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

Academic Booklet UM4002 Service Operations Management Studio 2020 Studio Tutor Prof. Mercy Samuel Teaching Assistant Himadri Panchal Students Aniruddh Vaghela Apoorva Bhate Irene Shaji Mayuri Varkey Rishabh Shandily Swapnika Vadali Vibhav Singhal Proof Reading Irene Anna Shaji & Mayuri Varkey Compilation Apoorva Bhate Design and Layout Swapnika Vadali CEPT University Ahmedabad Printed by: No part of this book may be reproduced, scanned or distributed in any printed or electronic form without permission. Please do not participate in or encourage

FOREWARD The studio was designed to focus on how urban institutions are engaged in service delivery and streamlining their operations for efficiency and citizen satisfaction in turn contributing for better quality of life and the service provided. The objective of the studio was to understand service operations management concept of the present COVID-19 management, understanding tools and techniques for designing optimal service mechanism, to assess the existing urban health services by applying tools, techniques and systems used for service operation management and to have city peer learning for better management of COVID-19 by the ULBs. The studio aims on understanding how a municipal corporation can deliver the public health service while combating the spread of the virus. Understanding the service needs of the citizens, managing the processes that deliver the services, ensuring that the service objectives are met, while also paying attention to the constant improvement of the services. Through this exercise the students learnt about the various tools and techniques to access different dimensions of COVID management from the Municipal Corporation’s point of view and identifying areas of improvement for city peer learning.

Pandemic effect accross 7 cities in India

Contents Abbreviations Abstract Introduction Individual City Analysis Summary List of Figures List of tables Annexures Bibliography

4 5 6 10 98 99 100 101 146

34 64 86

Sanskari Nagari Vadodara,

Gujarat

Green City Gandhinagar,

Gujarat

Land of Pilgrimages Pathanamthitta,

Kerela

Heritage City Ahmedabad,

Gujarat

Capital City Delhi

City of Nawabs Lucknow,

Uttar Pradesh

City of Pearls Hyderabad, Telangana

Abbreviations

Abstract

ASHA - Accredited Social Health Activist AUA - Ahmedabad Urban Agglomeration CB NAAT – Cartridge Based Nucleic Acid Amplification Test CFLTC –COVID First Line Treatment Center CCC - Covid Care Centre CFR - Case Fatality Ratio CHC - Covid Health Centre

The outbreak of COVID-19 in different parts of the world is a major concern for all the administrative units of respective countries. India is also facing this very tough task for controlling the virus outbreak and has managed to curb its growth rate through some strict measures. This report presents the current situation of coronavirus spread across seven cities of India namely Vadodara, Gandhinagar, Pathanamthitta, Ahmedabad, Delhi, Hyderabad and Lucknow along with the impact of various measures taken for it. With the help of various data sources like primary data source and interviews with the authorities and positive tested patients, an analysis of the situation is conducted.

CSLTC – COVID Second Line Treatment Center FMEA – Failure Mode and Effects Analysis

GHMC - Greater Hyderabad Municipal Corporation HITAM - Home Isolation Telemedicine and Monitoring ICCC - Integrated Command & Control Centre ICMR – Indian Centre of Medical Research IFR - Infection Fatality Ratio PPE - Personel Protective equipment

RACI – Responsible, Accountable, Consulted and Informed (Responsibility Assignment Matrix) RATER – Reliability, Assurance, Tangibles, Empathy and Responsiveness RT – PCR – Reverse transcription Polymerase Chain Reaction SERVQUAL- Service Quality SPEM – State Poverty Eradication Mission SVP - Sardar Vallabhbhai Patel Hospital True NAAT – True Nucleic Acid Amplification Test ULB - Urban Local body UPHC - Urban Public Health Centre USA - United States of America WHO - World Health Organization

Service Operations Management Studio 2020 I CEPT University

The report covers all seven cities exposure assessment, and strategies implemented by the respective urban local bodies to tackle the aggressiveness of the covid situation along with the organizational capabilities of each city. The process of fighting covid by each ULB has been studied considering 4 processess - Identification, Confirmation, Treatment & Prevention in a comprehensive manner. It has been noted that growth rate of infected cases has been controlled with the help of the lockdown, however some uncontrolled events have also negatively impacted the pandemic situation in the cities. The growth trends of confirmed, active, recovered and deceased cases as well as the testing patterns over a span of 4 months has been analyzed. Using different service operations & management tools the whole scenario of the pandemic has been assessed. Further finding the gaps in the processess , recommendations have been suggested. Lastly, the current scenario is compared with the predicted improvements on a service audit profile and then concluded with the city learnings.

Service Operation Management Studio 2020 I CEPT University

Introduction to Studio A service operation and management is a means of delivering values to the citizens by facilitating outcomes that citizens want to achieve by mitigating service risk. Therefore, a service operation is an open transformation process of converting inputs to desired outcomes through appropriate application of resources like material, labour, information and the citizens as well. The Service Operation Management focuses on the services related to the citizensand involves the basic concept of service delivery in an urban realm. Current practice reveals a lack of widespread understanding of effective service management in urban

services. Service operations management is not only delivering service to the citizens. But also, involving understanding the service needs of the target customers, managing the processes that deliver the services, ensuring objectives are met, while also paying attention to the constant improvement of the services. Service Operation Studio focuses on understanding the service delivery concept of COVID19 management in different Indian cities. Their effective delivery is studied based on tools for recommending optimal service mechanism. Existing COVID

management process analyse in identifying issues with the help of tools, techniques & systems used of service operations management are studied. The COVID-19 pandemic is managed by the respective local bodies of which some are successful in tackling this pandemic and some are still struggling to get the situation under control. Here, understanding the service needs of the citizens is highly important and then the process that delivers the services. Meanwhile the service objectives must be met, and constant improvements has to be taken care off by paying attention to the feedbacks and reviews. The health sector is a major player in this pandemic, so the health services are as-

Service Operations Management Studio 2020 I CEPT University

sessed with different dimensions like from backend operations to frontline workers. The end goal is to recommend solutions to improve efficiency and effectiveness of the operation of services in COVID19 management. This studio takes the position that there is enormous potential to improve services systems, processes and delivery mechanisms. It attempts to create an understanding of the service ecosystem. tools and techniques to improve service efficiency in the urban realm.

vices like testing, home quarantine facilites, sanitisation. At last Failure Mode and Effect Analysis(FMEA) was done to identify areas which requires improvement and further recommendations were given to improve ranking on service audit profile. Finally, city learnings were listed down and a comparative study across cities were conducted.

PRELIMNARY STUDY OF INDIVIDUAL CITIES

Methodology Firstly, preliminary study of individual cities was conducted on the basis of the following parameters namely, assessment based on exposure, aggressiveness of the issue and organisational capability. Afterwards, a process mind map was created to identify the key processes which took place in every city for COVID management i.e. Identification, Confirmation, Treatment and Prevention. Then, various analysis tools were applied like process identification, process profile worksheet, RACI, swimlane where various issues related to service timeline and reponsibilities were identified. Further SERVQUAL-RATER survey was done to analyse perception and expectations of the citizens regarding different serService Operation Management Studio 2020 I CEPT University

ASSESSMENT BASED ON

EXPOSURE ASSESSMENT, AGGRESSIVE OF ISSUE, ORGANISATIONAL CAPABILITY

APPLYING DIFFERENT TOOLS

PROCESS IDENTIFICATION, PROCESS PROFILE WORKSHEET, RACI, SWIMLANE, SERVQUAL, FMEA

SERVICE AUDIT PROFILE & SUMMARY

Introduction to Pandemic The COVID 19 pandemic of coronavirus disease which started in December 2019 caused by severe acute respiratory syndrome coronavirus 2 (SARS CoV 2). The first human case of COVID-19 was reported by officials in Wuhan City, China, in December 2019. As per the World Health Organization (WHO), COVID-19 has so far affected 216 countries and has infected almost over 9 million people globally.

public movement confirmed cases and depending on the sectorial priorities. Presently we are in Unlock 5.0: 1 October 2020 - 31 October 2020 India has presently overtaken Brazil to become the country with the second-highest number of Covid-19 cases after US. It reported a record daily jump of 90,632 Coronavirus Cases, which is the biggest One-Day Rise. Presently, Maharashtra has taken the highest places with 10 lakh.

Mizoram stood least with 1,428 cases. There were 4 phases during the lockdown period. Phase 1: 25th March 2020 – 14 April 2020 Phase 2: 15th April 2020 – 3 May 2020 Phase 3: 4th May 2020 – 17 May 2020 Phase 4: 18th May 2020 – 31 May 2020 After this the economy was opened in 5 phases: Phase 1: 1st June 2020 – 30th June 2020 phase 2: 1st July 2020 – 31st July 2020 Phase 3: 1st Aug. 2020 – 31st Aug. 2020 Phase 4: 1st Sept. 2020 – 30th Sept. 2020 Phase 5: 1st Oct. 2020 – 31st Oct. 2020

INDIAN SCENARIO The first case in India was detected on 30th January 2020, in Thrissur- Kerala. The first death was on 12th March 2020, in Kalburgi – Karnataka. To control the spread of the novel corona virus, Government of India has initiated a one day Nation-wide lockdown on 22nd March 2020 and continued it will a total lockdown from 24th March 2020. After the lockdown period, unlock of all the sectors didn’t take place at a single go. The government has given permission for the essential services to cater the needs of the citizens and slowly permitted the 8

Service Operations Management Studio 2020 I CEPT University

Location of study areas For the study, 7 cities/districts were identified and studied in detail, with respect to the COVID-19 management statistics and the overall strategies implemented. The 7 cities were Delhi, Ahmedabad, Gandhinagar, Vadodara, Pathanamthitta, Hyderabad and Lucknow. The study of the COVID management process has been looked across 7 cities and a comparative study has been done.

ASSESSMENT CRITERIA FOR THE STUDY All the cities/districts mentioned above are analysed on standardized parameters for easier analysis of the whole COVID19 scenario.

EXPOSURE ASSESSMENT

AGGRESSIVENESS OF THE ISSUE

ORGANIZATIONAL CAPABILITIES

• Understanding City/District/State demographics • Exposure to neighborhood • Population density analysis • City/District/State occupational profile

• Outbreak of the pandemic in City/ District/State • Community transmission • Growth & Fatality rate • Statistics of the City/District/State

• Healthcare facilities for COVID Management • Infrastructure capacities • Departments involved in pandemic management • Efficiency of testing, tracing & sanitization

Service Operation Management Studio 2020 I CEPT University

INTRODUCTION TO CITY APOORVA BHATE PG190169

Vadodara is the 3rd largest city of Gujarat state and the cultural capital of the state. It is based on the banks on river Vishwamitri, that flows from north east to south west through the city. Vadodara is 110 kms from Ahmedabad and is well connected with road, rail and air transport with other cities. Livelihood of city is based majorly on agriculture and industries. Over the last 20 years biotechnology and fertilizers industries have shown drastic growth. As the city lies on the Delhi Mumbai Industrial Corridor, many large-scale industries have invested in the city. GSFC

(Gujarat State Fertilizers & Chemicals), IOCL (Indian Oil Corporation Limited), L&T, ONGC (Oil & Natural Gas Corporation) are some of the industries present in city. This has resulted into migration influx of 25% as per the 2011 census and is rising exponentially. Also, it is rich in traditional artwork and has small scale manufacturing industries of cloth printing (Baroda Prints) in city. Local artisans are involved in handicraft making and nearby villages are also involved for the same.

City Governance

Exposure Assessment

The city is administrative head of Vadodara district which constitutes 8 talukas – Dabhoi, Karjan, Padra, Sinor, Desar, Waghodia and Savli. Vadodara being a metropolitan region with multiple outgrowths in all the directions, it has 2 administrative divisions – Vadodara Municipal Corporation (VMC) and Vadodara Urban Development Authority (VUDA). For ease of administration the city is divided into 4 zones and 12 wards. The corporation team managing this pandemic involves City Mayor – Dr. Jigisha Sheth, City Commissioner – Shri. N. B. Upadhyay, Officer on special duty – Dr. Vinod Rao & the Health officer – Dr. Devesh Patel.

Assessing the pandemic based on city demographics and neighbourhood exposure. As per the 2011 census, Vadodara has a population of 16.7 lakhs and including the outgrowths it totals up to 18.2 lakhs. The city is expanded over the area of 320 sq.km. having population density of 3,400. As per the urban economics standard, the ideal range for population density should be 2,000 – 5,000 for effective service delivery. An age wise assessment was done (Fig A2) which showed the elderly being low in population are affected more with pandemic as compared to other age groups. 65% of males and 35% females are affected in this pandemic (Fig A2). The slum constitutes 11% of the population with 396 pockets spread all

General Body

Mayor

Deputy Mayor

Chairman

(Standing Committee)

Municipal Commissioner

Administrative Section

Chairman

(Various Committees)

Fire & Emergency Services

Food Inspection Department

Revenue Department

Public Relation Department

Tourism Department

Land & Estate Department

Gas Department

11%

3000000 2500000

90.63%

2000000 1500000

93.83%

1000000

87.18%

500000 0

Total

Male

Population

Outbreak of the virus & community spread is important to assess to understand focal points. Vadodara witnessed its first positive case on 24th March 2020, who had a travel history from Spain. Initially just the travellers were infected with the virus and all the transport points were monitored strictly. But then a group went for Jamia meet at Ahmedabad and became the carriers of COVID as Ahmedabad was already a hotspot. Soon it was spread in the whole community. Then a doctor from that area treated other area patients and hence the pandemic outbreak. Till date only 0.6% population of

the city is affected with this virus. There were 4 lockdowns observed in the city as per national guidelines where people had to stay indoors, and all the businesses were closed. Necessities were available to the citizens, but limitations were imposed to stop the community transmission. Home delivery services were started by different agencies and services reached to doorsteps. Macro level containment was observed in initial lockdown and later when unlock period started micro containment strategies were imposed. Constant rise in cases is observed but the statistics show recovery rate of the city is 89%, which is higher as compared to other cities of the state. The death rate is low and comparing with the mortality ratio

81% 77%

with previous years during these months it is observed that pandemic hasn’t had impact on the death rate of the city which is a positive sign for the city. The IFR (Infection Fatality Ratio) of the city is calculated to be 1.4% and the CFR (Case Fatality Ratio) is totalling up to 1.56%. As per the WHO standards the city is performing good with the prevention strategies and the mildness of the virus affecting the citizens is curable with just boosting immunities. 100.0

Comparison of Deceased v/s Recovered

80.0

70.2

78.3

2.7

1.9

84.3

89.0

58.2

60.0 34.2

40.0 20.0

78.2

6.2

3.5

5.7

4.0

3.5

1.7

1.4

0.0

Female

Literates

Sex Ratio

Recovery Rate

Deceased Rate

Confirmed v/s Recovered

Pandemic Affect

30000 20000

Children (0-10years) Elderly (above 60 years) Middle (10-60 years)

Bio Chemistry Department

Street Light Department

3500000

Aggressiveness of the Issue

21%

Drainage / Road Project Department

Figure A1: Organogram of VMC Source: https://vmc.gov.in/departments.aspx 12

Water Works Department

Housing Department

Analysis of Literacy in Total Population

Age wise Distribution of Population

Chief Auditor

Technical Section

Health Department

over the city which might pose alert if the pandemic outbreak is not managed. Hence, there are assigned ANMs in all the slums which have a good communication network and situation is kept under control. The ICCC (Integrated Command & Control Centre) oversees monitoring the social distancing norms at public places. Also, other preventive measures are advised for people to follow at different locations to reduce the exposure against the virus.

