIPOC diagram. A way to control this risk was by availing on call consultation service and improving the time taken in delivery of test results and reports to the staff at government hospital in Vasai.

Process Name – Number Identification & testing Identifying COVID positive cases

Triggers Event beginning .Patient is unwell and observes symptoms Event ending Positive cases recorded Additional events Fever clinic visit, patients symptoms diagnosed, patients details informed,testing conducted, report prepared, test report delivered, digital test report sent, results informed to VVMC Inputs – Items and Sources Masks, PPE, medicines, testing kit, diagnosis equipment- VVMC; Testing recommendation - fever clinic staff Outputs – Items and Customers Test reports - hospital staff, updated covid records - citizens Process Units Process Unit Owners Diagnosing patients symptoms, providing General Physician medication Informing patient details to hospital staff Fever Clinic staff Collection of sample, delivery to JJ lab, Hospital staff informing test results to VVMC Update COVID status on dashboard VVMC staff Service Objective(s) Service Risks Diagnosing and testing patient accurately Inaccurate diagnosis, long waiting time, delay in and informing results to area-wise nodal informing nodal officer, delay in visiting fever clinic officer Key Controls Measure of Success Safety precautions by process unit owners, minimum contact with oatient, ensuring Number of daily visitors, number of patients diagnosed social distancing norms, followed by patient, abd tested, time required to inform nodal officer, SOP for diagnosis, management of inventory, minimum positive cases in patients acquaintances, availing consulting service on call, imporved minimum number of process unit owners getting process between report delivery and infected infroming nodal officer Table E2 Process profile worksheet - Identification & testing

Process Owner .VVMC Description

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Process Name – Number Treatment Quarantining/ treating patient

Process Owner VVMC Description

Triggers Event beginning Positive case reported with mild/ severe symptoms Event ending Patient discharged from facility Additional events Digital reports sent to patients, home isolation/ institutional quarantine recommended to patient, patient transferred to COVID care facility, patients data collected, bed allocated to patient, buying home quarantine equipment Inputs – Items and Sources Quarantine bed, O2 bed, ambulance, masks, PPE - VVMC; Email id, positive reports - GNM Outputs – Items and Customers Safe environment - Patients acqaintance Process Units Process Unit Owners Visiting patient, providing home isolation form, GNM monitoring patients health Transferring patient to institutional quarantine, VVMC staff collecting patients information, allocating bed, discharging patient Service Objective(s) Service Risks Delay in visiting patient, patient hiding symptoms, Prevent the spread of virus from patient to others unavailability of ambulance, PPE, masks, beds Key Controls Measure of Success Checking availability of bed beforehand, informing Number of successfully quarantined positive patients reports digitally before visit, precautionary patients, minimum number of postive cases in measures by process unit owners, planning of patients acqaintance, number of ambulances ambulances route the previous day, visiting availability, avaialbility of beds at facility patients during home quarantine

Table E3 Process profile worksheet -Treatment

B4.3.2. Process: Treatment Once a positive case was reported to the areawise assigned GNM, the treatment process initiatied. The digital reports were sent to patients and the GNM visited the patient to know about his/ her symptoms and get more information to decide whether to home quarantine the patient or shift to institutional quarantine. If symptoms of the patient were severe, he/she was transferred to Isolation centre by VVMC staff. In case of home quarantine the patient was supposed to buy necessary equipments and send daily reports of his health condition to the GNM. Incase of institutional quarantine, institutional isolation the patient was trasferred to the centre where his/ her details were collected and a bed was allocated to him/ her. Inferences: In the treatment process, observed risks were that patients could hide their symptoms during home quarantine. This can be controlled by visiting patients in specific time intervals. Other risks were unavailability of ambulance, PPE, masks,beds. This can be controlled by having an integrated data centre which mentoned the availability and need of various equipments, beds, PPE’s etc.

Table E3 Process profile worksheet -Treatment Source: https://pngtree.com

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E4.3.3. Process: Monitoring & Surveillance

The monitoring & surveillance process involved sanitization, containing neighbourhood and controlling movement of people in it. The process unit owners involved were police department, VVMC staff and areqise assigned GNM. Once a neighburhood was detected with more than 25 cases it was declared as a containment zone . Further the police department barricaded the entry and exit points of the neighbourhood and controlled movement of people in and out of the neighbourhood. Once declared a containment zone, the GNM assigned to the area conducted regular house to house survey in the locality with a register. The objective of the survey was to identify the high risk individuals and keep a check on symptomatic patients. Incase symptoms were informed the individual was suggested getting diagnosed at a fever clinic. The society of the positive patient was sanitized and bamboo poles were put up at the entry point of the building to mark it as a COVID spot. These poles were removed after a period of 14 days by the VVMC staff. Inferences: The risks identified in Monitoring and surveillance process was of missing out symptomatic patients during house to house survey. The symptomatic patients were identified based on the information provided by patients. Incase an individual hides the symptoms he/ she wont be identified in the current process. This can be controlled by checking temperature and pulseoximeter levels during survey. There was also a possibility of the virus spreading outside the containment zone due to in and out movement for essentials by the contained citizens. This can be controlled by making the contained neighbourhood self sufficient by providing facility for essential items in it or by having larger containment zones where all essential items would be available in it. 92

Process Name – Number Monitoring & Surveillance

Process Owner VVMC Description Isolating, sanitizing the neighbourhood and controlling movement of people in it Triggers Event beginning More than 25 cases recorded in neighbourhood Event ending Neighbourhood delisted from containement zone list Additional events Neighbourhood delisted from containment zone, barricaded entry & exit points, controlled movement of contained members, survey conducted, society and house sanitized, mark building as COVID spot, barricades Inputs – Items and Sources Barricades - Police department; Containment zone list, survey register, PPE, mask, testing kit, sanitizing equipments, bamboo poles - VVMC Outputs – Items and Customers Reduced number of cases - contained area Process Units Process Unit Owners Barricading & controlling movement of people in Police department containement zone, removing of barricades Updating containment zone list, marking COVID VVMC staff spot Conducting survey GNM Service Objective(s) Service Risks Spread of virus outside the contained neighbourhood, missing out symptomatic Containing the virus in neighbourhood patients, inefficiency in controlling movement, delay inidentifying symptomatic individual

Key Controls

Measure of Success

Self sufficiency of neighbourhood, police official Reduced number of new cases in at strategic points to prevent movement, neighbourhood, low movement of people in precautionary measures by staff, tracking surveyed neighbourhood house numbers

Table E4 Process profile worksheet - Monitoring & surveillance

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E4.4. RACI Diagram Process Name Identification Treatment Monitoring & surveillance

VVMC staff R R

JJ Volunteer Fever clinic laboratory GP nurse R R A I

GNM/ Nodal Officer A A

R R

Patient Police R R

Further an analysis was also performed to understand 0.6 best perceived and poorly perceived services of the the Municipal Corporation for managing COVID. The results are mentioned in figure E6 and figure E7. 0.5

Protective measures by staff

0.4

Well trained staff

Table E5 RACI diagram

Inferences: The fever clinic nurse is accountable for coordinating with different responsible stakeholders for the identification process while the accountbaility for quarantining and monitoring & surveillance is on the areawise assigned GNM. E4.5. Serv Qual: RATER Analysis

E4.5.1. Overall rating of service

A Survey was conducted to understand peoples perception and expectation of the service provided by the City Municipal Corporation. The service was rated based on various parameters like Reliability, Assurance, Tangibles, Empathy and Responsiveness. The rating was based on the gap between peoples expectation and perception of the service.

Inference: The perception of the service among citizens was lower than expectations for all the 5 parameters. The service in terms of tangibles and Empathy was rated -1.36 which is the lowest rated parameter. Reliability is the third lowest parameter with -1.3 rating followed by responsiveness and assurance.

Responsive to patients needs

0.3 0.2 0.1

Adequate number of beds

On demand sanitization

Figure E6 Top perceived services Source: Primary

0 -0.5 -1 -1.5

Fever clinic proximity

-2

Assurance

-2.5 -3

Responsive ness

Figure E4 Survey participants details

The participants in the survey were mainly citizens who had got themselves tested and also who had been quarantined in a quarantine centre. The results of the survey are mentioned below.

Reliability

Tangibles Empathy

Figure E5 Services rating for various parameters Source: Primary

-3.5 -4

Sanitization efficiency

Teleconsultation

Helpline staff competency

Cleanliness of fever clinic

-4.5 Figure E7 Poorly perceived services Source: Primary

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Current Process Potential Failure Potential effects of SEV Potential cause(s) of failure OCC Mode failure R Controls Missing out Sanitization Possibility of spread of Unplanned sanitization process Well planned important 5 8 of area virus with no SOP sanitization sanitization points Long travel distance to testing 9 laboratory (unavailability of lab 10 Informing 32 hours delay in in local area) Possibility of spread of reports to informing positive virus to acquaintance patient case to patient Reports informed manually/ no 7 10 use of digital medium Function

Cleaning of fever clinic

Irregular cleaning of fever clinic Poor cleaning of fever clinic

Missing out House to symptomatic house survey patient

Identification of symptomatic patient

Delay in identifying symptomatic patient

Unclean and unsanitized clinic

Symptomatic positive patients left undetected leading to spread of virus

Possibility of spread of virus

E4.6. Failure Mode & Effects Analysis

An FMEA chart was created to identify risk levels for each of the service risks identified using analysis tools and the causes of poorly perceived services. For wach of the failure its severity, occurence and detection based on current control measure was identified. The product of the three helped to

360 SOP for sanitization

Setting up a laboratory in local area Use of digital mediums to inform reports Attendance and confirmation of performance of task by nurse Setting up a standard for cleanliness and confirming daily

Verbal confirmation of action completed

No performance standards for staff

Visual assessment

Verbal survey questions

Keeping record of 48 houses visited and details

No record keeping of houses 4 visited

Late visit to fever clinic by 7 patient

Provision of fever clinic and private clinic for diagnosis

identify the scale of effect of each of the failure on the overall service which was mentioned as Risk Priority Number (RPN). The risk priority number helps in prioritizing the actions for each service failure based on its effect.

Inference: Out of the failures studied using FMEA tool, the highest priority needs to be given to efficiency of sanitization and delay caused in

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Reco. Actions

No check on performance of task by staff

Table E6 FMEA table to identify failures with maximum Risk Priority Number

DET RPN

Provision of a teleconsultation service 448 Increasing the number of fever clinics

identification of symptomatic patients. Other issues like delay informing positive patients, cleanliness of fever clinic and missing out of symptomatic patients during house to house survey also have an RPN between 50 to 100. For all the issues mentioned an action is recommended in the last coloumn. These recommended actions have a positive effect on one of the parameters contributing to RPN, thus

Figure E8 RPN of failures and risks Source: Primary

reducing the overall RPN. The impact on the overall RPN is measured and compared with the original RPN to determine effectiveness of the recommended action. Further the overall Cap Ex, Op Ex, human resource requirement, time and land requirement can be considered to take the action on a larger scale for the whole service. The impact of the recommended actions is shown in figure E9.

E5. Service Concept

The identified service concept for the service is mentuioned in table E8. The concept of the service is to identify, isolate, treat and reduce the spread f COVID virus in the city while its organizing idea is aiming to create a lifestyle that is safe and free of COVID.

E6. Service Audit Profile

Service audit profile rates the service based on 5 parameters and its sub categories. It also rates

the impact of the recommendations on the service being studied. The service audit profile for the service is mentioned in figure E9 Inference: The ratings received on the Serv Qual were plotted on the service audit profile to understand each parameter anf its efficiency. Further based on the study and issues mentioned recomendations are mentioned on the right side of the service audit profile. The dotted line on plot area shows the improvement in the overall rating

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Function

Reco. Actions

Sevr

Sanitization of area SOP for sanitization Informing reports to Setting up a laboratory in local area patient Use of digital mediums to inform reports Attendance and confirmation of performance of task by nurse Cleaning of fever clinic Setting up a standard for cleanliness and confirming daily Keeping record of houses visited and House to house survey details Identification of Provision of a teleconsultation service symptomatic patient Increasing the number of fever clinics

Occ

Det

RPN

4 2 5

3 1 1

1 1 1

12 2 5

4 4 8

2 1 2

1 1 4

8 4 64

Organization Organizing Idea Service Concept

Service Provided

Table E7 FMEA: RPN of recommended actions

500 450 400 350 300 250 200 150 100 50 0

Impact of recommended actions on the total RPN

Before

Service received

Setting up lab in city

Digital reporting

Regular Performance performance standards check

SOP for sanitization

Figure E8 Impact of recommended action on RPN of failures Source: Primary

After

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Record of houses

Teleconsultation Number of fever clinics

Vasai Virar Municipal Corporation A lifestyle that is safe and free of COVID A service aiming for a lifestyle free of COVID by identifying, isolating, treating and reducing the spread of COVID and its impact on the city. Health guidelines Preventive measures Medications Restrictions on movement COVID tests Treatment facility Ambulance service Important contacts Trained staff Quarantine facility Safe public transport facility Containment zones COVID tracking dashboard Helpline number Sanitization Food for needy Containment of COVID Awareness Guidance to fight COVID Safe and clean environment Treatment to COVID Information regarding COVID

Table E8 Identified service concept

unsymptommatic patients.In terms of processes there are risks identified that would hinder the goal of the service to efficiently reduce the number of new cases and deaths. The risks identified were delay in identifying symptomatic patients, delay in informing reports to patients, delay due to unavailability of ambulance and beds. No contact tracing was conducted by the Municipal Corporation and also rapid antigen testing kits were unavailable thus reducing the capacity of testing unsymptommatic patients.

Table E5 RACI diagram

Figure E9 Service Audit Profile

after the recommneded actions are implemented.

E7. Conclusion

In terms of processes there are risks identified that would hinder the goal of the service to efficiently reduce the number of new cases and deaths. The

risks identified were delay in identifying symptomatic patients, delay in informing reports to patients, delay due to unavailability of ambulance and beds. No contact tracing was conducted by the Municipal Corporation and also rapid antigen testing kits were unavailable thus reducing the capacity of testing CEPT University Service Operations and Management Studio 2020 97

NAVI MUMBAI

Service Operations and Management Studio 2020 CEPT University

Aakanksha Gupte PG190001

B1. About the City

The growth of Mumbai city is constrained by sea towards the south, east and west. As a result, the total land area available for the development of Mumbai is limited. Hence, developmental planners in the late 1960s started exploiting an alternative for dispersal and control of Mumbai’s population. By 1972 the satellite city, Navi Mumbai was developed. (Mumbai: Tourist Attractions: Navi Mumbai) Navi Mumbai formerly known as New Bombay is a twin city of Mumbai, situated between Thane Creek, Sahyadri Mountains and sea coast, which was designed to decongest Mumbai. Eminent architects like Mr. Charles Correa, Mr. Shirish Patel and Mr. Pravin Mehta suggested Navi Mumbai as

an alternative to Mumbai. The city was on 17 March 1971, the foundation of the ‘City and Industrial Development Corporation (CIDCO)’ took place which was initiated as per the ‘Companies Act’ of 1956.

F1.1. Location

Navi Mumbai is a part of the Mumbai Metropolitan Region. Located in the east of Mumbai, the satellite city is a part of two major districts, namely Thane district and Raigad District as shown in figure F3. The city parallelly has two Municipal Corporations namely, Navi Mumbai Municipal Corporation and Panvel Municipal corporation. The Navi Mumbai Municipal Corporation lies in Thane district whereas Panvel Municipal Corporation lies in Raigad. Other adjacent corporations to the NMMC shown in Figure F1 namely, Ulhasnagar Mahanagar Palika, Bhivandi Municipal Corporation, Thane Municipal Corporation and Bhrihan Mumbai Corporation. (Navi Mumbai Municipal Corporation, n.d.).This report looks at working of NMMC in manageing the pandemic.

Figure F2 Zones and wards in NMMC Source: https://www.nmmc.gov.in/navimumbai/history1540201195 retrieved, census 2011

F1.2. Demographics The NMMC is divided into 2 Zones, 8 administrative wards and 111 elective wards as shown in Figure F2. The population under the corporation is 11,20,547 as per the 2011 census. The male population in the city is 6,10,060 whereas the female population is 5,10,487. 8 lakh population is the migrant population settled in Navi Mumbai according to the report by CIDCO in 2017.

Figure F1 Map of MMR with districts and Municipal Corporations Source:https://www.quora.com/Does-Vasai-Virar-Thane-City-Mira-RoadBhayandar-Kalyan-Dombivali-Navi-Mumbai-etc-fall-under-MumbaiMetropolitan-Region-MMR

F1.3. Administration Figure F3 shows the organizational structure of the NMMC. Where an Additional Deputy Commissioner was added to tackle the situation. Currently, Mr. Abhijit Bhangar is the Commissioner of the City.

Figure F3 Zones and wards in NMMC Source: https://www.nmmc.gov.in/navimumbai/history1540201195 retrieved, census 2011

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The Deputy Commissioner is helped by an Assistant Medical Officer of Health. The Medical Officer of Health has a ward wise distributed Medical Officers who look after the affairs of the ward. The Medical officer is helped by 10 nurses, 2 Ward boys, 200 ASHA workers and 2 Data Operators. The teachers working in government schools also help. They are responsible for contact tracing. Further, 7 policemen are helping the MO. There are 18 departments in the NMMC which help in the efficient working of the Corporation.

the NMMC website which has updates of all, the vacancies, availability of oxygen and ventilators at the centers. To tackle the situation the NMMC came up with various strategies like for the workers or the citizen who didn’t have access to food, 18 Nivara Kendra were opened wherein people were given food. It was made sure that at least two Nivara Kendra are present in each ward. There were also

F2. Current COVID19 Scenario in the City

The first case that came in Navi Mumbai was on 19th March 2020. Looking at the COVID cases in the NMMC area, there is a total of 44,521 cases out of which 41,803 people have recovered whereas 901 are deceased. Active cases are 1,817 as of 30th October 2020. The government is conducting rapid antigen tests in huge numbers to track asymptomatic patients and treat them as soon as possible. Till 30th Oct, NMMC has conducted 1,81,368 Rapid Antigen tests and 1,00,499 RTPCR (Navi Mumbai Municipal Corporation, n.d.) As seen in the figure F4, Nerul has highest number of cases, 7,972 with 92.5% recovery rate. Ghansoli is most affected ward with 5,262 total cases, with respect to population (9.40% affected population) COVID Infrastructure The NMMC has made provision of three types of facilities to cater to the disease in its different stages. Namely, COVID Care Centers(CCC) that cater to patients with Mild symptoms. The Dedicated COVID-19 Hospitals(DCH) are responsible to take care of the severely affected patients and the Dedicated COVID-19 health Centres(DCHC) are responsible for to care of moderately affected patients. There is a COVID care dashboard on

Figure F4 COVID cases in various wards Source: https://navimumbai.city/containment-zones-navi-mumbai retrieved

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15 Community kitchens set up to help people get food easily. During the phase when migrant workers were to be sent home, 1605 workers were sent to the home town Reva. Meanwhile, Anna Saheb Missal who was the running commissioner ended his tenure and was replaced by Mr. Abhijit Bhanger. After taking over Mr. Bhangar, launched a mission named “Mission Break the Corona Chain”. The

F3.2 Treatment In treatment process -Home Quarantine, Institutional Quarantine and Hospitalization. Following are the startegies adopted by NMMC for effective implementation of treatment. COVID WAR ROOM (30th JUNE 2020) Tracing the case and allocate quarantine centre or hospital according to the symptoms 80% beds in a hospital to be regulated by NMMC

Figure F5 COVID Timeline Source: https://navimumbai.city/containment-zones-navi-mumbai retrieved, Primary

mission consists of screening high-risk contacts in the 42 high-risk areas. Further, working on a similar line, Mr. Bhangar, launched a helpline number to make the services accessible for the people. Likewise, he also launched mobile testing vans, responsible for conducting rapid antigen tests in large numbers. (NAVI MUMBAI MUNICIPAL CORPORATION, n.d.)

F3. Overview Of the COVID19 Management in the City

The C orporation is trying to do its best to contain the spread of the disease. To do that there are various stakeholders performing their jobs diligently. The NMMC is following the policy of 3T’s namely, Test, Treat and Track. The main reason for the spread of the Virus is coming in contact with another corona positive person. The worry starts after the patient starts showing prominent COVID like symptoms, the person is advised to call the COVID call center where the ward counsellor helps the patient with the nearest fever clinic and another necessary query is answered. The doctor is responsible to diagnose the symptoms, check if they are COVID-like or it is ILS (Influenza-

REAL TIME BED OCCUPANCY DASHBOARD (link on NMMC website) like sickness). If the fever prevails for less than 72 hrs or the doctor gives medicine for Viral/ Influenza.

F3.1 Identification In identification the processes included are testing, contact tracing and consultation. For identification of the COVID patients, NMMC is adopting following strategies Tests Conducted • Rapid Antigen • RT-PCR

• True NAAT • CT - SCAN

27 - Urban Public Health Centres converted into fever clinics MISSION BREAK CORONA CHAIN (22nd July 2020) – conducting rapid testing in 42 containment zones. MOBILE TESTING – dedicated testing vans to ensure early tracing of the COVID patients to target earlier treatment.

HELPLINE NUMBER – 8 helpline numbers published on NMMC website

NODAL OFFICER APPOINTED - to ensure the norms are followed in the hospital. COVID19 BILL Complaint Centre – to complain if the patient is overcharged.

F3.3 Monitoring and Survilliance In monitoring and survilliance, contact tracing and sanitization of the area fall in this category, strategies adopted for the implementation are NUISANCE DETECTION SQUAD A Squad consisting of 100 ex-army personnel to check spitting and other COVID preventive norms.

WHATSAPP GROUP The patient is added to a WhatsApp group in case of home quarantine. The patient is hence supposed to post pictures of the said parameters. LAST RITES Last rites are conducted for all religions where max 5 family members are allowed.

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F4. COVID19 Management Process Analysis F4.1. SWIMLANE Diagram

The diagram shows flow of activities taking place, by various stake holders to provide the service. The diagram here shows the process from the start, when the patient is affected by the virus and is showing the symtopms. After that, the role of the Navi Mumbai Municipal Corporation is described in the whole process.

Patient

Patient showing COVID like symptoms

Contact family consultant Calling the helpline no.

Ward Councellor

suggest near by fever clinic

Doctor

No No Covid like

Yes

Medicine for viral

Conduct appropriate test (CT- SCAN/RT PCR)

Pathologist

Check CoMorbid Conditions

Result

Send one copy to doctor and other to NMMC head quarter (Asst MOH)

Make a list of daily positive cases

Assist MOH

Send the list to the ward MO

MO Teacher Ward Boys Police Timeline

5 - 14 days

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10 min

24 hrs

10 mins

Half Day

Inferences: 1. Delay in teachers contacting the patient 2. Delay in MO contacting the patient 3. Delay in sanitisation process.