35% 52%

48%

10000

Female

Male

65%

City Distribution

Figure A2: Exposure assessment charts Vadodara | Service Operations Management Studio 2020 I CEPT University

Confirmed

Figure A3: Timeline of Covid19 outbreak in Vadodara Source: https://vmc.gov.in/coronaRelated/covid19dashboard.aspx Vadodara | Service Operation Management Studio 2020 I CEPT University

Recovered

Figure A4: Charts showing the statistics of COVID related parameters Source: https://vmc.gov.in/coronaRelated/covid19dashboard.aspx 13

2000

Active Cases Trend

June

May

July

August

September

October

1500

1000

500

0 26-04-2020

26-05-2020

26-06-2020

26-07-2020

26-08-2020

26-09-2020

26-10-2020

Figure A5: Active cases Rate as on 31.10.2020

Organizational Capabilities For any service delivery in city, ULBs organizational capability determines the efficiency of the service. So, the city’s organization capacity is assessed based on human resource, health infra (bed capacity, hospitals & institutional centres, testing labs) and health service that covers testing ability, sanitization & monitoring. The city health department is divided into 3 tier’s – 1st Tier involves all the top medical officers of the city, 2nd Tier involves all the medical officers of senior grade (physicians/UPHC) and 3rd Tier includes the juniors doctors. The 1st tier is the planning and monitoring body of the city. There are 11 government hospitals and 65 private hospitals under 14

them which are further categorized into 6 clusters that have 12 hospitals each under them. 2nd tier includes consultation doctors which help in detection of symptoms and also provide adequate treatment to the patients. There are 34 UPHC (Urban Primary Healthcare Centres) present in the city and each zone has minimum 6 UPHCs. There are total 820 teams of doctors consisting of 1700 members who are involved with door to door surveying. Out of the 1700 there are 400 government teachers who got training during the month of May to build the capacity of VMC. 3rd tier is authorized for field survey through Dhanvantri Raths and have a team of 150 members. The planning body has divided the health facility into 3 categories – Care centres,

Health care centres and Hospitals. The care centres are for non-symptomatic & mild symptomatic patients that provide minimal medical care including AYUSH. Health care centres cater for moderate condition of patients requiring oxygen support, ICUs and emergency services. Hospitals for critical patients, which will have specialists, ventilators and all-tertiary care systems in place. There are 5 authorized government hospitals & 6 medical colleges that provide free beds along with 7 private hospitals. Rest hospitals have designated beds provision and follow a standard ceiling rate for treatment. The city website

Figure A6: Healthcare details shown on VMC dashboard Source: https://vmc.gov.in/coronaRelated/covid19dashboard.aspx

Vadodara | Service Operations Management Studio 2020 I CEPT University

has a separate dashboard for the citizens, displaying the bed vacancy with their contact details. This way the booking process has been made easier for the patients. It is observed (Fig A6) that 70% of the beds are vacant and hence the hospitals can take patients from the neighbouring villages and also provide treatment to other disease patients. Beds per 1 lakh population was calculated to be 320 which adheres to WHO guidelines depicting that the city is future ready for the pandemic. The city has 10 institutional quarantine centres out of which 8 are hotels which are paid & 2 are medical colleges which are free. Total rooms assigned for institutional quarantine are 535. Hospital available per 1 lakh ratio was calculated to be 3, which as per guidelines is average. Recent statistics of 3730 patients undergoing home quarantine show that the patients are preferring home quarantine more compared to institutional facility. Hence it can be inferred that for now there is no requirement of additional healthcare facility in the city.

There are 12 laboratories assigned for RTPCR as well as Antigen testing. The UPHC provide free Antigen testing for the citizens. As observed in the graph (Fig A7) , the testing capacity has been doubled from August 15th, 2020. 2000 AntiTested v/s Positive v/s Recovered 6000 5000

gen kits were supplied daily to the UPHC and authorized laboratories. Each UPHC receives 20 kits daily and accordingly appointment must be booked prior. Also, it is observed that positive cases per day equals to the recovered cases per day which means there is no need to increase the availability of beds.

4000 3000 2000 1000 0 -1000

Tested/Day

Positive/Day

Recovered/Day

Linear (Tested/Day)

Figure A7: Tested vs Positive graph Statistics as on 31.10.2020

Figure A8: Micro Containment Strategy Source: https://vmc.gov.in/coronaRelated/covid19dashboard.aspx

Vadodara | Service Operation Management Studio 2020 I CEPT University

Even after increasing the testing capacity per day only 2.8% cases turned out to be positive. This means that the virus transmission rate seems to be stable. Average testing conducted in city is 3100 per day. So, testing to population ratio is derived to be 1:300 which is efficient looking at the current scenario. Sanitization in the households is done by VMC without any charge. Fire department is assigned the job of sanitization and 2-3 people visit the household and sanitize the interiors and immediate exteriors within 1-2 hours. This process takes place once the health department checks the patient’s reports or informed by the patient. But for the neighbourhood or commercial areas, private agencies are contacted.

Once the patient is positve, their immediate contacts & family members are made aware. And their health is monitored. During the lockdown contact tracing was efficiently done but as the unlock phase started and cases started rising contact tracing has been reduced.

Service Concept The organizing idea for the pandemic service delivery is – Early detection, early treatment & eliminating the virus. For this regular door to door survey and screening took place this led to quick identification of suspects thus receiving rapid treatment and help break the chain of community transmission. Vadodara is following a 3x3 strategy which has 3 phases of working with 3 typologies. For this a group of all the specialist doctors was formed named SETU. This induced collaboration of private hospitals and government hospitals and the bed capacities were planned in phases. Phase 1 – up to May 10th, Phase 2 – May 11th to May 31st and Phase 3 - after June 1st involving decisions related to three typologies – Covid Care Centre, Health Care Centre and Hospitals. Formation of SETU helped reach the 16

healthcare facility within proximity of 1km. The service concept was to implement the organizing idea with ease of service delivery to the citizens and avoid unnecessary panic conditions. The services provided by VMC involves distribution of food packets to the BPL people and daily wage workers. Free bed provision in hospitals and tele consultation. Drone surveillance to identify the violators of guidelines. Monitoring of slums through team of ASHA workers. Citizens received preventive medicines and immunity booster packets. Local grocery shops started doorstep delivery service with the permission of VMC. Vegetable vendors were fixed area wise and door to door service was made available. Rebate on residential & commercial taxes. Table A1: Case Study analysis Parameters

Case Study

Process Analysis

Two case studies were conducted to undertand the process of pandemic management in the city (Table A1).

Along with case study, authorities were interviewed to know the service delivery from their end. Then rough mind maps were produced, and four process were derived by categorizing the activities. The processes are – Identification, Confirmation, Treatment & Prevention.

Figure A9: Test reports - RT PCR & Antigen Report

Patient 1

Patient 2

Name

Ankit Darji

Karan Kadam

Occupation

Accountancy Business

Service in IT firm

Test done

RT-PCR & Chest X-Ray in Private Laboratory

Rapid Antigen in UPHC

Consultation

Initially Private Doctor, after testing positive consultation with Gov. Hospital

UPHC (Diwalipura)

Exposure

Frequent client visits

Society gathering

Symptoms

Mild

Quarantine

Home isolation for 14 days

Home isolation for 7 days

Medication

Provided by Government Hospital

Provided by UPHC

Follow Up

Alternate days during quarantine by health dept VMC & weekly after quarantine for 1 month

None till date

Sanitization

by VMC without patient communicating

by VMC after calling helpline by the patient

Contact Tracing

Details taken by health dept VMC

No such activity done

Vadodara | Service Operations Management Studio 2020 I CEPT University

PROCESS PROFILE WORKSHEET TOOL: For each process, a profile sheet was made describing the process units, owners, service objectives, risks associated and measure of success with key controls. In case of identification of the patients it is important for the patient to know the symptoms and take proper consultation from the doctor. VMC has provided a tele consultation line to help the needy and also a survey team is working on the field to track the suspects. Dhanvantri Rath is a new addition which has eased the job of contact tracing and identifying the patients. Here the risks involved are missing an area for survey, unauthenticated details and many people are reluctant to share the details or respond the team. Therefore, to mitigate the risks there should be

regular monitoring on the survey team and a standard protocol should be followed to collect authenticated details. Also, awareness among the citizens is highly important. In case of confirmation of a positive case, the authorized testing centre should have kits available and keeping of records is very critical as based on this the action plan is decided. Improper diagnosis or inaccurate reports are the risk factors in this process. To overcome these there should be standard testing procedures followed and regular

tab on the labs should be kept. Advance technology should be use along with trained and professional staff. The next process is treatment, in which patient has to decide the quarantine facility and get the treatment. Unavailability of favourable environment or lack of beds can be the risk aspects. Lack of monitoring the health data as promised in the package can also lead to distrust with the service delivery by VMC. Therefore, prior checking and proper consultation is required before booking the facility.

UPHCs of the city are seen overburdened with work If there is delay in these steps then treatment is affected

Testing process is a critical step which determines the dynamics of pandemic in the city

Figure A10: SWIMLANE chart

Vadodara | Service Operation Management Studio 2020 I CEPT University

As seen, for every process the health dept and UPHC are accountable and consulted but the responsibilities differ in all processes. UPHC acts like a backbone to VMC health department. The main process of record keeping, Table A2: RACI chart Vadodara Municipal Corporation (Health Dept & ICCC)

Medical Officer (Urban Primary Health Centre)

Doctors (hospitals/ clinics)

Quarantine Centre

Authorized hospitals

Fire dept

Police dept

Patient

SERVQUAL TOOL: After understanding the service delivery, it is important how the patients are perceiving the services and what is their level of satisfaction. So a sample survey was conducted of 20 patients. Where the patients had to score the 5 parameters of service quality - Reliability, Assurance, Tangible, Empathy & Responsiveness on the scale on 0-7. The patient were chosen from different zones & occupation then the difference in perception & expectations was calculated. Based on high negative scoring the gaps were identified.

Testing

Record keeping

Home Isolation

Institutional Quarantine

Hospitalization

Sanitization

Contact tracing

Monitoring

R R A

I I

R R

Accountable

Consulted

Informed

Vadodara | Service Operations Management Studio 2020 I CEPT University

Nagarwada

Empathy

TESTING

Responsiveness

3 Red Zone

0.5

0.2

0.0 -1.0 -2.0

-0.75

-1.1

-1.2 -2.0

-3.0

-0.5

-2.4

Orange Zone

Figure A11: Location of patients

-0.4

-1.0

-0.8

-1.5

Figure A12: Cumulative RATER Analysis for all process

More exposed to the virus

-1.7

-2.0

SANITIZATION 0 -1 -2 -2.1

-3

-3.05

-4

-2.8 -3.45

-3.85

-5

CONTACT TRACING

0.3

0.5 0 -0.5 -1 -1.5

-0.9 -1.45

Figure A13: Occupational aspects of patients

3 Makarpura

Green zone

• Tangible aspects in all the service process has gaps which needs improvements. • All the services are reliable but lacks assurance. • The staff of VMC is responsive and empathetic towards the patients.

Vadodara | Service Operation Management Studio 2020 I CEPT University

-1.65

-2.5 -3

-2.8

karelibaug

Waghodia

Akota

Tangible

-2

Responsible

0.0

Assurance

Laxmipura Slums

Gotri

Diwalipura

RATER Analysis of Pandemic Processess Reliability

Less exposed to the virus

Self identifying

R 18

Authorized labs

Survey

Prevention

Also using this swimlane tool, it is clear that testing is an critical point on which the whole dynamics of city management depends.

The corporation is responsible in sharing of data with the other departments and they keep a tab with the help of ICCC. Also, it can be seen here for contact tracing, UPHC is overburdened with work. As shown in Table A2 the stakeholders are informed with patients lists so that related actions are taken timely.

Identification

The activities included in the prevention process has to be so immediate to avoid further delay intreatment process of the patient. Inefficiency can be observed at this level and could turn out to be risky.

labs are accountable as the data is been circulated by them to the health department of the state and the city.

Confirmation

With the help of this tool, we can see in all the process the VMC health department and UPHCs are in loop with each other. Data is shared with the health department through 3 delivery points - Testing labs, Hospitals and UPHCs. Hence, a well equipped team needs to be present in the department so that no malfunctioning is observed.

RACI TOOL: Then RACI analysis was carried out for clarifying, defining roles, responsibilities & accountability of each department. The chart describes stakeholders’ level of involvement in each process.

Treatment

SWIMLANE TOOL: Further studying the process risks, understanding the connections, communication and handoffs between different departments conclusions are derived (Fig A10).

MONITORING

1.5 1

1.2

0.5 0 -0.5 -1

-0.5

-1.5

-1.3

-2 -2.5

-2.2

-2.1

Figure A14: Cumulative RATER analysis of all 4 process 19

RATER Analysis of Testing

RATER Analysis for Contact Tracing

Appointment as per the testing kits…

0.2

Special treatment to kids & elderly

Various ways to get details if nt shared

-0.9

-0.45

Sensitive & approachable staff

Create rapport & take info

-0.3

Screening & detail verification

-1.7

0.3

Inform isolation measures to contacts

Competecncy in services

-2.8

-0.2

Services from UPHC staff & doctors

Ethical & no data sharing

-1.35

Communicate timely results

-0.3

Lab equipment as per guidelines

-1.65

No tracing of immediate contacts

-1.45

-0.55 -2

-1.5

-1

-0.5

0.5

RATER Analysis of Sanitization Delivery timing

-3

-2.5

-2

-1.5

-1

-0.5

-3.5

1.2

Proper analysis of health condition

-1.7

-2.1

Regular free medicine

Work as per customers needs

-2.5

-2.95

Effective communication to understand need

Within time frame & error free

-3.5

Favourable condition & guidance

-3.05 -4

-2.2

Keeping tab on patients

-3.45

-4.5

0.35

Daily call to check health

-3.85

Well mannered and guided staff

-3

-2.5

-2

-1.5

0.5

RATER Analysis of Monitoring Motivation & Stress relief through helpline

Sensitive towards activity

Service provided to all

-1

-0.5

-1 -4

-3

-2

-1

Figure A15: Individual process RATER analysis

Figure A16: Individual process RATER analysis

Testing process is performed well in the city (Fig A13). Good points: The labs give appointments as per availability of the testing kits. The results are communicated timely to the patients. Scope of Improvement: • Screening & detail verification is not done as per protocols. • Also inadequate service is received from the UPHC staff.

Sanitization process observes majority of drawbacks (Fig A13). Good points: The staff is sensitive towards carrying out the activity & works as per the set protocols. Scope of Improvements: • The service is provided only to RTPCR tested patients and other patients have to rely on private players. • Also the service is not delivered timely to the patients.

Contact tracing is not been conducted in the city from past few months (Fig A14). Good points: The staff creates rapport with the patients and try to get information/details to take further actions. Scope of Improvements: • Patients hesitate in sharing information due to security reasons. • If details of contacts are shared, the contacts are not informed proper isolation measures. Monitoring of home quarantine patients lacks in promised daily follow ups hence more patients are prefering home quarantine (Fig A14). Good points: The patients get regular free medicines & motivation whenever required through helpline. Scope of Improvements: • As per the protocols, daily follow up with patients is not conducted. • During follow up, the staff is inefficient in diagnosing the health condition of patient. • Needs of the patient are not properly addressed.

FMEA TOOL: After identifying the gaps, FMEA (FailureMode Assessment) is done to find out reasons behind the failures and provide necessary recommendations. For that ranking scale was designed where the severity of the effect of failure was assessed based on dissatisfaction, adversity and displeasure experiencedbythe patient. Similarly the occurrence of the failure is ranked on the duration it takes to complete and the controls on the services are assessed based on how certainly it can detect those failures. Then the risk priority number is calculated to know the priority of mitigating the risk.

Refer Annexure A3 for details. For example, while testing in the UPHCs inadequate services were received from the staff, due to overload or absence of additional benefits to work on because of which the risk priority no is high. To combat this it is suggested that patients are divided as per capacity and if required more staff to be assigned in infected areas. Also the staff should get break from work & incentivised for their service. This will reduce the failure risk of this process. Similarly sanitization service should be subsidized. Minimal charge in the ratio

Table A3: Sanitization FMEA calculations

As contact tracing is not taking place, the risk priority is calculated and resulted in high numbers. So it is suggested a formatted sheet has to be filled by patient and the staff should upload on common portal which will smoothen the process. Also in monitoring, major risk is noted where there is no follow up with the home quarantine patient. Here digital interference can be done to combat the risks. Though there are recommendations provided but there are parameters which can influence the performance. The factors influencing are scaled based on status of other Indian cities and Vadodara’s ranking is marked. To cal the impact, firstly it is assumed that risk priority is ideal and further what factors are influencing and in what intensity is averaged out. From the ideal difference of the average value is calculated. And then mapped with previous gaps.

Therfore, scope of improvements are provided with recommendations further.

Vadodara | Service Operations Management Studio 2020 I CEPT University

70:30 where 30% paid by patient should be implied so that service is availed by all and government doesn’t feel the burden.

Vadodara | Service Operation Management Studio 2020 I CEPT University

Summary Service audit tool is used here to compare the current performance of system and with the recommendations how the system will be improved. All the positive aspects & negatives identified from SERVQUAL are mapped together. After suggesting the recommendations, negatives are improved and change in graph is seen. For example, currently Inappropriate screening & detail verification is observed at labs so after suggesting regular training & standardization of data the graph is converted into positive mode. Good points of city • Door to door survey through Dhanvantri Rath has increased the coverage area. Further increasing the efficiency to detect the probable positive cases. • Police department of the city is efficiently imposing the social distance norms & wearing masks in public guidelines. • BPL citizens are receiving free two time meals till date from the VMC. • The organizational capabilities are improved with daily forecast of rise in cases. 3 new CHCs were constructed in during lockdown 4.0. • Pandemic has affected to only 0.9% of population due to adoption of right

Figure A17: Service Audit Profile Graph

Vadodara | Service Operations Management Studio 2020 I CEPT University

measures timely. Improvement areas of city • Due to lack of contact tracing, community transmission is not contained. • No strict monitoring on the home quarantined patients. • Protocols are not followed at UPHCs which is the backbone of health dept of VMC.

Change In Business Landscape of City • The pandemic has improved the health infrastructure of the city. • More people are opting for health insurance. • City is expecting 4000 million investment from pharma companies. • Food safety on wheels vehicles provided to VMC for testing on food from various outlets for this festive season. • 30%-40% rise in sale of bicycles. • Reduction in on road traffic by 61% post Unlock 3.0. • Start-ups in the vertical of sanitization & cleanliness of places have grown during the pandemic.

Vadodara | Service Operation Management Studio 2020 I CEPT University

INTRODUCTION TO GANDHINAGAR CITY ANIRUDDH VAGHELA PG190121

Gandhinagar, the capital of Gujarat is named after Mahatma Gandhi. Gandhinagar is one of only three government planned cities in India. It was planned and implemented between 1965 - 1970. The planning of the Gandhinagar has been done by two planners from India namely H.K. Mewada and Prakash M Apte. Gandhinagar is spreaded over an area of 205 sq. km. which caters to a population of 2,06,167. Gandhinagar has been divided into 2 zones, 8 wards and 30 sectors. Each sector has health centre, community centre, school and recreational facility. Gandhinagar has IT Park, GIFT city and Industrial Estate Park. Estate

Park is having multiple units, which includes food processing industry, electronics, chemical, textile, automobile and ceramics. Out of which textile is main sector for creating employment in Gandhinagar district. Also, food processing industry is growing because of nearby areas like Manasa, Kadi and Kalol. Major population of Gandhinagar city is working in public sector because Gandhinagar is a capital of Gujarat. 43,127 people are employed in Large Scale Industries and 59,547people are employed in MICRO & SMALL ENTERPRISE UNITS in Gandhinagar district. (MSME- DEVELOPMENT INSTITUTE, 2012).

City Governance Gandhinagar Municipal Corporation was formed in 2011. Gandhinagar city is managed by two bodies: 1) Gandhinagar

Exposure Assessment

CORPORATION, 2017) Organogram GMC is responsible for all services which are mentioned in the 74th Amendment Act. There are six departments under GMC and two departments are under R & B, which is a state entity. Drainage and Parks & Gardens are being managed by R & B department. Sanitation, Health, NULM, Fire and Safety and Town planning departments are under Gandhinagar Municipal Corporation. Out of this sanitization, Health, NULM and Fire department are involved in COVID-19 management at Gandhinagar.

citizens for execution of any campaign in the situation of pandemic. Growth of Gandhinagar is towards south side. Also in the south of the Gandhinagar Ahmedabad has highest number of cases in Gujarat (Government of India, 2011).

To analyse the COVID exposure of Gandhinagar, various parameters were taken into consideration. This includes total population, population density, literacy rate, slum population, senior citizen population and expansion of Gandhinagar towards neighbouring city. Total population of Gandhinagar is 2,06,167 and population density is 416 people/sq. km. Senior citizen population is 14,372, which is 6.07% of total population (Government of India, 2020). Migrant influx is 7.08% in Gandhinagar district (TIMES OF INDIA, 2019). Migrant from Bihar, Uttar Pradesh,

Aggressiveness issue

the

To analyse the aggressiveness of COVID-19 situation at Gandhinagar, parameters like testing rate, fatality rate, recovery rate and containment zone were taken into consideration. As on 1st November, 4990 number of cases were reported with 92 deaths. Fatality rate is 1.8% in Gandhinagar which is bit high than other cities. Below chart shows the how cases have been increased with respect to recovery rate. During Jun-July recovery rate was very less

Figure B1: Gandhinagar District Map Source: GMC Website

Municipal Corporation and 2) Road and Building Department (R & B department). In Gandhinagar various authorities are involved for COVID management which includes Mayor, Municipal commissioner and principal health secretory. Mrs. Ritaben patel is current mayor of the city, Dr.Ratankanvar H. Gadhavicharan is a commissioner and Dr. JAYANTI RAVI is a Principal health secretary of Health and Family welfare department of Gujarat. (GANDHINAGAR MUNICIPAL

but from August recovery rate increased and now it’s equivalent to the rate of active cases (Government of Gujarat, 2020). Analysis of containment zones of last 14 days based on land use pattern To analyze the micro containment zones, data of micro containment zone from 16th to 30th Oct was taken for a sample size. After that it was segregated sector wise for further analysis. So total number of houses in particular sector under micro containment zone was derived. Further each sector with total number of houses was compared with land use pattern. In zone 1, class 1-2 officers and ministers reside whereas in Zone 2, Class 3 officers, migrant (lower and middle income group) resides (GANDHINAGAR MUNICIPAL CORPORATION, 2017).

Figure B3: Exposure assessment Source: Census, 2011

Maharashtra, Rajasthan, Madhya Parades and Chhattisgarh (Sugandhe, 2017).

Gandhinagar being the capital city of Gujarat, intra state migration is high comparatively. Also, literacy rate of Gandhinagar is 91%, whereas literacy rate of Gujarat is 78%. High literacy rate

Figure B2: GMC Organogram Source: GMC Website

helps in spreading awareness and engaging Gandhinagar I Service Operations Management Studio 2020 I CEPT

Figure B4: Confirmed vs Recovery rate Source: GMC Covid-19 dashboard

Gandhinagar I Service Operation Management Studio 2020 I CEPT

More than 60% slums are in micro containment zone and these group of people are more vulnerable in the COVID-19 pandemic. Also they are more exposed because most of them are being frontline workers. Sectors of zone 1 where ministers and class 1-2 officers resides has micro containment houses from 30 to 50 and few sectors is having more than 50 houses. Whereas Sectors of zone 2 where class 3 officers, migrant, slum dwellers resides has Micro containment with high proximity and covers more than 70% of total containment of Gandhinagar.Also, Approximately 50% slums are in containment zones and biggest slum of Gandhinagar sector 22 and 24 has highest number of houses under micro containment zone.

Organisational Capability To access the organizational capability in terms of Human resource, bed occupancy, testing capability, sanitization and contact tracing different cities and Govt. guidelines were taken as a basis. Whole assessment is divided into few parts which includes Hospital number, testing rate, sanitization coverage and contact tracing. Gandhinagar has four hospital allocated for COVID-19 treatment. Out of that 1 is Government and others are private. AS on 6th September out of 701 beds 318 were occupied and 383 were vacant. Which shows that as off now Gandhinagar has sufficient number of beds for the citizens. Also four labs are allocated for COVID-19 testing. For RT PCR cost is ₹ 2,000 and Rapid test is free for all which is

kits are provided by state government to the GMC every day (Government of

Gujarat, 2020). In Gandhinagar, 1026 tests are conducted per million whereas in Gujarat 1102 tests per million are conducted which shows that testing rate at Gandhinagar which is low than other cities like Ahmedabad and Delhi. Fire department covers neighborhood area of hospital, quarantine center, containment zone, slums, societies and government Table B. 1- Testing labs

Table B. 2- Human resource of Health team

Process Analysis Based on existing system in place at Gandhinagar, service concept was derived that emphasis on social distancing, strict quarantine, high testing and efficient monitoring. Which also includes service provided by the municipal corporation and received by the citizens. PROCESS IDENTIFICATION After analysing existing structure at Gandhinagar, mind map for whole COVID-19 process was made, which helped in deriving four key processes: 1)

Source: GMC Covid-19 dashboard

available at UPHC. Daily 1,500 antigen

Figure B5: Confirmed vs Recovery rate Source: GMC Covid-19 dashboard

office (If any positive report). It’s free of cost (Patel, 2020). Inside house sanitization is done by health team which covers internal space of Slums, societies and government offices. Malaria department is involved for sanitization inside house (kumar, 2020). Private sanitization services There are many private players involved in sanitization. For Commercial office/ industry price is ₹ 1.5 per ft. and house price is ₹ 2,000.

Source: Primary Interview Table B. 3- Bed occupancy

Figure B6: Land use pattern Source: GMC Covid-19 dashboard Gandhinagar I Service Operations Management Studio 2020 I CEPT

Source: GMC Covid-19 dashboard Gandhinagar I Service Operation Management Studio 2020 I

Identification 2) Confirmation 3) Treatment 4) Prevention. Each key process has trigger event which is responsible for particular key process to occur. Identification has a three steps which are Self-identification, Sample survey (Health team) and Contact tracing (Health team GMC Administration). Confirmation has a testing and a record keeping. Under treatment there is quarantine and hospital treatment. And prevention includes Sanitization (Health team, Fire department), Surveillance (Police) and Sensitization (Health team). PROCESS PROFILE To map all four key processes, process profile tool was used which gives clarity for the objective of the process till risk and also includes the key control for the particular process. Following process profile is identification. Objective of the process is Self-identification based on symptoms, contact history, sample survey and contact tracing by health team. Inputs would be Infrared from the thermal gun by Health Team, Questionnaire survey by Health Team and Notification by GMC Administration. For that output would be Temperature measurement and Survey result. Service risks are missed out any containment zone, Asymptomatic people won’t get detected by screening and 29

Figure B7: SWIMLANE Source: Primary 30

Gandhinagar I Service Operations Management Studio 2020 I CEPT

-3 -4

-5

-6

-4 -5

RATER

-6

Figure B. 8- Testing RATER Source: Primary Gandhinagar I Service Operation Management Studio 2020 I

-4

Responsiveness

Approachable staff

Helpful guidance

Waste collection

-3

Feedback system

-2

Consultation platfrom

-1

Monitoring

Waiting period

Approachable staff

Social distancing

Hygenic premises

Efficient communication

-3

Demarcation

GAP (P-E)

GAP(P-E)

-2

RATER

-5

-6

-1

Responsiveness

-2

Empathy

-1

RATER

-4

Reliability

-3

Assurance

Responsiveness

-2

GAP (P-E) Empathy

-1

Tangible

GAP(P-E)

0 Assurance

To know more about service quality of COVID management at Gandhinagar servqual survey was conudcted for which sample size was 20 people from the different areas of Gandhinagar. Out of 20, 8 samples were taken from zone 1 and 12 from zone 2. 8 samples were collected from containment zone , 6 from non-containment zone and 6 from slum areas. 4 samples were from age of 0 to 14 years, 10 from age of 14 to 60 years and 6 samples from age of more than 60 years. RATER survey was conducted for Testing, Home quarantine, Sanitization and surveillance.