Mild Condition Moderate Severe

Equire about living conditions

Forward list to the teachers

Make list of high risk contacts

Home Quarantine/ COVID care centre admitted to DCHC

Inform MO

admitted to DHC

Forward the list to the ward boys to conduct test of high risk contacts

WhatApp Valid prescription Get the building Sanitized

Conduct basic enquiries by calling patients

Regular follow up for 10 – 14 days

Inform police

-ve

Conduct Rapid Antigen test

Result +ve

Check co-morbid conditions and oxygen saturation

Inform MO seal the building and mark containment zone

10 min

24 hrs

30 mins

10 mins

Update on social media

15 - 20 mins

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F4.2 Process Identification

Inferences: From the above Swimlane Diagram, the following are the processes identified, namely Identification that includes Symptoms, Diagnosing and Testing. The next stage is the treatment which includes quarantining the patient which might be Home, Institutional, or Hospitalisation. And the last process identified is Monitoring and Surveillance. This includes Contact Tracing and Sanitisation.

Key Process Area: COVID19 management services Trigger Event Symptoms identified for COVID Stage of COVID is Identified

The patient is quarantined/admitted in the hospital

Process Owner Navi Mumbai Municipal Corporation Description The process of identifying the possible corona patients Triggers Patient coming in contact with COVID positive person Event beginning Receive test result Event ending Calling emergency call centre, Wearing mask ,Going to Additional events

doctor, sanitising hands, checking temperature, waiting in que, doctor diagnosing the patient, doctor writing suitable tests, patient going to test centre/hospital to get tested, lab/hospital conducting tests, printing reports

Process Name Identification Treatment Monitoring and Survilliance

Table F1 Process Identification Worksheet

F4.3. Process Profile Worksheets F4.3.1. Process Identification

Process Name – Number Identification

Inferences: From the Process Profile worksheet of Identification, the key inputs observed are COVID like symptoms, emergency call center, a ward councilor, doctor, thermometer, PPE kit, Masks, multiple testing kits, fever clinics, testing center, CT Scan and test result is the output. The process unit include transfer of virus, COVID like symptoms, calling at an emergency call center, suggest a fever clinic, going to fever clinic, conducting tests etc. Hence, the patient himself, the pathologist, ward counselor are the important stakeholders of the process. From the worksheet, identifies long waiting for the call and lack of manpower are the two major service risks observed. Hence, the control units are increasing in the number of telephones and recruiting more people.

Inputs – Items and Sources

COVID like symptoms, emergency call centre, a ward councillor, doctor, thermometer, PPE kit, Masks, multiple testing kits, fever clinics, testing centre, CT Scan. Test Result

Outputs – Items and Customers

Process Units

Process Unit Owners

Service Objective(s)

Service Risks

Transfer of Virus, COVID like symptoms, Calling at Another COVID positive patient, Patient himself, Patient emergency call centre, Listen to concerns and suggest a himself, Ward councillor, Patient himself, Pathologist, fever clinic, Going to fever clinic. Conducting test Pathologist, Doctor Emailing one report to NMMC head quarter and one to the doctor, Diagnosing patient

To identify if the patient is infected by the Virus

Key Controls

Increase in number of Rapid Testing, Increasing number of telephone lines, Trained/Certified Doctors, Trained staff, Trained staff, Tracking tested and distributing customers equally, Proactive staff, Frequent Recruitment/staff rotation, Frequent testing of staff Table F2 Process Profile Worksheet for identification process

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Patient not showing symptoms (asymptotic), Long waiting for call, Doctor not available, Faulty report, Over queuing of samples, Exchange of samples, Samples of potential patients not taken, Lack of manpower, Infected staff

Measure of Success

Getting tested within 4 days after showing symptoms

F4.3.2. Process Profile Worksheet - Treatment

Process Name – Number Treatment

Process Owner Navi Mumbai Municipal Corporation Description The process of treating the possible corona patients Triggers Knowing the stage of disease (patients with mild Event beginning

symptoms and adequate space at home have choice to home quarantine) Patient quarantined/ admitted in the favoured facility.

Event ending Additional events

Inform MO, arrival of ambulance, asking affordability of the patient, enquiring about the availability of Mediclaim, helping the person inside the ambulance, checking necessary parameters, dropping the patient in the said facility, Disinfecting the ambulance.

Inputs – Items and Sources

Ambulance, necessary equipment in the ambulance, quarantine centre, adequate number of beds and ventilators, Disinfectant in the ambulance (NMMC) Patient getting required treatment

Outputs – Items and Customers

Process Units

Process Unit Owners

Service Objective(s)

Service Risks

Knowing the stage of the disease, Informing Medical Officer, Sending the prescription in case of home quarantine, Sending the ambulance, enquiring for affordability/preference of quarantine centre, dropping the patient in the said facility, Disinfecting the ambulance, Providing food Maintaining Hygiene, Update data regarding availability of bed, ventilator.

To quarantine/admit the person as soon as possible

Key Controls

Shortening the calling process, Tie ups with NGOs, Additional Housekeeping staff for 24 hrs, Procure more ventilators, Protocol in place for ambulance attendant Keeping up with forecast of possible requirement and making management plan accordingly, Planned alternative for such situation.

Doctor, Patient, Medical Officer, Ambulance attendant, Hospital Staff

Delay in sending the prescription in home quarantine, Poor quality food given, Hygiene not maintained in the Quarantine centre/ Hospital, Lack of beds with ventilators, Ambulance not disinfected after last use, Unavailability of ambulance at the said time, Unavailability of bed in the centre at the said time

Measure of Success

Patient happy with the Quarantine service

Inferences: The process of treatment includes, Quarantine and treatment of the patient. If the patient has mild symptoms, the patient is home quarantined and the prescription is sent to them as soon as the medical officer gets the positive tested result. The medical officer is responsible for following up with the patient for the 14 days quarantine period. If not home quarantined, the patient can be institutional quarantined if the conditions like room size or availability of toilets at home are not fulfilled. Also, if the patient has moderate or severe symptoms they are admitted to the respective hospital. From the process profile worksheet, it is observed that the key processes are, knowing the stage of the infection, informing Medical Officer, sending the prescription in case of home quarantine, regular follow up for 10 – 14 days, sending the ambulance enquiring for affordability/preference of quarantine center, checking necessary parameters, dropping the patient in the said facility, disinfecting the ambulance, admitting the patient in the hospital / quarantine facility, providing food and maintaining hygiene, update data regarding availability of a bed, ventilator, oxygen, etc and the stakeholders being Doctor, Patient, Medical Officer, ambulance attendant, Hospital Staff. Hence, the service risks observed in this case are delay in sending the prescription in case of home quarantine, poor quality food given, hygiene not maintained in the quarantine center/ hospital, lack of beds with ventilators which can be tackled by shortening the calling process, tie-ups with NGOs, additional housekeeping staff for 24 hrs, procure more ventilators. Hence, the measure of success in this would be the patient happy with the quarantine service with the objective of quarantine/admit the person as soon as possible.

Table F3 Process Profile Worksheet for Treatment process

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F4.3.3. Process Profile Worksheet - Monitoring and Survilliance Inferences: The process of monitoring and surveillance includes monitoring implementation of said strategies, contact tracing (identification of high-risk contacts), and sanitization of building/ area. After the patient is tested positive in the building, the sanitization team is sent to the building consisting of ward boys and teachers asking about the basic information i.e. prevalence of co-morbid symptoms. If the symptoms prevail then a Rapid Antigen test is done and RT - PCR confirmatory test is suggested. In the worksheet, there is a risk observed as there is always a delay in the sanitization team to reach the residence, after being tested. It is observed that this is the case due to a lack of manpower to execute this task. As shown in the Process Profile Worksheet the process units are inform police about the detected case in the building, sanitised and sealed building/residence of the patient, update the records on the website, mark the area as a containment zone, make a list of highrisk contact, conduct rapid antigen test notify the traced people to get tested, perform a test where Medical Officer, Data Operator, Police Officer, Ward Boys, Pathologist are responsible. Priority service risks observed to be are delay in sanitisation of the building, unavailability of police, police not informed in time where the key controls could be appointing a dedicated sanitization team, asking the building/ residence owners to self sanitize the building wearing proper safety gears helping them with necessary instructions, ensure police staff rotation, NMMC officials crosschecking the people tested, regular check-ups of police officials maintaining proper staff circulation. The data is updated on the dashboard by the NMMC control room. The police have their Twitter page where they update daily numbers.

Process Name – Number Monitoring and Survilliance

Process Owner Navi Mumbai Municipal Corporation Description The process of Monitoring and Survilliance to prevent the spread of virus. Triggers Patient admitted to the Quarantine centre Event beginning People tested who all came into contact with the Event ending patient in last 14 days

Additional events

Inform police about the detected case in the building, update the records on the website, seal the building, mark the area as containment zone, forward the list of contacts to the Police, Trace listed people, Inform pathology of the traced details, notify the traced people to get tested, perform test, Inform the police and NMMC officials about the result.

Inputs – Items and Sources

Trained police, trained NMMC officials, protocols in places, SOP for various activities in place, data of citizens, notification infrastructure (message) Safe citizens

Outputs – Items and Customers

Process Units

Process Unit Owners

Service Objective(s)

Service Risks

Inform police about the detected case in the building, Medical Officer, Data Operator, Police Officer,Ward Sanitised and sealed building/residence of the patient, update Boys, Pathologist the records on the website, mark the area as containment zone, Make list of high risk contact, Conduct Rapid Antigen test notify the traced people to get tested, perform test

To prevent spread of Virus as much possible

Key Controls

Recruit more staff Ensure police staff rotation Ratio of NMMC officials to be maintained Updated city data NMMC officials crosschecking the people tested Regular check ups of police officials Maintaining proper staff circulation Table F4 Process Profile Worksheet for Monitoring and Survilliance process

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Delay in Sanitisation of the building, Unavailability of Police, Police not informed in time, All contacts in the list not traced, Notified people didn’t get themselves tested, Infected police officials, Ward boys unavailable

Measure of Success

Minimum Number of new cases from the area

F4.4. RACI Diagram Process Name

Patient

Identification Treatment Monitoring and Surveillance

R R,C C

Ward Councellor

Doctor

Hospital / Quarantine Centre

Pathologist

R R

A I R

Assit MoH

Medical Officer

I A A

Teacher

Ambulance staff

Police Official

I R

Ward boy

Table F5 RACI Chart

F4.5 ServQual Analysis An analysis was carried out to know about the expection and perception of the citizens. A sample size of 31 people taken from the NMMC area. Questions were framed on the basis of RATER i.e. Reliability, Assurance, Tangibility, Empathy and Responsiveness. The difference between Perception and expectation has helped in determining the issues and good points in the service. In the following graph it is seen that it takes more than 12 hrs for NMMC to contact the patient, once the patient is tested positive. Hence, it leads to delay in processes taking place. Also it may worsen the health situation of the patient.

Figure F6 Response time of NMMC after being tested positive Source: Primary

Figure F7 RATER analysis for Reliability Source: Primary

Reliability of the govt service, few questions on all the processes were framed and people were asked to rate the conditions on the basis their expectations and perceptions. The gap between P-E shows issues in the process. The difference between perception and expectation has helped in determining the issues and good points in the service. AREAS OF IMPROVEMENT• Prompt availability of bed • Availability of hygenic food • Availability of sanitization facility

Figure F8 RATER analysis for Assurance Source: Primary

Assurance The gap between P-E shows issues in the process. The difference between perception and expectation has helped in determining the issues and good points in the service. AREAS OF IMPROVEMENT• NMMC Officials not contacting the relatives of the positive tested patient GOOD POINTS • The government institutions are abiding by the approved rates. • The testing Labs are following the SOP by informing the NMMC officials about the positive tested patient.