Testing In testing tangible got highest negetive due to unhygenic premises. Also, waiting period at few testing centre is more than 20 minutes so under responsiveness it got second highest negetive which is -2.9. Good points for testing service are accuaret test results, results on time and social distancing is being followed at test centre. cleanliness at centre needs to enhance and waiting period should not be more than 20 minutes.

Professional staff

SERQUAL-TOOL

Source: Primary

Reliability

RACI-TOOL RACI tool was used to analyse the responsibilities of each task for COVID management system which explains information about who would be responsible, accountable, consulted and informed for particular task. Study of RACI explains there are two departments involved in sanitization which creates confusion amongst citizens.

Home quarantine In Home quarantine service reliability and assurance got highest negative ratings due to inefficient monitoring, sub optimal response from the consultation platform and no feedback system. Despite this issues, there is good day to day separate waste collection from patients house, good responsiveness and demarcation provided for all patients. People started prefering home quarantine over institutional so efficient monitoring plays a vital role in fight against COVID.

Table B. 5- RACI

Accurate result

Source: Primary

shortage of staff. For that key controls are 100% screening in containment zone, enrolling more medical staff and strict early stage detection policy.

Result on time

Table B. 4- Service Concept

RATER

-5 -6

Figure B. 9- Home quarantine RATER Source: Primary 31

-6 -7

Figure B10: Sanitization RATER Source: Primary

Assurance

Tangible

Responsiveness

Action againstcitizens

RATER

-6

-1 -2

GAP(P-E) Responsivenes s

Assurance

-5

Tangible

-3

Safety gears

-2

Effective policing

-1

Service audit profile

-3 -4

In surveillance responsiveness and reliability got highest negative ratings due to inefficient monitoring at micro containment zone and no action against those who are violating the government guidelines. For initial days police comes for surveillance yet monitoring was not ensured on all 14 days. It is observed that police wears mask during surveillance which is a good point.

-5 -6 -7

0 -1 -2 -3 -4 -5 -6 -7

GAP(P-E) Responsiveness

Understand needs of the citizens

Safety gears

Internal coverage

Sanitization within 24 hours

Neighbourhood coverage RATER

-5

GAP(P-E) 0

Action against those who are breaking rules

-4

GAP(P-E) Contacting family for sanitization

-3

-7

Policing effectiveness

-7

-2

-6

Figure B11: Surveillance cont. RATER Source: Primary

RATER

-6

-1

RATER

-5

-7

-5

-4

Safety gears

-4

-3

Reliability

-3

-2

Surveillance (PAN City) It is observed by people that surveillance is inefficient at high density areas during peak hours. Few public places where many people gathers everyday at particular hour, where more surveillance is required. Also, responsiveness got highest negative ratings because of no action taken against those who are violating the government guidelines. At many public places it was observed that people are not following the guidelines. It was suggested by people that surveillance during peak hours will help a lot in combating COVID.

Surveillance of high density area

-2

Empathy

Tangible

Reliability

-1

-4

GAP(P-E)

Reliability

In sanitization reliability got highest negative rating due to lack of sanitization within time frame, low internal coverage and lack of contacting family after getting positive report. It has been observed that sanitization is not done within 24 hours which is very important element of prevention strategy for a city. High income group mostly calls private companies for sanitization inside houses whereas it is not affordable for low income group and slum people. For them ULB should provide internal sanitization.

Surveillance (containment zone)

Everyday monitoring

Sanitization

Figure B12: Surveillance PAN city RATER Source: Primary

Gandhinagar I Service Operations Management Studio 2020 I CEPT

Gandhinagar I Service Operation Management Studio 2020 I

INTRODUCTION TO PATHANAMTHITTA DISTRICT IRENE ANNA SHAJI PG190397

Pathanamthitta is known as “Land of PILGRIMAGES and RELIGIOUS HARMONY” The thirteenth district in the state of Kerala nestles its head on the slopes of western ghats and stretches to the low-lying rice fields bordering Alappuzha district. The district consists of three natural divisions the lowland, the midland and the highland. The highland stretches through the western ghats and descends midland in the center, to the lowland and coconut gardens on the western borders of Alappuzha district. The topography of the district

is highly undulating. It starts from the tall hill slopes covered with thick forests on the east along the mountains down to the valleys and small hills to the flat land of coconut trees in the west. The District is known as PILGRIMAGE TOURISM (Sabrimala Temple, Parumala Church, an iconic festival of Hindu Muslim harmony in Erumeli Petta Thullal) of the Kerala State. It was formed on 1st NOVEMBER, 1982.

City Governance Pathanamthitta is an inland District situated in the Central Travancore region in the state of Kerala, India. Some of the key members involved in administrative system are Chief Minister of Kerala Shri. Pinarayi Vijayan, Health Minister Smt. K.K.Shailaja, Member of the Lok Sabha (MLA) Shri. Anto Antony and District collector of Pathanamthitta Shri. P.B.Nooh.

The administrative system is mainly divided into two, revenue division and local self governments (LSG). The revenue division has 6 taluks and 70 villages while the LSG has 53 panchayats and 4 municipalities (refer figure C2 and C3). The key agencies involved in COVID-19 Management across the District were District Administration, Volunteers (8,283), Police Department (1500) of which Janamaithri Suraksha Police (32) is part of,

Figure C4: Pathanamthitta District Business Profile Source: State Planning Board, 2019

Fire Department, Kudumbasree members (min. 1,042) and Health Care Team and COVID care Hospital Medical Team (425).

Figure C2: Administrative Division Pathanamthitta Source: Pathanamthitta District Administration, 2020

Pathanamthitta District has a business profile of agro and food-based industry due to some major crop cultivations of coconut, rubber, paddy, pepper, cardamom and tea. Hydroelectric power plants situated in the District provides one-third of the electricity demands of Kerala state. Some important rivers flowing through the District are Achankovil, Manimala, and Pamba (State Planning Board, 2019) (refer figure C4). Now, with a study of exposure assessment, the exposure of the district towards COVID-19 can be assessed.

Exposure Assessment

Figure C1: Pathanamthitta District Revenue Division 36

Figure C3: Administrative Framework Pathanamthitta Source: Pathanamthitta District Administration, 2020 Pathanamthitta I Service Operations Management Studio 2020 I CEPT University

According to the Census of India 2001, the District had a population of 11,95,537 with a density of 453 inhabitants/sq.km (low

density, Kerala average population density - 859 inhabitants/sq.km. - 2011 Census). The ratio of female is more than male, i.e., 53% female and 47% male. Percentage of population based on age group in the District, 18% falls in 60+ age group (District with highest senior citizen number in State), 63% in 15-59 age group followed by 19% in 0-14 age group. The literacy rate of Pathanamthitta District is 96.93%, highest in the state of Kerala (Census, 2011). The District has an influx migration of 16,066, as per the labor department, migrant laborers and composition ranges to 7,549 workers from West Bengal, 1,557 workers from Bihar, and rest from other parts of India. 835 labor camps were initiated by the District during COVID-19 lockdown in order to cater to their shelter and food so as to avoid the situation. The District also accounts for its large number of immigration which contributes to nearly 6% of the state’s immigrants. In the rise of COVID 19 forecast of expected returnees were prepared which added up to 21,000. Pathanamthitta District does not have an Airport and possible mode of connectivity is through the railway or by road. The District shares boundary with three other Districts of Kerala i.e., Alappuzha, Kollam,

Pathanamthitta | Service Operation Management Studio 2020 I CEPT University

Figure C5: District boundary neighborhood context

and Kottayam, it also shares the border with Tamil Nadu state which is a major path for import and export of goods (Pathanamthitta, 2020). Next, a study was required to access the aggressiveness of the issue in the district.

Aggressiveness of the issue From January to February 2020, even before COVID-19 case reporting started a 24-member state response team was formed for airport screening, testing, and isolation. The first COVID-19 case was reported on March 9, 2020 followed by 4 other cases were reported. The District was able to provide an efficient management system due to which there was no positive case reporting during the lockdown 2.0 phase (15 April – 3 May). Spike in cases started due to the inward movement of the international and national crowd 37

through the Vande Bharat initiative during unlock 1.0 phase (1 June – 30 June). There was a gradual increase in spread through contact (in vegetable and fish market due to import of goods from Tamil Nadu) which affected even the front line workers (9 police personnel and 3 health workers tested positive). Also, steep rise in community spread was seen due to gatherings during the festival of Onam. Based on the cumulative analysis study

it can be understood that though there was a rapid spike in cases there is a high rate of recovery (81.98%) and so far there have been 11 (0.08%) deaths, which shows that the cases so far was under the organizational capability of the District. The trend in positive case reporting is in the ratio of 67% through community spread and 33% through travel contact. Home quarantine was preference over institutional quarantine if the citizen

Figure C8: Case trend as on 31.10.2020 Source: Kerala Government COVID 19 Dashboard

had enough facility (Kerala Government, 2020). Further to understand the capacity of the district, a study on organisational capability is essential.

Organisational Capability

Figure C6: Cumulative Analysis of COVID 19 cases as on 31.10.2020 Source: Kerala Government COVID 19 Dashboard

Figure C7: Cumulative Analysis of COVID 19 cases as on 31.10.2020 Source: Kerala Government COVID 19 Dashboard 38

There are various bodies involved in providing manpower to the District which mainly includes, Janamaithri Police, Kudumbasree, Health Team, District Administration, and Volunteers (Kerala Local Government, 2020). Janamaithri Police was a community policing project of Kerala which was initiated in 2008 (Police, 2017). The objective was to seek the cooperation of the community, understands their needs, give priority to their security and taking into account the resources available within and thus attempting to streamline Pathanamthitta I Service Operations Management Studio 2020 I CEPT University

the activities of police personnel at local police stations to address the special problems of each community to increase their efficiency and productivity. All police staffs were involved in city surveillance and enforcement of norms (use of mask, social distancing, fine, etc.) during COVID 19 while the Janamaithri Police (Police S., 2020) focussed on sensitizing (Break the Chain), surveillance, and help to those in quarantine, documentation of details, tracking travel history for contact tracing and help for elderly. Kudumbashree was initiated on 17th May 1998 for the poverty eradication and women empowerment program under the State Poverty Eradication Mission (SPEM) of the Government of Kerala (Kudumbashree, 2020). The name Kudumbashree in the Malayalam language means ‘prosperity of the family’. The name represents ‘Kudumbashree Mission’ or SPEM as well as the Kudumbashree Community Network. Activities contributed during COVID 19 include a community kitchen, grocery kit preparation, IEC programs, production of masks and sanitizers, contacts citizens aged above 60+ for the supply of essentials or health status, or provides assistance and paid sanitization was also provided. The District has an effecient COVID respose

Figure C9: Kudumbasree Organization Framework

Figure C10: District Police Station Organogram

Figure C11: Enforcement actions taken by police department in Pathanamthitta District during COVID Source: COVID Jagratha Dashboard, Kerala

team to tackle offence reported also the District accounts for a total of 475 health team members (260 – Medical Professionals, 215 – Non-Medical Staff) followed by nearly 8,238 volunteering staff to undertake additional tasks. Also, additional psychological support was provided other than treatment for nearly 2,169 citizens during the quarantine and lockdown phase.

Pathanamthitta | Service Operation Management Studio 2020 I CEPT University

The District Administration is responsible for contact tracing during which patient id, name of the patient, gender, age, address, and contact number details are collected from the citizen. During the process, if a cluster is identified, it gets marked as a containment zone and further, it gets updated on the state dashboard for public viewing with details of the district, local body, and ward number and name. 39

Figure C12: District Volunteering Staff Activities

Figure C13: Psychological Support Treatment Table C1: Types of testing and procedure

Containment zone is mainly classified into four, Institutional Cluster (>2 COVID +ve case through contact), Closed Community Cluster (>2 COVID +ve case through contact), Limited Community Cluster (250 COVID +ve case within 14 days) and Large Community Cluster (>50 COVID +ve case within 14 days). Sanitization is done by fire department in case of government buildings while in private buildings or residences, kudumbashree undertakes a paid sanitation services where disinfection is done for 2rs per sq.ft., cleaning and disinfection for 3.5rs per sq.ft. and deep cleaning for 8rs per sq.ft. Across the District mainly four types of tests are being conducted Antibody test, RT – PCR (Reverse transcription Polymerase Chain

Reaction), Rapid Antigen Test and CB / True NAAT – (Cartridge Based) Nucleic Acid Amplification Test (Refer Table C1). So far 1,72,685 tests have been conducted in the District but a challenge here is that there is no classified documentation of repeated tests by the same person. On average it can be concluded that nearly 8.4 is the percent of positivity reported among the sample tested. This shows that the District has an effective system in place because there are higher tests conducted to the lower percentage of positive case ratio reporting (Kerala State IT Mission & NIC Kerala, 2020). The District has a total of 19 facilities allowed for providing treatment for

Table C2: Types of treatment centers and infrastructure

Source: COVID 19 Jagratha Dashboard Table C3: Types of quarantine centers

Source: COVID 19 Jagratha Dashboard Source: COVID 19 Jagratha Dashboard 40

Pathanamthitta I Service Operations Management Studio 2020 I CEPT University

COVID-19 positive symptomatic patients which can be classified into three namely,

Table C4: Service Concept Pathanamthitta District

1. Type A – Mild Symptom COVID First Line Treatment Center (CFLTC) COVID Second Line Treatment Center (CSLTC) 2. Type B – Fever, Breathlessness COVID District Government and Private Hospitals 3. Type C– Pneumonia, BreathlessnessMedical College Hospital During the initial phases, treatment beds were available in the ratio of 1:160, understanding there was wastage of available resources the treatment bed availability was revised to 1:505. An optimum number of treatment centers have been provided across the district. Yet the number of additional treatment facilities like ICU and ventilators seem lacking because only 1 in 1,526 (senior citizens, being the most vulnerable group) gets access (refer table C2). Further, the District has also expanded its capacity of institutional quarantine to facilitate for those immigrant returnees such that at least 1 in 12 gets access to institutional quarantine facility (refer Table C3). Next, is to look at the service concept of the district.

Service Concept Service concept was prepared (refer table C4) to understand the service provided by the district administration and service received by citizens.