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Empathy of the govt service are found on the basis of the gap between P-E shows issues in the process. The difference between perception and expectation has helped in determining the issues and good points in the service. AREAS OF IMPROVEMENT• Staff assuring comfort level at every point of the treatment procedure.

Figure F9 RATER for tangibility of the service Source: Primary

Tangibility of the govt service are found on the basis of the gap between P-E shows issues in the process. The difference between perception and expectation has helped in determining the issues and good points in the service. AREAS OF IMPROVEMENT• Hygiene maintained in the quarantine centers, hospitals and Ambulance. • Bigger room wrt to capacity of the patients. Detailed prescription in case of home quarantine is the service meeting the expectations.

Figure F10 RATER for Empathy of the service Source: Primary

Figure F12 Composite RATER ANALYSIS. Source: Primary

be considered to be worked on.

Figure F11 RATER for responsiveness of the service Source: Primary

Responsiveness of the govt service are found on the basis of the gap between P-E shows issues in the process. The difference between perception and expectation has helped in determining the issues and good points in the service. AREAS OF IMPROVEMENT• Time taken by sanitization team to reach the residence after being tested positive • Effective recommendations for the issues mentioned. GOOD POINTS • Time taken to receive prescription in case of home quarantine. From the above analysis and a composite RATER analysis we can see that assurance is the parameter performing well where as reliability is the factor to

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Figure F13 Vector image showing COVID treatment team Source: www.pngtree.com

F4.6 . FMEA Inferences: With the help of pointing system, the FMEA analysis was done on the issues listed dow in ServQual Analysis. The points were rated on the basis of severity, occurance and detectatbility on the scale of 1 - 10. The points having Risk Priority number more than 480 was marked as service risk.

Table F5 FMEA

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FUNCTION

TESTING

TREATMENT

POTENTIAL CAUSE OF FAILURE

POTENTIAL FAILURE MODE

NMMC takes >12hrs to contact the patient after being tested positive

Delay in sending test report from the lab Lack of manpower to make the number of calls treatment given more importance over provision of good food lack of manpower in the organization structure

Unhygenic food

Lack of budget Lack of manpower to maintain the quarantine centers

Unhygienic Quarantine centres Unavailability of Bed

Monitoring and survilliance

Beds fully occupied No beds kept as stand by for emergency situations Emotional concerns for relatives

Availability of sanitising facility whenever called for. Delay in sanitisation process

Lack of manpower Lack of manpower to cater to the demand

Differenc %age e Improved

RPN

441

405

91.8

504

480

95.2

448

430

89.5

378

354

93.6

120

60.0

576

552

95.8

336

300

89.2

448

424

94.6

252

228

90.4

343

307

89.5

504

468

92.8

Table F6 FMEA - Difference in new RPN

F4.6 . FMEA Inferences: Frome the FMEA, recommendations are given on the basis of the service risks found • Service Risk - Prompt availability of bed. Possible Recommendation - Keeping a spare beds in the hospital for thet extremely severe cases. • Service Risk - Availability of hygenic food Possible Recommendation - Giving contract to the NGOs. • Service Risk - Unhygenic Quarantine facility Possible Recommendation - This risk is arising due to lack of manpower. Hence, if the workers are motivated to work by giving them a increment in the salary, mediclaim policy and a bed booking in the quarantine center.

• Service Risk - Availability of sanitization facility whenever called for. • Possible Recommendation - This risk is arising due to lack of manpower in NMMC. Hence, dedicated sanitization team or integrating other department in order to fullfill the need would help cater to the situation better. Further, on the basis of the recommendations, new RPN was found. The new RPN tells the level of improvement that is possible after the new recommendations are inculcated. Further, the difference between original RPN nad new RPN was found. And the percentage of improvement was noted. On the basis of the percentage, points are marked on the Service Audit Profile.

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F5. Service Concept

Service Concept: INCREASE IN EFFICIENCY AND FOCUS ON PUBLIC HEALTH Organising Idea: A service aiming to increase the efficiency of the health department and focusing on the PUBLIC HEALTH for tackling the COVID by identification of the disease, consulting, isolating, treating and preventing the spread as much possible. Service Provided: Awareness, screening, health guidelines and SOPs medications, quarantine facility, mobile testing facility, helpline facility, help line number, ambulance service, trained and qualified staff, containment zones, sanitization, food in quarantine centers, listing down of NGO’s for providing food to the poor, COVID mitigation plan Service Reveived: Awareness, guidance and ways to tackle COVID, medications, isolation COVID testing, testing facility at the door step, solution of the queries, containment, transportation to the hospital with care, trained assistance, Food facility during isolation

F6. Service Audit Profile

The figure F14 shows the service audit profile of the COVID management service provided by NMMC. The firm line on the left shows the existing situation of the service on the basis of the perception of the people taken in the ServQual analysis above. The average P-E of the responses show the position on the profile where they are percieved. The dashed line on the profile, shows the level of improvement possible after the recommendations are implemented. Inference: The servise risk can be mitigated to approx. 90% if the recommendations are taken into consideration.

Figure F14 Service Audit Profile Source: Primary

F7. Conclusion

From the study of the city and the analysis done using various tools. It is observed that NMMC need improvement in following aspects : Identification : It takes more than 12 hours by NMMC to get in touch with the patient after being tested as positive Treatment: Hygiene in quarantine centres,

ambulance and food. Monitoring and Survilliance: Time taken by sanitization team to reach the residence after a positive case. According the recommendations it is likely to improve the Service Quality in Managing the Pandemic Figure F15 Vector image showing health sector fighting COVID19 Source: www.pngtree

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Snigdha Kanta PG190961

G1. About the City

Gulbarga, formally known as Kalaburagi is a city in India, located in the Northern part of Karnataka. It is the administrative headquarters of Gulbarga district and the largest city in the Hyderabad-Karnataka region of North Karnataka. Gulbarga city is situated at 623km North of the Karnataka state capital Bangalore and 220 Km from the Telangana state capital Hyderabad. Gulbarga city has a population of 5,43,147 (2011), with the total households of 1,02,830 in 55 wards having an area of 192 sq.km and with a population density of 9,875/sq.km. The city is governed by Municipal Corporation and is located in the Gulbarga urban region, which also houses the circuit bench of High court of Karnataka. G1.1 Administration of Gulbarga city Description City Government Urban agglomeration State

Particulars Gulbarga Municipal Corporation Gulbarga Metropolitan Karnataka

Figure G1 Location of Gulbarga city in Karnataka state Source: Kalaburagi district website - Kalaburagi.nic.in

Region Chief Minister City Commissioner City Mayor

Hyderabad Karnataka B.S. Yediyurappa Rahul T. Pandve Mallama SiddWalkeri

Table G1 Showing the administration of Gulbarga city Source: Government of Karnataka website- Kalaburagi (https://kalaburagi.nic.in/ en/)

G1.3 City Organisation - Departments

There are six departments in the city municipal corporation and they are: 1. Revenue department 2. Electrical department 3. Environmental department 4. Technical department 5. Health department 6. Town planning department

G2. Current COVID19 Scenario in the City

The first death of COVID-19 in India was seen on 12th March in Gulbarga. As of October 31st, 2020, there were 19,695 confirmed cases in Gulbarga district, of which 18,887 are recovered, 496 are active and 312 are deceased. Whereas, in Gulbarga city, there were 9,968 number of confirmed cases of which, 9,503 are recovered, 257 are active and 208 are deceased. This implies 49% of the total cases in the Gulbarga district are seen in the Gulbarga city with 85% recovery. The below dashboard shows the cumulative cases i.e. total confirmed vs recovered vs active vs deceased information of Gulbarga district as of 8th of September.

Presently, the health department formed a committee to control Corona virus, which includes: 1. Surveillance and contact tracing committee 2. Training and awareness generation committee 3. Material management committee 4. Infrastructure committee and 5. Media surveillance and monitoring committee

Figure G2 Dashboard of COVID-19 cases in Gulbarga city (as of 31st October) Source: Tableau Software

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Female Male Figure G3 Number of COVID cases with age and gender Source: Kalaburagi mahanagara palike http://www.kalaburagicity.mrc.gov.in/en/home)

G2.1 COVID-19 Health centres in Gulbarga city

There are in total 19 major COVID hospitals in Gulbarga city, of which two are government hospitals and rest 17 are private Hospitals and there are 18 Fever Clinics (UPHCs), which are set up by the Gulbarga Municipal Corporation. (Annexure-1)

Figure G4 Map showing the location of COVID hospitals in Gulbarga city Source: Google Maps

G2.2 Timeline of the measures taken by the Gulbarga Municipal Corporation

There are various measures taken by the Gulbarga Municipal corporation to combat the pandemic in the city since the first case in the state on 9th of March 2020.

Month of March – On 9th March, COVID-19 committees were formed by Gulbarga Municipal Corporation, to control the corona virus in Gulbarga district & the members are hereby directed to carry out their functions carefully and brief to the Deputy Commissioner daily. Covid-19 committee of Gulbarga includes: Surveillance and Contact Tracing Committee – The function of surveillance and contact tracing committee is to collect the data from the private hospitals, update the status of contact tracing, manage the sample collection, ensure home quarantine of the COVID patients/suspects. Human Resource Management Committee – The function of Human resource management committee is to take stock of health personnel

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and to deploy the health teams at the check post, isolation/quarantine, bus stand, airport and railway station. Training and Awareness Generation Committee – Training and awareness generation committee looks after the training of police personnel at check post and containment area and the Corporation staff about sanitation and hygienic practices. They also design the module to raise awareness about the prevention and COVID situation in the city. Material Management Committee – Material management committee takes everyday stock of availability and requirement of materials/drugs and the equipment. They also ensure the supply of materials on daily basis and take stringent action on hoarders. Infrastructure Committee (Isolation and quarantine wards) – The infrastructure committee looks after the overall functioning of isolation/ quarantine wards. They also ensure functionality of medical equipment and check if adequate treatment is given to the patients. They also report condition of patient to the control room. Media Surveillance and Monitoring Committee (IEC, BCC and Sanitation) – Media surveillance and monitoring committee conducts sanitation drive in the city, they also promote IEC through pamphlets, newspapers, radio, local cable channel and public announcements in railway stations and bus stands. They identify fake news and take strict action and brief daily updates to the Deputy Commissioner. On 13th March, government ordered to close all schools /colleges /theatres /malls and multiplexes in the city to contain the virus. On the 15th March government also implemented ban on the sale of liquor and ordered to close all bars and restaurants in the city. On 17th March government ordered to avoid the crowds at all the prayer places (Mosques, temples or churches). On 18th March, city started a helpline number for the COVID related queries. On

23rd March, government came up with the sale of masks and sanitizers at minimum rates to promote the health and hygiene in the city and 3 months free ration was given to the lower income groups as well as the migrants in the city. On 25th March, basic food supplies were being provided to each ward in the city by the Municipal Corporation.

Month of April – On 5th April, with the increase in the cases of COVID patients, 18 fever clinics were introduced to the city just for the COVID related consultation and medication. On 16th April, certain restrictions were implemented by the government during the month of Ramzan, to avoid mass prayers and gatherings. On 30th April, 48 hotels in the Gulbarga district were converted to quarantine facilities (COVID-care centres) by the government. Month of May – On 17th May, national sero surveillance was conducted for COVID-19 survey from ICMR (Indian Council of Medical Research). On 21st May, 15 containment zones were demarcated by the government in the city. On 24th May, a rule

was implemented to file FIR against those who violate the rules of home quarantine. On 30th May, rule of complete lockdown on every Sundays was implemented by the government to combat the unnecessary spread of virus. Month of June – On 16th June, Gulbarga government deployed Tele-ICU solution to deal with increase in COVID-19 cases. Month of July – On 6th July, SOPs were made regarding regular sanitization of the containment zones along with the restriction of marriage gatherings in the city. On 24th July, Gulbarga city adopted change in the testing strategies from RTPCR to Rapid antigen to cope with the heightened pressure to ramp up testing as the city experienced a sharp rise in COVID-19 infection. On 27th July, partial lockdown was implemented in the city.