Process Analysis For analysis of the process firstly a mind mapping was prepared (refer appendix C1) from which the process flow was understood clearly. Based on this, the process identification matrix was created

Pathanamthitta | Service Operation Management Studio 2020 I CEPT University

(refer table C5) from which it was broadly classified into four namely identification, confirmation, treatment of the patient, and prevention of neighborhood. During this process of identification, there are mainly two activities happening, self-identification and contact tracing. Based on identification further testing is done to identify if the person has COVID or not and the result gets updated on the DISHA portal by the hospital staff. Further 41

all primary and secondary contact. In the confirmation process, the process owner is the Health Team Member. The business risk would be delay or error in test results and not conducting enough tests. Thus the key controls are quicker sample collection, higher testing and ensuring testing with precise results. Hence the measure of success in this process is more tests in a ratio of lesser percent of positive cases reporting and ensuring maximum waiting time for the precise result not exceeding 30 mins in case of Rapid Antibody Test, 24 hours in case of RT – PCR test and less than 30 mins in CB / True NAAT Test.

Table C5: Process Identification

after confirming a COVID positive patient treatment starts, i.e., home or institutional quarantine or hospital isolation. Since a person in the neighborhood is quarantined or under treatment, various precautionary measures taken at the neighborhood level are daily surveillance, sanitization, and sensitization. PROCESS PROFILE WORKSHEET TOOL: Process profile worksheets (refer appendix C2, C3, C4, C5) were prepared for all four processes, to identify the key controls and 42

measure of success in each of the process. In the identification process, the process owner is the District Administrative Staff. Business risk in this process would be missing out on high-risk patients during contact tracing leading to high chance of spread. Thus the key controls are that all high-risk symptomatic persons should be tested, all people who have come in contact should be notified and norms for prevention like social distancing and use of mask should be mandated. Hence the measure of success is when there is 100% identification of

In the treatment, the owner is the District Administrative Staff. Business risk is when a person does not report or breaking treatment norms. Thus the key controls are continuous monitoring and status update for quick recovery followed by strict enforcement of treatment regulations. The measure of success is when there is recovery within a maximum of 14 - 28 days and citizen feedback rating is more than or equal to +4. Finally, in the prevention process, the process owner is the District Administrative Staff while the business risk is the lack of surveillance or delay in sanitization. Thus the key controls are sanitization of the neighborhood and strict

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isolation with daily surveillance to ensure no primary contact occurs. The measure of success is when there is no reporting of community spread cases hence showing the efficiency of the process. RACI AND SWIMLANE TOOL: The RACI chart (refer table C6) helps to deduce the process holders who are responsible, accountable, consulted and informed in each step of the process, followed by which the swimlane (refer table C7) helped to elaborate on the process flow undertaken by each process holders and duration required to complete each process. Hence from RACI and swimlane, some of the key analysis is that the key process holders are District Administrative staff and Health Team who is accountable throughout the process where District Administration ensures the transfer of required data with all departments while Health Team puts forth the required guidelines for undertaking the entire process efficiently. SERVQUAL TOOL: For the Servqual RATER analysis firstly a survey was conducted on a sample size of 20 people (14 male and 6 female). The age group of person surveyed were 80% in the 15-59 group and rest 20% were in the

Table C6: RACI Chart

Table C7: Swimlane

+60 group. COVID was detected through contact tracing in case of 70% while the rest 30% confirmed through self-identification. Further 35% of persons surveyed fell in

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the containment zone while 65% were from the non-containment zone. Out of total tests done Rapid Antigen Test and RT-PCR was done by 23%, RT-PCR alone by 69% and True /CB NAAT test by 8%. 43

The service wise survey results are shown in figure C14. Inference from the results shows that in the testing process, key learnings were the inter-department coordination and minimum wait time at test centers while areas requiring improvement was the lack of enough social distancing at test centers, unclassified documentation of multiple tests by the same person and poor isolation for vulnerable groups at test centers.

Figure C14: Service-wise survey result of RATER 44

Inference of quarantine process shows that there is daily location tracking in quarantine process and the staff is approachable and attentive. While, areas requiring improvement was the lack of citizen feedback system and no waste collection while a person was in quarantine. Next, inference of sanitization process shows that the key learnings was the household sanitization being done as per SOP by trained sanitization workers while improvement was required for neighborhood sanitization

as per SOP. Further, the inference of the surveillance process shows that there is an efficient daily symptom monitoring process in place while areas requiring improvement was lack of enough public place surveillance and no strict actions for those breaking quarantining norms. FMEA TOOL: Setting the leverage point at -2, issues falling below this range is considered as the most critical. Based on these parameters

Figure C15: Calculation of new audit profile ranking Pathanamthitta I Service Operations Management Studio 2020 I CEPT University

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were framed for each issue analyzing its severity, occurrence, and detectability. This was analyzed on the FMEA chart for impact assessment. The criteria set for risk assessment were RPN < 40 under tolerable risk, 40 ≤ RPN ≤ 100 under controllable risk, and RPN > 100 under unacceptable risk. Further, issues falling in the unacceptable risk category were improved by providing recommendations as shown in appendix 7. These recommendations will also be impacted by (refer figure C15) parameters from an exposure assessment, aggressiveness of the issue and organizational capability. Considering the recommendation given as best and further subtracting it with value obtained from asssessment its efficiency of actual improvement can be assessed. This can be understood in detail by plotting both issue and recommendation on a service audit diagram inorder to understand the amount of improvement that can be attained.

Figure C16: Service Audit Profile showing issues and its recommendation based improvement 46

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Service Audit Profile

SUMMARY

The service audit shown in figure C16 reflects the expected improvements, each suggested recommendation can provide. Issues provided on the left of the audit profile diagram can be improved using recommendations given on the right.

The district has some uniqueness which helps in the ease of implementation of strategies. Some of them are namely, the district has 96.93% literacy which is highest in Kerala and has low population density. Though on an average 5000-6000 are quarantined per day, enough facility has already been set in place. Further, the district accounts for high volunteer staff, psychological support and daily monitoring of all the elderly staying alone and to deliver essentials at their doorstep. Thus some good points that can be highlighted in the district are inter-department coordination and minimum wait time for citizens at test centers. When a person goes into quarantine the guidelines are systematically conveyed also, daily location tracking and symptom monitoring is done to track person status. Trained attentive and approachable staff ensures household sanitization is done as per SOP.

Some of the examples are, the lack of citizen service feedback system can be improved through online feedback system implementation, social distancing at test centers, public place surveillance and ensuring of norms during quarantine can be improved enforcing fine or 48hrs arrest for breaking norms, documentation of multiple tests by the same person can be improved through classified documentation and availability of the same on public domain for analysis and improving efficiency. One of the biggest challenge faced by the district is the high ratio of vulnerable group population hence, the need for social distancing at test centers is quite essential and this can be improved by providing segregated vulnerable group entry at test centers. Also waste collection can be ensured by providing daily waste collection while in quarantine ensured by the district administration.

Next looking at factors making efficient working of the district challenging are large percentage i.e. 18% of population residing in the District are senior citizen and nearly 6% of state immigrants are from Pathanamthitta District. So far, 72% dead is from the 60+ age group. Also, there is a

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high health staff ratio and police officers ratio while ICU bed is limited which makes it challenging. Thus finally on looking at the areas requiring improvement, there is no adequate social distancing at test centers and also there is lack of classified documentation of multiple tests by the same person. There is no enough isolation for vulnerable groups at the test center and no waste collection while a person is in quarantine. No provision for citizen feedback has been set in place, which might help the ULBs to develop its services further. Another challenge seen was that not enough public place surveillance was being done on internal roads.

Change in business landscape Public started gaining trust and confidence in the service provided by the government hence a boom was seen in the preference of government healthcare services. There has also been rise in online grocery shopping which also created employment for those who lost jobs during the pandemic. Though the pandemic has been a challenging phase, the government and citizens together are overcoming it with mutual courage and support. 47

INTRODUCTION TO THE CITY MAYURI VARKEY PG190538

COVID-19, popularly known as Novel Corona Virus, is associated with the respiratory disorder in humans which has been declared as a global epidemic and pandemic in the first quarter of the year 2020 by the World Health Organization (WHO). As per the latest data (31st October 2020) and tracking web sites, Ahmedabad has 42,514 confirmed cases. Ahmedabad is located in the state of Gujarat which covers 33 districts. The chief minister is Shri Vijay Rupani, the city commissioner is Shri Mukesh Kumar and the mayor is Bijal Patel. The Primary Health Secretary of the state is Dr. Jayanti S. Ravi. Dr. Rajiv Kumar Gupta is the covid control

commander and the Medical Health Officer of Ahmedabad is Dr. Bhavin Solanki. Dr. HG Koshia the Commissioner of Gujarat Food & Drug Control Administration (FDCA) and Dr. Bharat Gadhvi head of the Ahmedabad Hospitals and Nursing Association (AHNA) are also working closely with the city Covid team. The city, currently the 7th largest metropolis in India and the largest in Gujarat, was founded in 1411 AD as a walled city. Located in the center of Gujarat, on the eastern bank of the river Sabarmati, Ahmedabad is 23 kms from the state capital Gandhinagar- its twin city.

About the city The ULB is the Ahmedabad Municipal Corporation (AMC) which is spread over an area of 464 Sq.Kms and covers 9 talukas namely - Dholka, Dholera, Daskroi, Detroj, Sanand, Bavla, Viramgam, Mandal, Dhandhuka. The headquarter of district is Ahmedabad city. Elaborating further on Ahmedabad, it has 6 Zones, 48 wards (in which 4 areas have been recently added), 77 health centers (as shown in table D1), 7 Municipalities, 7 Nagarpalikas, 1 Cantonment and 474 identified villages. Administratively seeing, the Ahmedabad Municipal Corporation has 8 departments – Health, Revenue, Environmental Services, Road and Transportation, Urban poor and Housing, Town Planning, Support and Other Services. The organogram of the health department is shown in Figure D2 below. Historically, Ahmedabad has been one of the most important centers of trade and commerce in western India. Currently the leading businesses in Ahmedabad are the textile and pharmaceuticals which contribute 34% and 27% respectively to the state’s business growth and account for the maximum number of migrant laborers employed. The food industry, engineering industry and petroleum industry also contribute 9%, 9% and 6% respectively to 50

ZONES

WARDS

UPHC

North Zone

South Zone

East Zone

Central Zone

West Zone

New West Zone

Figure D1: Zone, City Administration Classification Source : https://ahmedabadcity.gov.in/

the state’s business growth. Additionally, Ahmedabad stock exchange, Adani, Reliance industries and the tourism

In order to get a clear understanding about how to manage the current covid scenario an accurate exposure assessment is needed to understand how many vulnerable pockets of people will be directly affecting and which pockets will be a risk to the rest. After getting this data based on the aggressiveness of the covid scenario and cases growth as well as fatality rate we can understand how the population is exposed and that amount of risk being caused to them especially senior citizens, illiterates and slum populations. Now, once we have understood the seriousness and extent to which we have to control the spread a look into the organizational capabilities and resources available with the AMC to combat the virus will help us understand how to control the spread and protect the vulnerable groups in our city.

Exposure Assessment

Figure D2: Organogram of AMC’s Health Department Source : https://ahmedabadcity.gov.in/

industry are also prominent in the city.

Ahmedabad city is governed by Municipal Corporation which comes under Ahmedabad Metropolitan Region. According to the 2011 Census, the population of Ahmedabad is 55,77,940 - of which male population is 29,38,985 and female population is 26,38,955. The municipal area is under the jurisdiction of

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The Ahmedabad Municipal Corporation (AMC), whose limits were last extended in 2010 to cover an area of 464 sq.km and include 11,79,823 households. The population density is 11895 people/sq. km and the population is growing at the rate of 13.46% annually. The Sex Ratio in the city is 898 women / 1000 men. 66.78% of the population falls in the working-class people (15-59 years). The total child population (0 to 6 years) is 6,21,034 which includes 3,36,063 males and 2,84,971 females. The total number of literates are 43,76,393 out of which 24,02,523 males and 19,73,870 females are literate. The literacy rate is 88.29 % with 92,30% males and 83.85% females literate. The total illiterate population is 12,01,547 which includes 5,36,462 males and 6,65,085 females. There are 51,451 identified slums in the city for which the slum population is 2,50,681. An interesting fact about Ahmedabad is that 46% of the city’s population are migrant population which adds up to 25.64 lakhs. Out of this 46% migration 12.4% is intrastate migrant population and 33.6% is interstate migrant population mainly seen from Rajasthan, UP, Maharashtra. Although Ahmedabad city has population of 55,77,940 the Ahmedabad Urban Agglomeration (AUA) has a total population

Figure D3: Exposure Assessment Vulnerable Population of Ahmedabad City Source : : https://www.census2011.co.in/census/city/, http://population.city/india/ahmedabad/

of 63,61,084 of which 33,50,582 are males and 30,10,502 are females. It includes four towns and 103 villages besides the municipal area, and covers a total area of 1,866 sq.km. There is one more entity in the governance structure of the city which is Ahmedabad Urban Development Authority (AUDA), that is a planning authority and largely covers the AUA area and more (AUDA 2013). The AUA area is defined by population census office and is not an administrative unit, and is larger than the AMC area. The most vulnerable and exposed people to the virus are the child and senior citizen population, the working-class people who

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go out and interact with other people, the slum population where social distancing and Covid norms are not followed which could lead to spread of the virus, the illiterate population who need to be educated about the risks associated with the virus and the migrant population who come in from heavily infected areas which will lead to community spread.