Total number of hospital beds in the city for COVID treatment are 853, of which 219 beds are available in government hospitals and 222 beds are available in private hospitals and the rest beds are occupied.

Figure G5 Showing the timeline of the measures taken by the government of Gulbarga city Source: Kalaburagi COVID website - kalaburagi.nic.in/en/covid-19-orders-and-circulars/

G3. Overview Of the Management in the City

COVID19

There are 3 major processes which are followed by the government to manage the COVID-19 transmission in the city and they are:

G3.1 Identification and testing – COVID-19 suspects/ patients are identified by self-reporting. Suspects with symptoms are ordered for COVID-19 testing in labs. There are mainly two types of tests carried out in the city for identification of COVID patients and they are Rapid Antigen tests and RTPCR tests. The report of Rapid Antigen is given within half an hour, the result of which is verified with RT-PCR test if symptoms persist. The report of RT-PCR is given within 24 hours. G3.2 Quarantine and Treatment – COVID-19 positive patients/suspects with mild or no symptoms are ordered 14 days of home quarantine from the Municipal Corporation, wherein ASHA workers monitor the patients/suspects regularly until the patient is healthy and COVID-19 negative, Patients with moderate symptoms are ordered COVID-19 care centre isolation, wherein 14 days of monitoring is done by the isolation centres and the recovery report of the patients is sent to the control room and the patients with severe symptoms are hospitalized with 24*7 monitoring by the health care staff. G3.3 Monitoring and surveillance – Areas with maximum COVID-19 positive patients are contained with barricades to stop the vehicular movement and are regularly sanitised to contain the spread of virus. These containment areas are under 24*7 surveillance, the information of which is given to the control room. These 3 processes are explained in detail through various tools such as Swimlane, Process identification worksheet, Process profile worksheets, RACI and SIPOC.

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G4. COVID19 Management Process Analysis G4.1. SWIMLANE Diagram

Inferences: Swim Lane diagram is a process flowchart that is used to distinguish the duties and responsibilities, as well as sub-processes within these service processes in the management of COVID-19 in the city of Gulbarga.

Patient

Self reporting of COVID like symptoms

Negative

Inquiry about the nearest fever clinic

Control room

Healthcare staff/ physicians

Consultation/ Medication

Symptoms Prevail?

Negative

Lab Staff

Yes

Rapid antigen testing

Positive

Municipal Corporation Timeline

COVID negative

Contact Tracing

15mins

5mins

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30mins

4-5 days

30 mins

RT-PCR test

Positive

Survey of Low risk/ High risk contacts

24 hours

Symptoms

24 hours

In Gulbarga city, there are various stakeholders such as suspect/patient, Control room managers, physician/health care workers, Lab staff and Gulbarga Municipal Corporation. Swimlane clearly distinguishes the objective of each stakeholder responsible in carrying out the activities. The below Swimlane chart helps in visualizing the process of COVID-19 management from reporting of COVID to Containment strategies. In the vertical rows, the roles of various stakeholders in the COVID-19 management of Gulbarga city is distinguished and the activities they carry out is listed along with the timeframe. No symptoms or mild symptoms

Home Quarantine for 14 days

Yes

No Symptoms Prevail?

Yes

COVID negative Continue quarantine

Many positive cases in an area

COVID care isolation for 14 days Moderate symptoms

14 days

Recovery

24 hours

Hospital Isolation

14 days

Yes

Sanitize and barricade the area

Thermal screening and IEC at Ent and Exit points

24 hours

Symptoms

Allow emergency movements

14 days

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G4.2 Process Identification

Inferences: COVID management in the city can broadly be classified into 3 processes and they are Identification and Testing, Quarantine and Monitoring and Containment and Surveillance, depending on the trigger events mentioned below.

Key Process Area: COVID19 management services Trigger Event A. Suspect is sick and self reports through helpline number and gets tested in labs A. Patients with mild symptoms or no symptoms of COVID are ordered home quarantine B. Positive patients with moderate symptoms and patients with severe symptoms are ordered COVID care isolation/ Hospital isolation Containing the area of positive patients with barricade and surveillance

Process Name Identification and Testing Quarantine and Treatment

Containment and Surveillance

Table G2 Showing the processes of COVID management in Gulbarga city

G4.3. Process Profile Worksheets G4.3.1. Identification and Testing

Inferences: This process focuses on self-reporting the symptoms and identifying the positive patients, wherein the service risks such as unawareness of helpline numbers, delay in consultation, faulty testing kits and wrong reports are seen, which can be avoided by certain key controls for the efficient functioning of process. Measure of success depends on the number of reports provided in promised time.

Process Name – Number Process Owner Identification and Testing (through Self-report) Suspect Description Self-report the symptoms through helpline number to trace out COVID-19 Triggers Event beginning Suspect gets sick Event ending Municipal Corporation receives the positive report of the patient from the laboratory Additional events Suspect inquiries about the symptoms, Consults the nearest fever clinic and gets prescription, Visits path lab for COVID test, Suspect tests positive Inputs – Items and Sources Symptoms – Suspect Outputs – Items and Customers Laboratory report – Municipal Corporation Process Units Process Unit Owners Inquiring about the symptoms and nearer fever Suspect clinics through helpline number Checking suspect at the fever clinic and providing Physician necessary medication and prescription for lab test Collection of samples and analyzing sample for Lab staff the report at the Path lab Collection of positive report Control room Service Objective(s) Service Risks Unawareness of helpline numbers Delay in the process of consultation To Self-report the symptoms through helpline number, to identify the COVID-19 results Faulty testing kits Wrong report Key Controls Measure of Success Advertising helpline numbers to spread awareness Number of calls responded to the helpline Allocation of slots for each patient / Intimation of number. time for each patient Number of reports provided within half an High quality testing kits hour of sample collection for rapid antigen test and within 24 hours for RT-PCR test. Cross check the report using RT-PCR method

Table G3 Showing the process profile worksheet of Self reporting and Identification

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G4.3.2 Quarantine and Treatment G4.3.2.1 Home Quarantine

Inferences: The process of home quarantine and treatment focuses on ordering home quarantine for 14 days for suspects with mild symptoms or COVID positive patient with no symptoms with regular

monitoring, wherein the service risks such as lack of regular monitoring and people not following the order can be seen, for which key controls are designed for safety of patients. Measure of success would depend on number of people quarantined and record of regular monitoring of quarantined patients.

Process Name – Number Home Quarantine and monitoring

Process Owner Municipal Corporation Description To order home quarantine for Covid-19 suspects Triggers Event beginning Patients with negative reports with mild symptoms Event ending Monitoring of the quarantined suspects Additional events Inform about the precautionary measures, Order Home quarantine for 14 days Inputs – Items and Sources Suspects with negative reports/ list of traced contacts – Municipal corporation Outputs – Items and Customers Record of monitoring – Symptomatic patients Process Units Process Unit Owners Providing the details of the report to the patient Municipal Corporation Inspecting the house of patient and add a home Municipal Corporation quarantine sticker at the entrance of the house Regularly monitor the patient to see the progress Municipal Corporation Service Objective(s) Service Risks People may not follow the order To order home quarantine for mild symptomatic patients and monitor symptoms for 14 days. Lack of regular monitoring

Key Controls

Measure of Success

Regular tracking of quarantined patients on Corona watch app and strict rules for those who Number of monitored track records of a patient break the order under home quarantine in 14 days Make a checklist and cross check the suspects who are not being monitored regularly Table G4 Showing the process profile worksheet of Home quarantine and Monitoring

Figure G6 Showing the images of Home Quarantine Sticker and form Source: Kalaburagi COVID website - kalaburagi.nic.in

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G4.3.3. Quarantine and Treatment - COVID care center and Hospital Isolation

Inferences: The process of COVID care/Hospital isolation and treatment focuses on isolating the moderate and severe symptomatic patient in COVID care centres and hospitals with regular monitoring, wherein the service risks such as lack of regular monitoring, wrong medicines and delay in isolation can be seen, for which key controls are designed, to avoid the further delay in the process and for the safety of patients. Measure of success in this process would depend on the record of the status of each patient under isolation for 14 days and number of treated COVID positive patients.

Figure G7 Isolation beds in COVID care centers and hospital in Gulbarga city Source: Newspaper article - thenewsminute.com

Process Name – Number COVID care center/Hospital isolation and treatment

Process Owner Municipal Corporation

Description To order isolation at COVID care centers/hospital for patients with moderate or severe symptoms Triggers Event beginning Positive report informed by municipal corporation to the patient Event ending Separation of patient from the crowd Additional events Provide precautionary meaures, sanitize the patient, fill the form for records, take the patient to the nearest COVID care center/hospital, regularly monitor the patient Inputs – Items and Sources Positive report – Municipal corporation Outputs – Items and Customers Recovery register – Symptomatic Patient Process Units Process Unit Owners Informing the patient about the rules of Municipal Corporation quarantine Take the patient to nearest COVID care center/ Municipal Corporation hospital for isolation Regular monitoring of the patient to see the Municipal Corporation progress in recovery Service Objective(s) Service Risks Order COVID care center/ hospital isolation to the Lack of Monitoring patients moderately/severely affected by Covid-19 Wrong medications to reduce the spread of virus Delay in Hospital isolation Key Controls Measure of Success Prepare a checklist for regular monitoring and Number of people isolated with respect to number record the symptoms of people affected Crosscheck the prescription Monitor the recovery status of patient every day to Number of people following the rules and regulations of isolation check if the symptoms prevail Table G5 Showing the process profile worksheet of COVID care isolation/ hospital isolation in Gulbarga

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G4.3.4. Containment and Surveillance

Inferences: The process of containment and surveillance focuses on containing the virus in a closed perimeter by sanitizing, barricading and controlling the movement of vehicles, wherein the service risks such as unidentified containment zones

and lack of sanitation and thermal screening are seen, for which key controls are designed to avoid the spread of virus. The Measure of success will depend on the number of healthy people and the 24/7 surveillance in an area to contain the spread of virus.