Aggressiveness of the issue On 11th March WHO declared the Novel Coronavirus as a pandemic. The nation 51

Figure D4: Covid time line in the Ahmedabad City Lock down Source : : https://www.covid19.india.org

wide Janta Curfew was announced on 22nd March 2020 by the central government of India, prior to which multiple markets, theatres, schools, colleges, etc. had already been shut down by the state governments. On 16th March till 29th March a 14day lock down was initiated by the state government banning all movement and urging citizens to stay indoors. Citizens were only permitted to go out in emergency situations, with prior permissions from ULB and with all safety protocols being followed. 3 more lock downs were imposed in the city from 1st April to 14th April, 15th April to 3rd May and 4th May to 31st May respectively with the hope to flatten the curve of confirmed cases and to restrict the spread of the virus. In the lock down AMC’s many initiatives such as fines and penalties imposed on Covid norm violators, equipment assembling 52

Figure D6: Covid time line in the Ahmedabad City Unlock Source : : https://www.covid19.india.org

and purchases, sanitization drives, plasma therapy approval, civil hospital testing approval and the struggle of sending migrant workers’ home were prominant. Gujarat had its first cases on 19th March from Surat and Rajkot before the Janta Curfew while Ahmedabad recorded it’s first case on 19th April a month later. Ahmedabad has seen a steady growth in the confirmed and active cases at the rate of 1.4% and 15.8% respectively while the fatality rate was at a scary 3% during the lock down. (Figure D4) The testing patterns which were almost nil in the first two phases of the lock down have seen a sharp growth (Figure D5) due to the constant efforts of the CM and Deputy CM. As on 31st May, Ahmedabad has 12,180 confirmed cases, 4,420 Active cases, 6,918 recovered cases, 842 deceased cases and has conducted 78,936

Figure D5 : Testing Patterns of Covid in Ahmedabad Source : Tableau

tests. From the time of Covid being detected throughout the lock down till September the Ahmedabad Covid Model of Test, Trace and Isolate was followed and is one of the best practices as well. It covers key aspects and initiatives such as the Dhanvantri Raths (mobile testing vans), Fines, Isolation norms, Mask mandating, Recovery focus, Surveillance, aggressive testing, Seropositivity surveys, etc. (Annexure D1) Now, coming to the Unlock of Ahmedabad which was done in a systematic 5 phase manner; the initiatives of additional testing labs, free private hospital treatment, plasma bus banks, E – Janmashtami, Vijay Raths, Vadil Sukhakari Yojana for the elderly have played a crucial role in the unlock patterns. On August 31st Ahmedabad

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recorded the highest tests conducted in a day at 78,840 tests. Though the cases have stabilized the major threat of festivals is looming over the city for which the strategies of Revamping Containment Zone strategy, Management of isolated cases, Aggressive contact tracing, identifying workplace clusters, testing strategies, Preparedness for 15,000/day case surge, Minimization of gatherings and Prevention of infection among health staff will be given heavy weightage. As on 31st October, Ahmedabad has 42,514 confirmed cases, 3,278 Active cases, 37,334 recovered cases, 1,902 deceased cases and has conducted 16,40,974 tests. Talking about the overall confirmed cases graph – India has peaked in September and now the bell curve has taken a 20% downward dip to reach almost mid-way while many cities including Ahmedabad

have not yet reached their peak (Figure D7) which is why the coming three months are very crucial for the city.

Figure D7 : Confirmed Cases Ahmedabad and India Peak Point Source : Tableau and times of India (31/10/20)

Organizational Capabilities Firstly, talking about the stakeholders involved in the Covid process, they are: 1. Medical Staff which includes the paramedics, the doctors, the frontline workers, the ASHA and the female health

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workers. 2. Health Care Providers like the hospitals, UPHCs, physicians, private organization. 3. Provision Suppliers like the pharmacies and grocery stores 4. Government and Civic Body including the Police and Fire Dept. as well as government officials. 5. Vulnerable Population such as the elderly people with underlying health conditions, health care and front-line workers as well as travelers. Talking about the facilities available in the city to tackle the Covid situation, the testing, treatment, monitoring and sanitization facilities are covered here. The first testing center was established in the city on 7th February. 6 other labs were added in Gujarat state from 19th to 29th March. Coming to Ahmedabad, there are 60 testing labs – 36 government labs and 24 private ones with the aimed capacity of 80,000 tests per day. 1,161 tests per million is being conducted with the ratio of Rapid is to RT-PCR at 90:10 for which 7,12,000 lakh RT-PCR kits are available. Under monitoring, contact tracing and surveillance we have a vehicular power of 159 police vans with the task force of 1,556 police personnel and Jawans deployed. 100 SHE teams of 5 person each are also part of the contact tracing and 53

monitoring. Till date 27.6 lakh people have been contact traced from which 6,910 have tested positive. Under the Vishwas project 6,065 CCTV cameras were installed over 40 areas in the city which have helped solve 2,866 Covid violation cases. 374 Nakabandhi points have been created for surveillance all over the city. The sanitization aspect involves 499 private manufacturers who have been allotted 3,637 product licenses to manufacture sanitizers (2,487 licenses), sodium hypo chlorite (684 licenses) and equipment (466 licenses) for the 633 sanitization teams deployed on ground. Coming to the treatment facility aspect the occupancy rate in private hospitals is 83.3% and 75 beds per 1 lakh population is made available. The national average is 118 beds per 1 lakh population and we rank 14th in that position. According to the Aarogya Setu app I have 18 government hospitals, 44 private hospitals and 146 quarantine centers in my 50 km radius. As of the current data available hospitals are consuming 250 tons of oxygen per day for which the government has a tie up with 52 private licensed suppliers to 150 hospitals at the price of ₹ 35/liter. A major initiative called Dhanvantri Raths (mobile testing vans) was started on 15th May with just 40 raths covering 160 locations. Currently 54

we have 123 Raths covering 450 areas. The raths test 10,000 people a day and have till date tested 1.5 lakh citizens from which 8% were symptomatic, 2.3 % had fever and 5.7% showed signs of cold and cough. Additionally, the treatment facilities cover: • Sardar Vallabhbhai Patel (SVP) hospital the best tertiary care hospital in India • Samras hostel - 2,000 patients as Covid care center • 800 + medical teams of 4 members each (1 ASHA, 2 Nurse, 1 Staff) are sent all over the city for testing and contact tracing • Recruitment of 100 doctors and 750 paramedic staff and training of over 5,000 medical personnel and 1 lakh MMBS and medical students have been roped in for Covid duty and isolation to prevent the spread. From the lock down till unlock phase 3

some of the services provided by the AMC consist of testing kits, vaccines, medical teams, drone surveillance, E – Rickshaws, mobile testing vans, quarantine centers, covid hospitals, covid care centers, migrant special transportation train and facilities, PPE equipment for medical staff, ration for the needy, specialized transportation, hygienic beds and healthy meals, mass vaccine testing and sampling. (Annexure D2) The facilities received by the citizens out of the above provided services cover the testing procedures, vaccines testing, medical teams, door to door grocery services, covid hospitals, covid care centers, quarantine centers, safe transportation norms, fumigation and disinfection as well as food rations. MIND MAP

Service Concept

Process Analysis

The organization idea of the service concept model is to have advanced, state of the art of real-time monitoring of the pandemic and to provide useful equipment that can be used to detect and prevent the spread of the virus. The service concept for covid 19 is - A citizen health care and welfare-oriented service providing systematic testing, treatment

Part- 1 A rough covid process flowchart (Fig D5) was created to get an idea about the whole process and method idea of what is being done to Detect, Isolate, prevent and treat the victims of this virus. Part- 2 The mind map was then divided into 3 main processes to get more clarity and

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drawn out again in the layout of these three categories to exactly pinpoint the ongoing detection, isolation, treatment and prevention process: 1. Identification (Self Identification and Sample survey) 2. Confirmation Process 3. Patient (Self and Neighborhood) Part – 3 The final categorization of the process was then made into 4 processes which gave a clear and crisp outlay of the whole Covid process being done by the AMC: 1. Identification 2. Confirmation 3. Treatment (Patient) 4. Prevention (Neighborhood)

PROCESS IDENTIFICATION

Figure 9: Rapid Test centre and Treatment Source : Primary Survey

Figure D8 : Covid process rough mind map Source : Primary

The process of covid has various parties involved and the main players are the AMC, the covid command center, the Police and Fire department, testing centers (Private and public) and covid hospitals. The Covid process consist of 4 main sages namely: 1.Covid Identification If an individual has high fever and dry cough and goes for testing or makes an inquiry on the state help line number then

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The process of Identification starts which covers the steps of self-identification and sample survey and includes activities like - symptoms onset and inquiry, survey form filling, testing, identification and reporting. 2.Covid Confirmation When an individual gives his nose swab sample at the testing center (Rapid Test center or for RT-PCR Lab test) then the process of confirmation is initiated which covers the steps of home quarantine and institutional quarantine and includes activities such as - symptoms a match of not, retesting if needed, confirming and report making, quarantining. Based on 7 primary interviews, it was observed that at the point of contact tracing and monitoring by the police if there are less than 5 confirmed cases there is slow response time by the AMC and police personnel to start investigation, contact tracing, containment and

Figure D10: Containment and monitoring Source : Primary 55

monitoring (Figure D10). There is an even slower response time or no response if 1-2 cases are confirmed in the area. In the event that suspected cases are noted in the area no response is received by the corporation. Thus, most of the time the society committee members take action and decisions for the suspected/confirmed patients and start preventive measures. 3.Covid Treatment The patient being isolated and is put in quarantine is the trigger event for starting the treatment procedure by the AMC doctor which has the step of patient treatment and covers the activities of routine check-ups, Covid chart maintain and cross checking, dosage administration, symptom progression notes, discharge process, documentation and reporting. 4.Covid Prevention The point where the Police department and the Fire department personnel are notified about the positive patients and given their demographic details is part where the preventing strategy against Covid is initiated which covers the family and the neighborhood and includes activities such as respective personnel being dispatched, contact tracing, monitoring, sanitization, reporting to the Covid command center. Sanitization which should be done at least twice in the 14 days quarantine duration 56

happens once or otherwise nil but not more than once which is not as per the guidelines or prevention strategies. This is mainly due to shortage of manpower and equipment. PROCESS PROFILE WORKSHEET TOOL After identifying the processes, the steps and the process activities, 4 process profile worksheets were created (annexure D3, 4, 5, 6) for each of the 4 covid processes. The covid confirmation process profile Worksheet will be described in detail in the report. It shows the process owner as the Testing center and the process unit owners as the testing team who are responsible for conduction the test. The main service objective here is to appropriately test the patients in a systematic manner with all precautionary measures followed to create a safe and assured testing experience. The possible risks according to my observations and surveys are the risk of unaffordable testing, faulty testing, delay in testing, no sanitized or systematic testing, misplaced or replaced test samples for which key controls such as adequate PPE kit, lab equipment maintenance, hygiene and disinfectant at all times, systematic testing and increase in designated testing Centers. The measures of success for the confirmation process will be based on the:

• Maximum number of patients successfully tested and detected • Maximum positive feedback received from the patients (4+ Rating) • Maximum positive feedback received on the efficient testing process (4+ Rating) RACI CHART TOOL Coming to the RACI matrix which indicates the decision taking authorities and activities undertaken in an organization as against people and responsibilities. At each point of the process and activity/task it is possible to hold someone responsible, accountable, consulted or informed for that activity/task. Thus, in the RACI char here (Figure D11) the leading party who is accountable for majority of the activities is the AMC and the command center are kept in the loop and informed about all the on-going activities and decisions being undertaken. The patient is the one who is consulted at each step from the treatment right through the contact tracing, monitoring, sanitization and till the discharge procedure is complete. The major parties responsible are the testing team for accurate test results, the AMC doctor for proper treatment, the police department for contact tracing and monitoring and the fire department for sanitization and disinfection.

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The RACI chart which shows the accountable, responsible, consulted and informed parties in the Covid process shows that high accountability lies with the AMC. This indicates severe decision making and work load on the AMC which shows a need for delegation of authority and distribution of accountability with the concerned process departments.

SWIMLANE TOOL The covid process swimlane diagram (annexure D7) is a flowchart that outlines which party does what in the process. Utilizing the metaphor of lanes, the swimlane diagram highlights and gives clarity and accountability by outlining process steps inside the horizontal “swimlanes” of a particular party/ department.

It has detailed out the process of covid in Ahmedabad city from the time of symptom onset till the patient is recovered or hospitalized. ( Figure 12) The swimlane which has a detailed outline of the Covid procedure and activities falters at the point of feedback and followups after 7 days by the AMC doctor. The AMC doctor who is responsible for daily consultation and dosage of the patient for 7 consecutive days is also responsible for follow ups and inquiry of the patient till full 14 days are completed. It is noted that after 7 days if the patient’s symptoms get worse then he/she is hospitalized but if the symptoms are noted to be fading then the patient is told to self-monitor and stay in quarantine till 14 days are completed but during the self-monitoring period the doctor fails to come to check up on the patient. This can lead to the patient not taking precautionary measures, the doctor not being updated on the patient’s condition in case it deteriorates which could have severe repercussions.

Figure D11: RACI Chart for covid process analysis Source : : https://www.covid19.india.org Ahmedabad I Service Operation Management Studio 2020 I CEPT University

• Assurance aspects in the treatment process has gaps which needs improvements. • Tangible aspects in the monitoring process has gaps which needs improvements. • Responsiveness aspects in the sanitization process has gaps which needs improvements. To delve deeper and get a more thorough analysis of the gaps and areas of improvement the process graphs based of each question were created to see exactly which issues was creating dissatisfaction among the citizens.

Figure 12: Swimlane for Covid Identification, Confirmation, Treatment and Prevention Source : Primary

SERVQUAL - RATER TOOL After research and studies on covid and it’s strategies in the city it was necessary to understand the on-ground scenes and the perspective of the citizens, what they perceive and expect the administration to do and if they’re expectations were being met. Hence, a questionnaire of 30 questions was created. These 30 questions were divided into the RATER category i.e. Reliability, Assurance, Tangibility, Empathy and Responsiveness to asses to covid testing, treatment, monitoring and Sanitization expectation and perception in each RATER category. A sample size of 20 people were surveyed. This sample was 58

inclusive of 4 dimensions namely - age, gender, containment zone people and slum habitants to get a better perspective of the services offered to the citizens. The overall age group of the sample ranged between 16-64 years and out of the 20 people there were 9 males and 11 females from which 12 had got the Rapid test done and 8 had gone for the RT-PCR of which 9 were positive and 11 were negative but living with a positive person in the same house. According to the cumulative graphs D13: • Empathy aspects in the testing process has gaps which needs improvements.

Figure D14: Individual RATER for testing process Source : Primary

Figure D13 : Cumulative RATER for each process Source : Primary

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Good Points In the testing process the reliability in providing accurate test results is the highest score at 0.9

Improvement Points The tangibility in testing center hygiene is the lowest score at -1.4

Empathy to give patients individual attention and time. Empathy in having patients best interests in mind. Responsiveness in taking feedback from patients after treatment.

Figure D15: Individual RATER for treatment process Source : Primary

In the treatment all parameters need improvement except one Good Points Responsiveness in helping patients when needed is the highest score at 0.3 Improvement Points The reliability in constant routine observation by the doctor is the lowest at -1.9 Other improvement points cover The reliability in sincere follow-ups with the patients. Assurance in special attention to positive patients. Assurance in safe treatment. Tangibility in modern equipment.