Process Name – Number Containment and Surveillance

Process Owner Municipal Corporation Description To contain the virus spread of COVID-19 positive suspects with barricades and police surveillance Triggers Event beginning Increase in the incidence of Covid-19 patients in an area Event ending Barricading the area with surveillance Additional events Identify the area, Sanitize the area, block the unnecessary movement with barricades, Carrying out thermal screening and IEC to trace the suspects. Inputs – Items and Sources Suspected cases of Covid-19 - Municipal Corporation Outputs – Items and Customers List of low risk and high risk contacts – Residents of the community Sanitizing the perimeter of the COVID-19 hit area Blocking the movement using barricades Carrying out thermal screening and IEC Make a list of low risk and high risk contacts Service Objective(s) To contain the spread of virus within a defined geographic area by early detection of cases to break the chain of community transmission. Key Controls Proper contact tracing to identify the containment zones Follow SOP for sanitization and surveillance

Table G6 Showing the Containment and Surveillance strategies in Gulbarga city

Municipal Corporation Municipal Corporation Municipal Corporation Municipal Corporation Service Risks Unidentified Containment zones Lack of sanitation and thermal screening Measure of Success No healthy person is affected by COVID. 24/7 surveillance. Figure G8 Showing images of Containment Strategies Source: Primary, Kalaburagi COVID website - kalaburagi.nic.in

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G4.7. RACI Diagram Process Name

Patient

Control room Healthcare team/Physician I C

Identification and Testing

Home quarantine and monitoring

COVID care isolation/Hospital isolation and monitoring Containment and Surveillance

Table G7 Showing the RACI chart

Inferences : The RACI diagram shows the various stakeholders who are responsible, accountable, Counsulted and informed in all the processes that

G4.8. SERVQUAL RATER Analysis

SERVQUAL is a multi-dimensional research instrument designed to capture responder’s expectation and perception of COVID management in the city along with the five dimensions that are believed to represent service quality, which are: 1. Reliability - Ability to perform the promised service dependably and accurately. 2. Assurance - Knowledge and courtesy of employees and their ability to convey trust and confidence 3. Tangibles - Appreance of physical facilities, equipment personnel and communication materials. 4. Empathy - It includes acknowledge the feelings of the citizens to enhance their experience. 5. Responsiveness - Willingness to help Citizens and provide prompt service.

Lab staff R

COVID committee I R

SERVQUAL Survey Details

A R

Male - 24 Survey Sample - 30 Female - 6 Type of Testing Labs

are followed for COVID management in the city. By the above RACI chart, it can be seen that most of the tasks is handled by the COVID committee of Municipal Corporation of Gulbarga. Based on the above five parameters a survey was conducted of 30 citizens, of which 6 were Female and 24 were Male, about the experience of the COVID management services of three processes i.e. Identification and testing, Treatment and Monitoring and Surveillance in the city. Their responses were analysed and scored based on their expectations and perceptions which were later represented graphically.

Age Group

In the survey conducted among 30 citizens, it was seen that, 5 citizens of age group below 30 years, 15 citizens of age group 30-50 years and 10 citizens of age group above 50 years were surveyed out of which, 21 of them prefered private labs and rest 9 of them prefered government labs.

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Figure G9 Showing the demographics of Survey Source: Primary Survey

G4.8.1. Testing

Inference

Parameter Reliability

Expectation The lab staff are available during operational hours

Assurance

The lab staff is reponsible and handles the samples carefully

Tangibles

The lab staff abide by laws and wear safety gears

Empathy

The lab staff are sensitive towards the safety of patients

Responsiveness

Lab staff respond quickly to patients Test reports are provided within the promised time

Score Perception Score 6.63 Were the lab staff 5.70 available to collect your sample 6.43 Were the lab staff 5.73 responsible enough to be gentle and careful about the sample collection 6.67 Did the lab staff wear 6.03 masks and gloves to maintain hygiene 6.36 Were lab staff sensitive 5.8 towards safety precautions 6.5 Was there a longer 4.93 waiting time in COVID testing labs 6.9 Did you receive the 5.1 COVID test reports in promised time

Table G8 Showing the SERVQUAL analysis of testing

Figure G10 Showing composite RATER analysis of testing Source: Primary

GAP (P-E) -0.9 -0.7

-0.73 -0.56 -1.57 -1.8

COVID-19 testing involves analyzing samples to access the current or past presence of SARS-CoV-2. The two main branches detect either the presence of the virus or of antibodies produced in response to the infection. Tests for viral presence are used to diagnose individual cases and to follow public health authorities to trace and contain outbreaks. There are two types of tests conducted in Gulbarga city and they are Rapid antigen and RT-PCR tests. If a symptomatic suspects tests negative in Rapid antigen, he is ordered for RT-PCR test for cross verification.

There were six questions asked to 30 respondents about the testing process in the city with respect to five paraneters and it was seen that Responsiveness was the lowest among all the parameters.

According to the survey conducted, it can be concluded that: • The good point which got the least GAP is that the lab staff are sensitive towards maintaining the safety precautions. • There is a scope of improvement in the responsiveness parameter wherein, most of the respondents faced problem with the delayed test reports.

The Rapid antigen test reports should be given within 30mins after the test, but most of the respondents got the report in 1-2 days and RTPCR test should be given within 24hours, which took 2-3 days. The delay in test reports might lead to further spread of virus in the city of Gulbarga leading to further surge in the cases of COVID-19 virus. It is necessary to follow the SOPs which are prepared by the government, to reduce the time taken by the lab authorities to provide the reports to the patients. CEPT University Service Operations and Management Studio 2020 123

Inference

G4.8.2. Home Quarantine Parameter Reliability

Expectation ASHA workers visit home during quarantine to record progress Good communication of ASHA workers with home quarantined patients

Assurance

Empathy

Responsiveness

ASHA workers are helpful and caring towards the home quarantined patients ASHA workers respond quickly to the COVID symptomatic patient

Score Perception Score 6.23 Did ASHA worker visit your 2.90 home during quarntine to check symptoms 6.36 Were ASHA workers 5.26 efficient enough to communicate in local language 6.76 Were ASHA workers caring 5.90 and helpful about queries you asked during home quarantine 6.06 Did ASHA workers respond 5.22 quickly to your symptoms and help you with further process

Table G9 Showing the SERVQUAL analysis of home quarantine Source: Primary

Composite RATER Analysis GAP (P-E)

Figure G11 Showing composite RATER analysis of Home quarantine Source: Primary

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GAP (P-E) -3.33 -1.10

-0.86

-0.84

Positive suspects with mild symptoms or no symptoms and the contacts traced are ordered Home quarantine for 14 days as a safety precautions. Community health workers form a vital link between the community and the health department in the city of Gulbarga, the role of which is being played by Accredited Social Health Activists (ASHAs), who are city-level female workers. The health status of the home quarantined patients should be recorded by ASHA workers for the period of 14 days. When asked during the survey about the regularity of ASHA workers, 19 of 30 quarantined suspects told ASHA workers never visited their home, which shows lack of monitoring. Whereas, rest 11 of the quarantined suspects told ASHA workers are helpful and caring and responds to the symptomatic patients quickly. The study shows that an ASHA’s motivation and performance is affected by a variety of factors in Gulbarga city, majorly being lack of PPE kits and insufficient salary by the government. Inorder to improve the performance of ASHAs, there is a need to take corrective actions at the professional and organisational front on a priority basis.

G4.8.3. COVID care isolation Parameter

Expectation

Reliability

Healthcare workers monitor recovery of patients everyday in isolation centers The doctors/nurses at COVID care isolation centers convey trust and confidence

6.06

Were the lab staff available to collect your sample

3.33

GAP (P-E) -2.90

6.46

3.9

-2.56

The isolation centers are not overcrowded

6.13

3.73

-2.90

The nurses in isolation centers wear safety gears and maintain hygiene Healthcare workers try to comfort patients in isolation centers to avoid panic Healthcare workers respond quickly to positive report of the patient

6.6

Were the lab staff responsible enough to be gentle and careful about the sample collection Did the lab staff wear masks and gloves to maintain hygiene Did nurses in isolation centers wear PPE kits and maintain hygiene Did healthcare workers make an effort to comfort you in isolation centers Did healthcare workers respond quickly to your positive report

5.63

-0.97

2.9

-2.73

4.33

-1.73

Assurance

Tangibles

Empathy Responsiveness

Score

6.66 6.06

Perception

Score

Table G10 Showing the SERVQUAL analysis of COVID care isolation

Figure G13 Showing the newspaper clippings of COVID care isolatuion centers Source-Times of India

Figure G12 Showing composite RATER analysis of COVID care isolation Source: Primary

Inference

According to the survey conducted, it can be concluded that: • The nurses in isolation centers wear PPE kits and maintain safety precautions. • There is a lack of monitoring in the isolation centers by the healthcare workers.

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G4.8.3. Monitoring and Surveillance Parameter Reliability

Assurance

Tangibles

Empathy Responsiveness

Expectation Score Perception Score Contacts are traced for low6.06 Were the contact traced 2.2 risk and high-risk suspects to list suspects Containment area is 6.23 Was contained area 2.63 sanitized and barricaded sanitized and barricaded Traced contacts are 6.13 Were the traced contacts 3.63 communicated about safety communicated about precautions safety precautions Effective communication 6.00 Were the rules of 2.46 about rules of containment containment area area effectively communicated Hard barricades are used in 6.16 Were hard barricades 2.46 containment area to restrict used in containment areas movement Municipal workers who 6.70 Did municipal workers 5.33 sanitize contained area wear wear safety gears during safety gears sanitization COVID Care Committee 6.13 Was CCC polite enough 3.43 politely communicates with to communicate with you patient for contact tracing for contact tracing Conatinment area is 6.16 Is containment area 2.36 sanitised as per the request sanitised as per the of neighbours request Quick response from CCC to 6.36 Did you experience quick 2.46 barricade and sanitize the response from committee area with high cases for sanitization and barricading

GAP (P-E) -3.86 -3.6 -2.5 -3.54 -3.7 -1.37 -2.7 -3.8 -3.9

Table G11 Showing the SERVQUAL analysis of Monitoring and Surveillance

Inference

According to the survey conducted, it can be concluded that:

• The city lacks contact tracing. • Containment zones lacked sanitization and barricading.

Figure G14 Showing composite RATER analysis of Monitoring and Surveillance Source: Primary

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Figure G15 Showing the newspaper clippings of Lack of Contact Tracing Source: The Hindu Newspaper, July 2020

G4.9 FMEA

Table G12 Showing the FMEA of Containment strategies in Gulbarga city Source: Primary

FMEA (Failure Mode and Effects Analysis) is a structured approach to discovering potential failures that may exist in the covid management process of Gulbarga city. FMEA is evaluated based on the criteria of frequency of threat occurence (O), probability of threat detection (D) and threat severity (S) from which the Risk Priority Number (RPN = O*D*S) is evaluated.

In Gulbarga city, it can be seen that the Contact tracing has the highest risk priority number where the potential failure modes are Lack of information by the patient, Information is not shared to the immediate contacts and Missing out of symptomatic patients for which the actions recommended would be Awareness of severity of the spread of virus among the people, Training and demonstration of

work methods, regular check on the suspects and efficient use of app (Corona Watch App) initiated by the karnataka government, which might help in reducing the extra work of ASHA workers. by the karnataka government, which might help in reducing the extra work of ASHA workers.

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G5. Service Concept

The Service Concept outlines how a service organiser can realize the value and desired outcomes of its services. It can be best descirbed as thw way in which an organisation would like to have its services perceived by its stakeholders. The service concept of the Gulbarga Municipal Corporation has been described below in detail. Organisation: Gulbarga Municipal Corporation

G6. Service Audit Profile

Organising idea: To prevent the spread of COVID-19 in the city and to ensure the health and safety of the citizens.

Service concept: To ensure health and safety of the citizens of Gulbarga city by providing them all the health care services at the doorsteps. Service Provided : • Testing kits • Medical team • Quarantine centers • COVID hospitals • PPE equipment • Free ration for low income groups • Economical RT-PCR tests • Transportation facility for migrants • Vegetables at economical rates in each ward • Free masks and sanitizers • Free COVID helpline numbers • Fever clinics • Rapid antigen testing kits at low rates Service Received:` • Responsive staff • Door to door services • Ease of accessibility to medical supplies • Hassle free quarantine centers • Free ration for 3 months • Transparency • Sero surveillance • Ease of accessibility to medical services

Fig

Figure G16 Showing the Service Audit Profile of Gulbarga city Source: Primary

Inference: The Service Audit Profile shows the issues of the existing services on the left and the recommended actions which were studied through FMEA, on the right hand side of the chart. For each services and recommendations, a rating was given from -7 to +7.

On the above service profile, for each parameter of RATER, issues such as Lack of monitoring of home quarantine, Lack of contact tracing of the suspects, Lack of sanitization andbarricading has a very low rating on the profile which can be improved by

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recommending actions like use of corona watch app, initiated by the Karnataka government for regular monitoring of home quarantined patients and to trace the suspects who have been in contact with the positive patient for the last 15 days, to list out the low-risk as well as high-risk contacts efficiently, to create a checklist for regular monitoring of the COVID-19 suspects and lastly, proper supervision to follow the SOPs created by the Karnataka government for regular sanitization and barricading of the containment areas in the city.

G7. Conclusion

Existing scenario of the COVID management of the Gulbarga city is studied using various tools as well as with respect to the other 6 cities accross the country, by which it can be concluded that there are both good services as well as few areas of improvements.

Good points such as ample testing kits and skilled lab staff can be seen and all the testing labs maintain safety precautions and hygiene. Corona Watch App was initiated by the Karnataka government for efficient monitoring and contact tracing. Gulbarga city is performing well on overall parameter of tangibility, empathy and assurance whereas, there is a scope of improvement for Reliability and Responsiveness. The city needs to follow SOPs prepared by the karnataka government to improve on the Containment strategies such as efficient contact tracing, regular monitoring, sanitization and barricading to reduce the further spread of virus.

Figure G17 Showing the interface of Corona Watch App initiated by Karnataka Government Source: https://www.indiatoday.in/information/story Fig

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CITY LEARNINGS

The cities are analysed with respect to various parameters namely 1. City Case Analysis - wherein cities are analysed with respect to overall performance of the city in controlling number of cases. 2. Process wise service analysis - Performance rating for each of the process studied in the service 3. RATER analysis of City’s COVID Management Services - Perception of citizens of the service provided by Municipal Corporation 4. RATER analysis for various Services - Comparison of ratings for various services provided by the Municipal Corporation 5. Unique features in Cities - Identifying unique services in each city

Figure 9 Worldwide confirmed COVID19 cases visualisation

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1. City Case Analysis

In the figure 9 cities are compared with respect to overall performance of the city in controlling number of cases. From figure 9, it can be seen that Navi Mumbai has the highest number of cases per lakh population. The reason for the same was the footfall in the APMC (Agricultural Produce Market Cooperative). It was a part of essential services due to which lockdown was not applicable there. Hence, the affected traders coming down from various parts of the state stood responsible for the spread of the virus. In the same parameter, Hapur was the least affected city among the others, the reason being the wide-ranging perimeters of the containment zones helped them contain the virus effectively. In the case of deaths per thousand cases, Ahmedabad’s position is unsettling due to less number of treatment facilities, whereas, Faridabad was doing well as the Faridabad Municipal Corporation are hospitalizing all the patients aged above 60, showing any sign or symptom. Lastly, the Positivity rate of the tests conducted per thousand tests, Ahmedabad was lowest as compared to other cities, the reason being setting up of rapid antigen testing booths. Whereas on the other side, Navi Mumbai is performing relatively well as high numbers oh rapid tests conducted in in the containment zones. Hence, from the above observations, it can be noticed that some cities are getting more affected in some parameters that can be looked into else practices of the other cities performing well can be adopted.

2. Process wise service analysis

As in the above study, the processes identified are identification, treatment and monitoring and surveillance. RATER analysis of these processes is done, to see which city is most affected and which city is doing well in the said processes. According to the graph in figure 10, monitoring and surveillance is the process in which all the cities are lacking. According to the RATER, the cities that have the scope of improving their service in terms of identification are, Vasai Virar

with a maximum difference of perception and expectation, followed by Gulbarga and Faridabad. Similarly, in the case of treatment Faridabad, Gulbarga and Vasai Virar are the cities need improvement. In the case of monitoring and surveillance, Faridabad is the city demanding maximum attention followed by Gulbarga and Vasai Virar respectively. The cities doing comparatively well, in all the three processes are Lucknow, Hapur and Ahmedabad respectively.

Figure 10. Process wise RATER analysis Source: Primary

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i.e. the health care services lack everywhere in the listed city. Further if observed closely, the city performing well in terms of reliability RATER analysis of City’s COVID Management is Lucknow whereas Faridabad is showing the services. The difference between perception and lowest P-E difference indicating the need for expectation helps to understand which RATER improvement in the parameter. In the case of parameter is the city doing well in and where is assurance, Navi Mumbai is the city performing the improvement required in the city. The city well whereas Gulbarga needs improvement. RATER gives an overall idea that how are the Lucknow is again doing well in the case of services perceived in that city with respect to tangibility whereas Hapur needs improvement. others. From figure 11, it is seen that reliability Empathy is the factor that determines the is the factor that is going low for all the cities

3. RATER Analysis of City’s COVID Management Services

Figure 11. RATER Analysis of city’s COVID Management Services Source: Primary

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behavior of the staff. Hence, if we look at the graph in figure 4, Lucknow is performing the best whereas Gulbarga needs improvement. Lastly, responsiveness is good in Lucknow whereas in Faridabad it needs to be improved. In the next section, it is looked into detail, that what common parameters in the cities are resulting in the particular factor to rise up or down in the graph.

4. RATER Analysis of various services

Various services taking place in the cities in order to combat the virus, are identified with the help of the difference between perception and expectation as marked by the people. The services marked yellow in the table1 are a few of the services that might be the reasons for affecting the city. It might be in terms of process or the service quality provided by the particular municipal corporation. The dark red colour in the table shows, the service risk according to the perception of the citizens of that city. Whereas the white shows that the service is satisfactory. 1. Sanitization Service in various cities. Sanitization is a part of the monitoring and surveillance process and lies in reliability. The service is marked as the highest P-E difference in Faridabad and Gulbarga. The major contributing factor fot the low rating identified, in Faridabad there is a lack of communication channels within the government institutions responsible for implementing the service while in the case of Gulbarga, there was a lack of Human Resources with respect to the number of cases to cater to. Ahmedabad and Lucknow are the cities that are

Table 1. RATER Analysis of various services carried out in the city as a part of COVID management Source: Primary

close to white and are taking good measures in order to make the service quality better. In Ahmedabad, the Integrated fire department services to sanitize the public spaces and a dedicated sanitization team appointed to conduct and coordinate door to door sanitization activity helped the Municipal Corporation to achieve the satisfaction of the citizens.

2. Frontline workers wearing PPE Kits This service is part of tangibility and falls in the identification process. Hapur and Gulbarga are the cities that need to encourage their workers to wear the kits whereas Vasai Virar is doing comparatively well in this aspect. The reason being, in Gulbarga PPE kits, were not given to the ASHA workers whereas, in the case of Vasai

Virar, the PPE kits were locally manufactured. 3. Waiting area at the testing center. This service falls under tangibility in the RATER and is part of the identification process. Hapur is the city ranging to red due to lack of space and furniture at the testing centers whereas, in the case of Vasai Virar, the makeshift Fever clinics were created in

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government schools, wherein common open to sky areas are used as waiting spaces. Hence, the service is marked satisfactory. 4. Constant follow-ups in case of home quarantine. The service falls in Responsiveness and is part of the treatment process. Vasai Virar and Gulbarga are folling in red range in this parameter. Reasons being GNM worker having too many responsibilities and lack of human resource

as ASHA workers have boycotted work as PPE kits were not given respectively. In this service, Ahmedabad and Navi Mumbai are noticed doing well comparatively. Reasons being, Sanjeevni Rath – dedicated mobile van used for monitoring and follow-ups and A WhatsApp group being made by the Medical Officer, were in the patients are supposed to send the photos of the said parameters. If anything wrong is

Figure 12 Unique features of the cities. Source: Primary

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found, the patient is contacted respectively.

5. Unique Features in the Cities The figure 12 shows the unique features of the cities in containing the COVID. 1. Faridabad - Senior citizens with any symptoms/ infection mandatorily asked to

quarantine/ hospitalized. Pupose - To immediately treat high risk patients and reduce number of deaths. 2. HAPUR: Neighbourhood surveys Purpose: Identify symptomatic patients early and tracing contacts 3. LUCKNOW: DSO portal for updating all data record and maintenance. Integrated COVID Control Centre Purpose - An integrated system for collection and provision of all data 4. AHMEDABAD: Kiosks for free rapid antigen testing Purpose - Make contact tracing easier. 5. VASAI VIRAR: Voluntary service provided by General Physicians at fever clinics Purpose - To mobilize resources immediately 6. GULBARGA : Corona Watch App Purpose - Monitor patients activity and condition remotely during home quarantine; helps in contact tracing 7. NAVI MUMBAI: A WhatsApp group of home quarantined patients to track their health condition Purpose - Monitor patients condition in a particular ward remotely by the Medical Officer

carried. The family members are informed, and only 5 members from the family are allowed in the crematorium. 2. Bio - Medical Waste Management According to the news report published by NDTV on 18th September 2020, a report has been filed by Central Pollution Control Board (CPCB) in the National Green Tribunal in July stating that India generates about 101 Metric Tonnes per day (MT/day) of COVID-19 related bio-medical waste, in addition to the regular bio-medical waste generation of about 609 MT per day. According to the CPCB report, the inceneration capacity of the of COVID-19 biomedical waste in the country is about 840 MT. (Ahuja, Aastha ; Bhaskar, Sonia ;2020) According to the Guidelines for Quarantine Facility COVID-19 issued by the Ministry of Housing and Urban Affairs, used personal protective equipment (PPE), gloves, shoe covers, head covers, disposable bed sheets,

and PPE with spill is to be discarded in the yellow bin which are then incinerated or buried in deep pits. CPCB has also released a few set of guidelines, stating isolation wards in hospitals need to keep up discrete shading coded canisters for the isolation of waste. A dedicated bin marked “ COVID 19” to be kept in a separate space, handled by approved staff only. The board has also requested to record the generation of the this kind of waste. For the patients in home quarantine the CPCB has asked them to dispose the waste in yellow pack, and handover them to approved authorities. (Ramteke & Sahu, 2020) The news report clearly claims that Maharastra is highest bio - medical generating state. But, the state is coping up with the situation by making stand by arrangements with Treatment, Storage and Disposal Facilities (TSDF) to avoid spread of disease through waste route. (Ahuja, Aastha ; Bhaskar, Sonia ;2020)

6. Other Services 1. Dead body Management. The last rites of the COVID positive person is the responsibility of the Municipal Corporations. The rites are done following the religious norms of the patient. The patient is packed in a black cover and is taken to the respective crematorium with in an ambulance. The roads are at times blocked for a while when the infected body is

Figure 13 Process of COVID waste management Guidelines. Source: (Ramteke & Sahu, 2020)

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References

Faridabad: 1.https://www.smartcityfaridabad.co.in/cityprofile/, 2.https://faridabad.nic.in/municipalcorporation-faridabad/, 3.https://www.census2011.co.in/census/ district/227-faridabad.html 4.https://bharatmaps.gov.in/map. aspx?dtcode=088 5.https://faridabad.nic.in/municipalcorporation-faridabad/ 6.http://14.139.116.20:8080/jspui/ bitstream/10603/113067/9/09_chapter%202. pdf 7.https://www.covid19india.org/state/HR 8.http://haryanahealth.nic.in/Documents/ CovidManagePlan/Annexure%202%20 (Surveillance%20Guidelines).pdf 9.http://haryanahealth.nic.in/CovidManPlan. html 10.https://www.instagram.com/p/ CGAgJ7VFhAP/?igshid=xlkclrddmse3 Hapur 1. Covid19 India. (2019). Uttar Pardesh. Retrieved 09 09, 2020, from Covid19 India: https://www. covid19india.org/state/UP 2. Directorate of Medical & Health Services, Uttar Pradesh. (2020, 05 30). Districtwise L1/ L1 Covid Care Center, L2, L3 Isolation Beds . Uttar Pradesh. Retrieved 09 10, 2020, from http://dgmhup.gov.in/DocumentsCovid19/ Districtwise_Hospital_IsoBeds.pdf 3. District Administration. (2020, 09 11). Home.