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Figure D16: Individual RATER for monitoring process Source : Primary

Good Points The empathy in police coordination and responsiveness of the residents to the police instructions are the highest at 0.9 Improvement Points The tangibility of the police carrying equipment while monitoring is negative at -0.1 In the sanitization process the Good Points The tangibility in the sanitization team getting up to date equipment is the highest score at -0.3 59

Figure D17: Individual RATER for sanitization process Source : Primary

Improvement Points The responsiveness in prompt arrival of the sanitization team is the lowest at -1.7 Thus, the overall process rater shows the treatment process to have the most gaps to improve upon while the monitoring process is seen to be positive. FMEA TOOL Now that the survey gave an insight into the problems faced; a root cause analysis was needed to see the exact point at which the processes were failing. For this the Failure Mode and Effect Analysis (FMEA) tool was used. This tool helps to find the cause and effects behind each failure and give appropriate recommendations. For this a scoring scale was designed for 60

both the failure causes (threat) and the recommendations (action) to reduce the Risk Priority Number (RPN) where the threat was analyzed based on the severity, occurrence and detection. The severity of the effect of failure was assessed based on dissatisfaction experienced by the patients. Similarly the occurrence of the failure was ranked on the frequency of the services while the key controls are analyzed on the certainty of detecting those failures. Then the risk priority number is calculated to know which are the unacceptable risks, controlled risks and tolerable risks. (Refer to Annexure D 7 to D 18) Testing Process FMEA: The failure mode was testing center hygiene and cleanliness for which the causes were shortage of staff and high influx of patients and staff wearing dirty uniforms which could create a threat of increasing the spread of the virus or contaminate the testing samples. This had an RPN of 648 which was an unacceptable risk. The recommended action suggested was an SOP manual ( Quality Assurance) for shortage of staff and Daily Quality Check manual at all testing centers which has an RPN of 16 which indicates a tolerable risk. Thus, here the recommended actions brought the RPN down from 648 to 16.

Treatment Process FMEA: No routine health check ups by the doctor due to shortage of manpower and resources would make it difficult to control the virus spread and detect the progress of patients recovering and had an RPN of 729 for which the recommended action was SOP manual (Covid treatment training), the RPN of which was brought down to 36.

Service Audit Profile

Monitoring Process FMEA : the potential failure mode was the lack of monitoring equipment with police personnel posted due to shortage of police staff for monitoring which could lead to improper monitoring of suspected persons and had a RPN of 729. For this the recommended action was hiring staff and quarterly staff training which has an RPN of 18 that is a tolerable risk. Sanitization Process FMEA: Receiving untimely and impromptu sanitization services is the potential failure mode caused due to the shortage of equipment and funds which has an RPN of 144. For this the recommended action of maintenance of rented equipment’s and replacement of current defective gears while getting more sponsors was suggested which has the RPN of 48 that is a controlled risk.

Ahmedabad I Service Operations Management Studio 2020 I CEPT University

Figure D18: Service Audit Profile Source : Primary Ahmedabad I Service Operation Management Studio 2020 I CEPT University

The service audit profile is a tool which is used to compare the current scenario (based on the citizens perception of the administration) with the recommended actions how the system can be improved which are the ideal scenario. An additional line is shown with yellow dots which represents how much of the ideal scenario can the city administration currently accomplish with the resources at hand. The resources were analysed based on the exposure assessment, aggressiveness of the issue and organizational capability of the city administration. All the positive aspects and negative aspects pointed out in the SERVQUALRATER are mapped in the black line. The ideal case scenario based on the recommended actions are mapped with blue dots and the amount of change achieved from is mapped in the yellow dots. An example of this is - currently the testing lab hygine and cleanliness is inappropriate and is plotted in negative in the black line but after recommending an SOP manual for quality check the ideal case was positive and is marked as such on the graph.

City learnings and Summary Good Points 1. Inter department knowledge and communication of on-going activities 2. Maximizing coverage for testing 3. Intense stakeholder involvement 4. Special initiatives and research for senior citizens and vulnerable population 5. Approachable and ready to help staff 6. Trained specialists on the treatment team 7. Mental stress help line number and tripling the help line systems

C, D and B12 tablets 2. Vijay Rath covid norms awareness drive through skits and dances 3. 37 persons contact traces for each positive case

Improvement Points 1. Inadequate sanitization and hygiene at test centers 2. Insufficient feedback and regular follow-ups done 3. Additional attention can be given to vulnerable groups at treatment facility 4. Stationary issue of biomedical waste 5. Need of more public place surveillance 6. Impromptu or devoid sanitization services. Unique Points 1. Dhanvantri Raths test 10,000 people per day as well as provides free vitamin

Ahmedabad I Service Operations Management Studio 2020 I CEPT University

Ahmedabad I Service Operation Management Studio 2020 I CEPT University

INTRODUCTION TO CITY RISHABH SHANDILY PG190763

The National Capital Territory of Delhi is the capital of India. It shares its border with Haryana and Uttar Pradesh. The state stretches over an area of 1484 sq.km. The capital of India witnesses subtropical weather. Delhi has 11 districts in total. The National Capital Territory of Delhi shares excellent connectivity and transcends to the nearby major cities like Faridabad, Noida, Gurgaon, and many more. The maximum share of the capital city comes from the tertiary sector, which has accounted for up to 85% of the total revenue

generated as per previous year trends. With an exorbitant GDP of ₹7.80 lakh crore, Delhi is ranked at 13th place in terms of GDPs of states and Union Territories across India.

About the city The national capital territory (NCT) of Delhi with an area of 1,483 sq.km. NCT of Delhi is be divided into 11 districts and 272 wards. (Ministry of Home Affairs, 2011). The Municipal Corporation of Delhi was established in 1958 and was one of the largest municipal bodies across the world. Delhi was divided in nine districts which came in existence from 1997 and further two more districts Shahdara and South East Delhi were added in the month of September in 2012. The Municipal Corporation of Delhi was trifurcated in 2012 and divided into South Delhi Municipal Corporation, East Delhi Municipal Corporation and North Delhi Municipal Corporation. Currently Delhi has three municipal corporations, one cantonment board and one municipal council. They are named as: • Delhi Cantonment • New Delhi Municipal Council (NDMC) • South Delhi Municipal Corporation (SDMC) • North Delhi Municipal Corporation • East Delhi Municipal Corporation

Figure E1: Delhi District Division Source: https://www.mapsofindia.com/delhi/

of 1,6787,941 out of which 89,87,326 are males and 78,00615 are females. About 10.5% of the total population contributes as migrants in the city which sums up to 17,64,122 and a literacy rate of 86.2% as per Census of India 2011. The key players in

the management of COVID19 in Delhi are: • Chief Minister- Shri Arvind Kejriwal • Health Minister- Shri Satyendar Jain • SDMC: Mayor- Smt. Anamika Mithilesh Singh; Commissioner- Sh. Gyanesh Bharti, IAS • EDMC- Mayor- Sh. Nirmal Jain; Commissioner- Dr. Dilraj Kaur, IAS • NDMC Mayor- Smt. Mira Aggarwal; Commissioner- Smt. Varsha Joshi, IAS The NCT of Delhi has 1 international airport and 1 domestic airport, 46 railway stations, 3 Interstate bus terminals and 8 highways, these are the major entry points to the city. Delhi shares it’s boundaries with 2 states i.e. Uttar Pradesh and Haryana, and 7 districts i.e. Gurugram, Faridabad, Gautam Buddha Nagar, Ghaziabad, Baghpat, Sonipat and Jhajjar. Being the capital of the nation and advance healthcare infrastructure, there is a heavy population flow in Delhi.

The first patient to be tested positive of COVID19 in Delhi was on 2nd March 2020, who had an international travel history and had travelled from Italy in the end of February. The first death due to COVID19 in Delhi happened on the 13th March 2020 and on 25th March a nationwide lockdown was imposed allowing only the essential services to be functional in the duration of the lockdown. The total number of confirmed cases crossed 1,000 with 19 fatalities on 12th April. Then the cases started growing rapidly with 10,000 cases reaching in just 6 days and the total confirmed cases crosses 10,000 and 160 fatalities on 18th April. The unlock process started on 1st June with certain activities being permitted with restrictions and in two months from 10,000 cases the total confirmed cases reached to 50,000 with 1,969 fatalities. The number further doubled up in just 18 days reaching 1,00,000 confirmed cases with 3,115 fatalities. (DELHI, 2020)

Figure E3: COVID spread in Delhi Source: Primary

the management of COVID19 from centre government to state government to urban local bodies and the departments involved are Delhi Police, National Disaster Response Force(NDRF), Indo-Tibetan Border Police(ITBP), Central Industrial Security Force (CISF), Delhi Disaster Management Authority (DDMA), Delhi Fire Services (DFS), Delhi Jal Board (DJB) and Department of Environment Management Services (DEMS).

Table E1: Healthcare Infrastructure

Category Aam Aadmi Mohalla Clinics Dispensary Nursing Homes Maternity Homes Speciality Clinics Hospitals Medical Colleges

Number 189 1,298 1,160 230 178 88 17

Organizational Capabilities

Exposure Assessment With a population density of 11,297 inhabitants/sq.km the NCT has a population

Aggressiveness of the issue

Figure E2: Everyday scene in major parts of the city Delhi | Service Operations Management Studio 2020 I CEPT University

NCT of Delhi being the capital of the country has a lot of agencies involved in

Figure E4: India’s Largest COVID Care Centre

Delhi | Service Operation Management Studio 2020 I CEPT University

Source: delhifightscorona.com 67

The state government of Delhi has launched a website and a mobile application naming Delhi Fights Corona which provides the citizens with live status of the beds and ventilators available in the hospitals. The website also shows the list of containment zones, government and private testing centres with complete address and phone number, application forms to request and donate plasma and home isolation guidelines and instructions.

found in a particular area. (Department of Information & Publicity, 2020) Fullform of SHIELD: • S- SEALING of the area • H- HOME QUARANTINE • I- ISOLATE people who came in contact with the patient • E- Uninterrupted supply of the ESSENTIAL goods • L- LOCAL SANATISATION • D- DOOR TO DOOR health check-up

The sanitisation is being done by the Delhi Jal Board in the containment zones and public spaces is done free of cost while in residences and offices sanitisation is done by private players and the price ranges from Rs1-2 per sqft. in residential areas to Rs4-6 per sqft. for commercial and office spaces.

Service Concept Organisation

SDMC, State Government of Delhi

Organising Idea

Contain the spread in the most efficient way

Service Concept

Testing, Sanitization, Treatment and Containment with emphasis on controlling the spread of virus

Service Provided

Table E2: Available beds and Ventilators on 30th October 2020

Total

Occupied

Vacant

• • • • •

Percentage of Vacant

Beds 15,760

6,199

9,561

60.66%

1,244

783

461

30.05%

Ventilators

With an objective to control the spread of Corona, the Delhi government has launched ‘Operation SHIELD’ to trace and identify positive coronavirus cases in the city. The operation has been implemented to mitigate the risk of community transmission. The government has begun the implementation of Operation SHIELD in all the containment zones across Delhi. The containment zones are notified when three or more Corona positive cases are 68

• • • •

Figure E6: Sanitization being done by DJB Source: Twitter/ArvindKejriwal/

Service Received

• • • • • •

Free government institutional quarantine facility for everyone Drive thru testing facility Movement pass/ e-pass for people dealing in essential services Monetary help of Rs1Cr to families of deceased front-line workers from Government doctors, Delhi Police to Sanitation workers 24X7 Telemedical Helpline Monetary help of Rs5000 to auto rickshaw drivers. Free testing at various locations Sanitation of containment zones Live data of beds and ventilators online

Treatment for all Various methods to get testes Ease in performing operations Motivation to fight the pandemic Sanitized surroundings Transparency in data

Process Analysis Figure E5: Delhi Fights Corona Poster

Source: delhifightscorona.com

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The entire process can be divided into four smaller processes naming Identification,

Confirmation, Treatment and Prevention. A person contaminated from the virus can be identified either by the door to door survey

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done in the containment zones or if the person has symptoms and came in contact with a person who has been tested positive. To get a person tested there are three methods Rapid Antigen Test, True-NAT and RT-PCR Test. The Rapid Antigen Test takes 10-15 minutes to confirm the result and True-NAT takes around 30 minutes while on the other hand the RT-PCR test takes 24 hours to confirm the result whether the person is tested positive or not. If a person tests positive in any of the tests he/she has to mandatory quarantine of 14 days. If space is available at the patient’s house he/she can opt for home quarantine and if there is no space, the patient has to undergo intuitional quarantine. Once someone is tested positive the health department checks if there are more active cases in the area where the patient lives and if there are more than 3 cases in a radius of 150m then the area is declared as a containment zone. Having an international airport catering to the Vande Bharat Mission the travellers returning via international flights have to be quarantined for 7 days in hotels converted into instuitional quarantine centres to control the spread of virus.

Table E3: Process Flow

Identification

Confirmation

SelfIdentification Sample Survey

Visit Testing Centre (Citizen)

Testing

Rapid Test

Testing of Family Members (Medical Staff)

Checking of people on roads, slums, ISBTs, railway stations and door to door survey in containment zones (Delhi Police & Medical Staff) Test Centre Mobile Lab Test RT-PCR Test

Test Centre Drive Thru Test

Treatment

Self

Negative

Positive

Result in 10-15 mins (Medical Officer) Result after 24hrs (Medical Officer)

Test Centre

Result In 30 Mins (Medical Officer)

Did not come in contact with COVID19 +ve Patient

No COVID19 Certificate (Medical Officer)

Came in contact with COVID19 +ve Patient

RT-PCR Test & Isolation (Citizen & Health Staff)

Space at home

Home Quarantine (Delhi Police)

No space at home

Institutional Quarantine (Health Department)

Mandatory 7 day Institutional Quarantine (SDM, Delhi Police, Health Staff & Quarantine Centre Staff)

Prevention

Sanitization

Individual Houses (Private Companies)

Markets (Health Department)

Hotel (Hotel Staff)

Containment

Individual Houses (Delhi Police)

Markets (Delhi Police)

Societies/ Colonies (Delhi Police)

Figure E7: Drive Thru and Test Centre

For all the four processes, process profile worksheets (Refer Appendix E1, E2, E3, E4) were prepared to identify the key controls and measure of success in each of the process. Further the RACI chart (Refer Figure E8) helped to deduce which process holder is responsible, accountable, consulted and informed in each step of the process. It helped to identify the overlaps occuring in completing various processes. Followed by which the swimlane diagram (Refer Figure E9) helped to detail out the process flow undertaken by each process holders and identify the shortcoming in the process. It was found that no test with a negative result is required to end the home quarantine.