Retrieved 09 15, 2020, from Hapur District: https://hapur.nic.in/ 4. Khandelwal, P. (2020, 04 04). Three-tier system to deal with Covid-19 cases in UP. Hindustan Times. HT Media. Retrieved 09 10, 2020, from https://www.hindustantimes.com/cities/threetier-system-to-deal-with-covid-19-cases-inup/story-VReEC8jewDRKxeO2C1bqyJ.html 5. ODOP Cell, Uttar Pradesh. (2019, 06 15). About ODOP. Retrieved 09 15, 2020, from One District One Product: http://odopup.in/en/ article/hapur Lucknow 1. All Schemes. (n.d.). Retrieved October 28th , 2020, from Ministry of Micro,Small & Medium Enterprises: https://msme.gov.in/ 2. Chief Minister’s Office. (2020, May 30th). Districtwise L1/L1 Covid Care Center, L2,L3 Isolation beds . Lucknow, Uttar Pradesh, India. Retrieved September 24th, 2020, from http://dgmhup.gov.in/DocumentsCovid19/ Districtwise_Hospital_IsoBeds.pdf 3. Covid19india.org members. (2020, October 31st ). Home Page. Retrieved November 5th, 2020, from COVID19India: https://www.covid19india.org/ 4. Indian Council of Medical Research (ICMR). (2020, October 31st). Laboratory list. Retrieved from Covid-19 Collection Centre for Rapid Anibody Test and RT-PCR: https:// covid19cc.nic.in/icmr/Citizen/LabList.aspx Ministry of Home Affairs, Government of India. (2011). Census india. Retrieved October 30th,

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2020, from Office of the Registrar General & Census Commissioner, India: https://censusindia. gov.in/2011-common/censusdata2011.html 5. Municipal Commissioner of Lucknow. (n.d.). About The District. Retrieved October 30th, 2020, from Lucknow Municipal Corporation: https://lucknow.nic.in/ Ahmedabad 1. Corporation, A. M. (2020, September 14). Steps Taken By AMC to Keep Citizens Safe And Secure. Ahmedabad, Gujarat, India. Retrieved September 14, 2020, from https:// ahmedabadcity.gov.in/portal/ 2. Division), G. o. (2020, March 11). Guidelines for home quarantine. New Delhi, India. Retrieved September 14, 2020, from https://www.mohfw. gov.in/pdf/Guidelinesforhomequarantine.pdf 3. Grewal, K., & Jain, P. (2020, July 27). ThePrint. Retrieved from Youtube.com: https://www. youtube.com/watch?v=kmmyesnXvtI 4. IndiaTV. (2020, June 29). Ahmedabad: New color coding of covid zones introduced based on data available from Arogya Setu App. Ahmedabad, Gujarat, India. Retrieved September 14, 2020, from https://www. youtube.com/watch?v=LHKjfYH2kDU 5. Welfare, G. o. (2020, April 5). Guidelines for Quarantine facilities COVID-19. New Delhi, India. Retrieved September 13, 2020, from https://www.mohfw.gov.in/

References

Vasai Virar 1. The Times of india. (2020, July 02). Maharashtra: 1,000-bed Covid-19 hospital opens in Vasai. Mumbai, Maharashtra, India: The Times of India. Retrieved from https://timesofindia. indiatimes.com/city/mumbai/maharashtra1000-bed-covid-19-hospital-opens-in-vasai/ articleshow/76755029.cms 2. Vasai Virar Municipal Corporation. (2020, April 15). Vasai Virar Municipal Corporation. Retrieved September 15, 2020, from https://vvcmc.in/ vvmc/corona/wp-content/uploads/2020/04/ Appeal.pdf 3. Vasai Virar Municipal Corporation. (n.d.). Vasai Virar Municipal Corporation. Retrieved September 15, 2020, from https://vvcmc.in/ vvmc/?page_id=523&lang=en Gulbarga 1.Gulbarga Municipal Corporation website retrieved from http://www.kalaburagicity.mrc. gov.in/en/home 2.Karnataka COVID dashboard retrieved from https://covid19.karnataka.gov.in/storage/pdffiles/Private%20Hospitals%20for%20Covid%20 19%20with%20List%20of%20Hospitals.pdf 3.Gulbarga COVID dashboard retrieved from https://kalaburagi.nic.in/en/covid19dashboard-en/ 4.Interview with health officer, Gulbarga Municipal Corporation on 7th September 2020 5.Gulbarga COVID website retrieved from https://kalaburagi.nic.in/en/covid-19-ordersand-circulars

6.Primary Survey of 30 COVID suspects from 13th October- 21st October 7.Quarantine centres in Gulbarga, Indian Express newspaper, June 11th 2020, retrieved from https://www.newindianexpress.com/states/ karnataka/2020/jun/11/quarantine-centre-ora-jail-ask-kalaburagi-inmates-2155008.html 8.Lack of Contact Tracing in Karnataka cities, Times of India newspaper, 23rd July 2020, retrieved from https://timesofindia.indiatimes. com/city/bengaluru/karnatakas-contacttracing-drops-from-47-per-patient-in-juneto-6/articleshow/77118069.cms 9.Speedy Contact Tracing is must to contain Virus, The New Indian Express newspaper, 29th April 2020, retrieved from https://www. newindianexpress.com/states/karnataka/2020/ apr/29/speedy-contact-tracing-must-tocontain-covid-19-spread-says-study-2136682. html 10.Boycott of Contact Tracing by ASHA workers, The Hindu newspaper, July 11th 2020, retrieved from https://www.thehindu.com/news/ national/karnataka/health-activists-boycottwork-contact-tracing-hit-in-karnataka/ article32047705.ec

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APPENDIX List of Quarantine hotels in Ahmedabad 1. CHEPI ROG HOSPITAL,BEHRAMPURA 2. SHIFA HOSPITAL, JAMALPUR 3. LOKHANDWALA HOSPITAL,DARIYAPUR 4. SAMRAS HOSTEL 5. FERN HOTEL 6. HAJ HOUSE 7. DOUBLE TREE HILTON HOTEL 8. LEMON TREE HOTEL,KHANPUR 9. LEMON TREE HOTEL,NAVARANGPURA 10. AL-AMIN,GOMTIPUR 11. HOTEL RAJDEEP INN 12. HOTEL GINGER 13. HOTEL PRITHVI 14. HOTEL TUNE 15. HOTEL MANILA 16. HOTEL CHATAKO 17. HOTEL KOHINOOR List of Hospitals in Ahmedabad & capacity of beds Name of Hospital Number of beds 1 Rajasthan hospital 62 2 Life care hospital, Khanpur 32 3 Shalby,Nikol 50 4 Spandan Hospital ,Vastral 25 5 CUH,Central United Hospital,Odhav 30 6 Narayana Hospital, Vastral 50 7 CIMS Hospital, Sola 80 8 Sterling Cancer Hospital, Pakwan Char Rasta 34 9 Global Hospital 20 10. Bopal ICU & Trauma Centre ,Ambli 15 11. SAL Hospital 99 12. Sanjivani Hospital, Vastrapur 24 13. SGVP Hospital,SG road 35 14. Saraswati Hospital,SP Ring Road 35

15. Kothiya Hospital,Nikol 138 16. Gujarat Cancer Society Medical College Hospi-tal,Naroda 200 17 Anand Surgical Hospital Pvt.Ltd, Naroda Road 40 18 Sindhu Hospital,Kubernagar 39 19 Star Hospital,Bapunagar 30 20 Narayani, Rakhial 50 21 Karnavati Super Speciality Hospital, Naroda Road 21 22 Iqra hospital (Amena Khatun Multi speciality Hospital) 50 23 Tapan Hospital,Satellite 20 24 Medilink Hospital, Shyamal char rasta 17 25 RATAN Multi Speciality Hospital, Isanpur 15 26 SMS Hospital, Chandkheda 218 27 Dr.Jivraj Mehta Vasna 85 28 HCG Hospital,Mithakali 20 29 Saviour Annexe Hospital , Ashram Road 21 30 Aartham Hospital,Ambawadi 45 31 Shalby,Navrangpura 12 32 Solar Hospital,Naranpura 14 33 Aims Hospital Sushrusha, Navrangpura 22 34 Sushrusha,Navrangpura 20 35 Pukhraj Hospital, Sabarmati 37 36 Bodyline Hospital, Paldi 10 37 Shrey Hospital, Stadium Circle 28 38 Trisha Multi Speciality ,Nirnay nagar 15 39 Apollo City centre, Paldi 15

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List of Zonewise Quarantine centres for travellers

Sr no. 1 2 3 4 5 6 7 8 10

Zone

Location

West zone civil hospital West zone civil hospital North west zone North west zone North west zone North zone South zone East zoned East zoned

SPORTS CLUB, NAVRANGPURA Vishwakarma eng.boys hostel, chandkheda R.c.technical, sola Avas yojana, gota Rajpath club, bodakdev Jamia faizal, saraspur Vyasvatika, isanpur Sports complex, nikol Tapi apartment, nikol (bhiksuk)

List of COVID Testing Labs in Ahmedabad

Sr no. 1 2 3 4

Name of testing Lab

Gujarat Cancer Research Institute

6 7 8 9 10 11 12 13 14 15 16

BJ Medical College

NHL Medical College

GMERS Medical College

ICMR-National Institute of Occupational Health Dr. H.L. Trivedi Institute of Transplantation

Type of institute Government Government Government Government Government Government

Type of institute

CELLCARE Pathology Lab

Private

Lambda Therapeutic Research Limited,

Private

Speciality Microtech Laboratory

Private

GCS Medical College and Hospital

Government

20 21

National Institute of Pharmaceutical Education & Research

Government Private

Supratech Micropath Laboratory & Research Institute Pvt Ltd,

Private

Dept of Lab Medicine, Zydus Hospitals & Healthcare Research Pvt Ltd,

Private

Green Cross Genetics Lab Pvt Ltd,

Private

Gujarat Pathology Lab & Diagnostic Centre,

Private

Unipath Specialty laboratory limited,

Pangenomics International Pvt Private Ltd, Ellis Bridge, Ahmedabad

Dept of Lab Medicine, Apollo Hospitals International Ltd,

Private

Sunflower Laboratory, Helmet Circle, Rudra Arcade,

Private

Scientific Diagnostic Centre Pvt.Ltd,

Private

Form for informing and testing of suspected

Sr Name of testing Lab no. 17 Salvus Bioresearch Solutions, 18 Curovis Healthcare Pvt Ltd,

B – Block,

Private Private

Narayana Multi speciality Private Hospital Care Institute of Medical sciences (CIMS hospital),

AMC MET Medical College and Hospital

Private

Form for appointment of COVID coordinator

Government

Form for Contact tracing

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Service Operations & Management Studio 2020- Covid-19

Articles inside

City Learning

F- Navi Mumbai

D- Ahmedabad

A- Faridabad

List of tables

Executive Summary

Introduction to Pandemic at Global and National Level

Service Operations & Management - COVID 2019 (Part-I)

List of Figures

Abbrevations

Abstract