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Figure E8: RACI Chart

SERVQUAL-RATER: To know what perception of people of the city, a questionnaire was floated and based on responses of 20 people out of which 13 were male and 7 females from an age group ranging from 22 to 62 years. It was derived that people felt that there were issues with operational hours of the testing centre with erratic lunch breaks, late opening and early closing, people also felt that the staff at the testing centre was untrained and were not careful while performing tests. The testing centre is not sanitized regularly with people not following social distancing norms at the test centre and no feedback mechanism. Once a person undergoes home quarantine there is no provision of providing doorstep delivery of essential services and hence the person or other members of the family have to step out of the house. People also felt that there were issues with the containment and sanitization of the neighbourhood areas.

Figure E9: Swimlane Diagram

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Figure E10: Reliability

Figure E13: Empathy

Figure E11: Assurance

Figure E14: Responsiveness

Figure E12: Tangible

Figure E15: Testing RATER

FMEA TOOL: Based on the responses from SERVQUALRATER questionnaire and after identifying the gaps, FMEA (Failure-Mode Assessment) 72

was done to find out reasons behind the failures and provide necessary recommendations. For testing, it was derived that the

potential modes of failure are staff not being careful while testing, test centre not operational during mentioned hours and social distancing norms not being followed at the test centre. For each potential mode of failure potential effects of failure and potential cause of failure were listed down. The potential effect of failure for staff not being careful while testing can include patient getting hurt and patient hesitant to get themselves tested next time; the possible causes of failures can be untrained staff, enhanced workload and sub-standard equipment used for testing. The current process controls were also listed and the recommendations included training of staff before deploying to the testing centre, following operational hours with defined breaks and procuring ICMR recommended testing equipment. For that ranking scale was designed where the severity of the effect of failure was assessed based on dissatisfaction, adversity and displeasure experienced by the patient. Similarly, the occurrence of the failure was ranked based on the duration it takes to complete and the controls on the services are assessed based on how certain it can detect those failures. Then the risk priority number was calculated to know the priority of mitigating the risk.

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Service Audit Profile The service audit tool was used to compare the current performance of the system and with the recommendations on how the system will be improved. All the parameters identified from SERVQUAL were mapped together. After suggesting the recommendations, the negatives were

improved and change in the graph was moticed. Good Points of City • Testing at Inter-State Bus Terminals and Railway Stations for travellers and migrant workers. • Reduced rates of tests at private labs. • Free Rapid Testing at various locations.

• Largest COVID Care Center in the country with a capacity of 10,000 beds. • Number of occupied and vacant beds and ventilators available online. • Converted hotels and banquets into isolation centers. • Dedicated website, mobile application and helpline number.

Figure E16: Service Audit Profile Delhi | Service Operation Management Studio 2020 I CEPT University

INTRODUCTION TO THE CITY SWAPNIKA VADALI PG191087

With an area of 217Kms, Hyderabad is the most populated city in Telangana state with a population density of 18,172 per sq. km, taking its place as the 6th most populous urban agglomeration in India. It includes a part of the metropolitan capital city area of Hyderabad. It is the smallest in terms of area, among all the districts in the state, but has the highest human density residing in it.

From 1956 to 2014 Hyderabad was the capital of Andhra Pradesh state, but, with the seperation and formation of Telangana state from Andhra Pradesh in 2014, it was redesignated as the capital of both states for a set period of time.

Hyderabad City is located along the banks of the Musi river, which divides the city in half. It is Telangana’s largest and most-populous city and is the major urban centre for all of south-central interior India. 75

About the state & city Telangana is the 29th state of India, which was officially formed on June 2, 2014, with an area of 1,12,077 Sq. Km. Since its formation, the Chief Minister of the state is K. Chandrasekhar Rao. With a population of 3.5Cr, the state consists of 33 districts in total, with its capital being Hyderabad. Hyderabad is a city-district in Telangana, which contains a part of the metropolitan area. It is one of the smallest districts in Telangana spread over 217sq.kms (Telangana Tourism, 2016). When looked from the COVID19 case

scenario, the first case of Telangana was detected in Hyderabad on March 2nd 2020. Since then, the growth rate in the state has summed up to be 0.6%. As and on 31st October 2020, the state has 2,37,187 confirmed cases, 18,456 Active cases, with Recovered cases of 2,17,401 and Deceased cases as 1,330 (India, 2020). Telangana’s statistics have shown an active rate of 7.41% and recovery rate of 92%. In India, the state takes the 10th position, right after Odisha with the number of confirmed cases. From the figure F1 it is clearly seen that there is some glitch in maintaining the

Figure F1 Timeline showing the Telangana’s COVID state as and on 31st October 76

number of tests being conducted by the state department. At the end of Phase 4, the state has received a notice from the High court stating to update the number of daily tests being done and to increase the number of tests in the state. A constant growth in testing numbers have been seen since then. From Unlock 3.0 phase, effective and improved testing numbers have been seen pan city and state. City - Hyderabad had a population of 39.43 Lakhs in 2011 with a slum population of around 32.7%. Out of the total Hyderabad population, almost 100% lives in urban regions of city. It has a male population of 2,018,575 with 86.99% being literate and female population of 1,924,748 with 79.35% being literate respectively (Census, 2011). Presently, according to the world population review, in 2019 Hyderabad has become the home for 97 Lakhs people, with 39 Lakhs migrant population. The city is divided into 5 zones, 18 circles, 150 yards and 1 contonment zone (Hyderabad Corporation, 2014). The municipal corporation has 15 departments, out of which the health & sanitation department and the Disaster Management teams are currently working for the COVID19 management in the city along with the police department.

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Aggressiveness of the issue District data of the number of COVID cases have not been updated by the state portal from the beginning of the pandemic. As per the daily newspaper calculations and updates by Microsoft Bing tracker, the number of cases in the district are listed in figure F2 as and on 31st October 2020.

there was an increase from 63 zones to 94 containment zones i.e. increase in 31 hotspots spread all over the city (Telangana, health facilities, 2020). For further analysis, this information was inferred as the effective monitoring and testing happening in the city in a positive manner.

Figure F2 City statistics as & on October 31st

When calculated Hyderabad’s active cases contribute up to 53.14% of the total cases in the state. From the above statistics the recovery rate of Hyderabad is coming up to 0.5% and Telangana’s statistics have shown to have an active rate of 7.41% and recovery ratio of 92% (India, 2020). With Hyderabad being the most populated city in Telangana, the state statistics don’t match up even remotely with the district. Containment of areas within the zones The state portal has recently started updating the details of the activities going on in the city. When the number of containment zones growth was analysed between a span of two months (i.e. from 14th August – 14th October 2020),

Figure F3 Containment zones in Hyderabad

Organizational Capabilities Departments - There have been 3 major activities which are being managed in the city, by various departments (Telangana, Operational Guidelines for day to day management of Containment zones, 2020) 1. The Health care facilities department is headed by the Health and Medical Minister of the state himself in coordination with

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the district medical officers. 2. Disaster management department – The sanitation activities are handled by this department. 3. Monitoring & containment activities of areas in the city are monitored and headed by the Municipal Commissioner. Next to him are the deputy commissioners who have taken charge as the nodal officers for the surveillance teams. The Nodal officers monitor the activities done by the Zonal Level Surveillance Team, which is in-charge for overall regulation of the Containment zones. The team includes. •Zonal Commissioner, GHMC •Deputy Commissioner of Police •An official appointed by the Director of Health •Superintendent Engineer •GHMC Zonal Level officials •Medical Officers in the zones Circle Level Surveillance Team comprises •Assistant Medical Officer of Health •Sanitary Field Assistants •Representative from the Police Dept. •Sewer Line maintenance workers from HMWSSB (water board) •Representative from ASHA/ANM/AWT •Executive Engineer 77

Table F1 Healthcare Infrastructure in Hyderabad for COVID19 as and on 31st october 2020

Table F2 Bed Status in Government & Private Hospitals as and on 31st october 2020

Figure F4 Present service concept of COVID management in Hyderabad

Healthcare Infrastructure The types of healthcare facilities provided by the city corporation to the citizens are the testing centres and treatment hospitals. Initially only the government was the only service provider for all the facilities, later the private parties stepped in and started providing testing and treatment facilities. At present there is a vacancy of 69% with the government hospitals and 56% with the private ones. This concludes, that there is no further improvement in infrastructure.

Present Service concept of COVID The strategies implemented by the city government has moulded the service concept of COVID management in Hyderabad in a clear & simple way. The city majorly focussed on spreading awareness through various mediums and connecting the people with a fulltime helpline service catering to all the doubts and needs of the citizens. From providing a 24/7 helpline centre to providing PPE (Personal Protective Equipment) to all the frontline workers, the government has provided various services to the citizens, the administrative staff and the frontline workers as well. Services to cater the homeless and poor have also been looked into. Hyderabad I Service Operations Management Studio 2020 I CEPT University

Process Analysis For better understanding of the stages involved in the COVID Management system, a flow chart has been created. It is observed that all the activities have been mapped out into 5 processes and analysed that few of the activities happen simultaneously & others have a circular pattern. For further simplifying the process identification of COVID management, the 5 processes identified from flow chart are clubbed under 4 basic processes, namely – 1. Identification 2. Confirmation 3. Treatment 4. Prevention From the analysis of all the above mentioned parameters and processes, SWIMLANE, RACI and process profile worksheets have been made and analysis from them have been noted down. PROCESS PROFILE WORKSHEETS : (Detailed worksheets are shown in the Annexure 1, 2, 3 & 4) 1. Identification – Neglecting the presence of symptoms, Lack of awareness of available service details for citizens and Negligence towards social distancing are the service risks that have been identified in identification process and Awareness

Table F3 Process identification and responsible body of all processes

about symptom identification, Easy availability of all the service amenity details and strict monitoring are the key controls that need be considered. 2. Confirmation – Mixing / misplacing of samples resulting in wrong results and Delay in test results are the two major service risks identified in this process and Following the right protocol for sample collection and Handling & testing the samples according to SOP are the key

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controls. 3. Treatment – Inadequate healthcare facilities (beds, ventilators, etc.) & staff personnel and Unhygienic surroundings in the treatment wards are the service risks considered and Constant check on statistics to meet the demand and Maintaining clean & sanitized surroundings all the time in the hospitals are the key controls identified. 4. Prevention – Unsanitized surroundings/ neighbourhood, Lack of data for contact 79

tracing and Failure in providing the essential services are the service risks and Regular sanitization following the SOP issued, Mandatory proforma filing by citizen tracking of the people in contact of the patient and Good monitoring teams in containment zones are the concerned key controls. SWIMLANE and RACI : Swaimlane - All the COVID19 management activies happening in Hyderabad by the government have been mapped in the swimlane with the timeline. The activites have been mapped with the respective stakeholders involved in it. A shown in figure F5, the rectangle is indication of the activity, the square is potraying a scenario, the rhombus is the possibility of option and finally the circle is the end of that particular activity/process.

problems were looked into detail. Further, identification of drawbacks from the SWIMLANE & RACI have been highlighted. Reflections from aggresiveness of the issue and organizational capabilities. Community spread of the virus is evidently seen in the city and the growth rate pattern is also taking a gradual growth. There are enough vacancies of about 58% in the city hospitals and enough monitoring & surveillance teams formed for monitoring.

Figure F5 COVID Management process through Swimlane

RACI- Raci shows the stakeholders who are Responsible, Accountable, Consulted and Informed for all the activities happening as a part of the COVID management in the city. Firstly the hindrances or the problems faced by the city government through all the phases have been identified. Possible reasons for the occurrence of these 80

Reflections from Swimlane and RACI: The negative tested patients with symptoms from the testing centres are not further tested for RT-PCR testing. It is left up to the citizens and further doctor consultation is not mandatory. Contact tracing is done only for available immediate contacts. The surveillance teams were not working efficiently as there is free movement in the containment zones. Lack of updated data availability in the city dashboard even though the COVID Command Centre is Responsible for the task. To further understand the current scenario of covid management, a survey was conducted to understand the service quality of all te activities being conducted pan city.

Figure F6 RACI mapping Hyderabad I Service Operations Management Studio 2020 I CEPT University

SERVQUAL using RATER PARAMETERS : For the analysis, 20 samples were collected and the other details are listed below in figure F8.

the test center, test result type of testing center, quarantine period was also inquired to understand the profile of the citizens interviewed.

All the citizens interviewed were under 7 to 14 days Home quarantine. Out of the 20 citizens, immediate contact details of 15 citizens were taken. The citizens interviewed had gone through the testing process ranging from may to october months. Out of 20 citizens surveyed, only 5 citizens were aware of the HITAM (Home Isolation, Telemedicine and Monitoring) app for provision of essential services. Most number of citizens were interviewed from the area of more containment zones to understand the monioring strategy implementations on ground. Comon questionnare regarding the approach to

Figure F8 Area wise details of samples collected

The questions for the survey were based on the parameters of RATER * Reliability * Assurance * Tangibility * Empathy and * Responsiveness The questions for all the parameters considered, were framed for 3 processes namely Testing, Quarantine & Sanitation and Monitoring for better understanding and structuring of the analysis.

Figure F7 Survey sample details

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All the RATER parameters considered for the questions have been mapped on the bar graphs and shown in figure F9. TESTING - In testing, tangibility parameter has scored the highest, which clearly shows a huge gap between the expectations & the perceptions of the activities. When looked in detail, the availability of space at the test center was a concern for the citizens whereas the behavior of the staff was extremely commended by all the citizens interviewed. QUARANTINE & SANITATION - With both private & public sectors acting as service providers, it has become easy for the citizens to trust accordingly and choose. One such activity is sanitization which to some extent met the citizens expectations in sanitizing the neighborhood timely. On the other hand, the expectations of provision of essential goods and doctor consultation were missing when looked for activities during the quarantine period.

Figure F9 Statics of all the point weight results received from the survey questionnaire. Individual and compiled rating of all the questions and parameters of RATER considered.

MONITORING - With all the surveilance teams & police department in place, there have been few errors or gaps from the citizens perspective regarding the efficiency of moitoring in containment zones and from all the areas pan city. The

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citizens expected a feedback mechanism which was again missing from the whole COVID management structure of the city and state. Failure Modes and Effects Analysis (FMEA) This particular tools was used to analyze and understand the potential effects of the issues identifies till now. Potential causes of those loopholes have also been identified and the current proces controls have been listed down to further analyze the situation. Accordingly, recommendations for all the issues have been given and rated on the point scale. Most of the recomendations have been given considering all the present infrastructure that the city already has in place. For example, the city has the arogyasetu app already in action. Improving and updating the services through that app for locating the test center, getting statistics of the number of citizens at the particular test center, etc., can be easily updated for better monitoring by the service providers and is helpful for the citizens to track the activities happening within the city to take move cautiously. More the amount of transparency maintained by the service provider, the better amount of trust will

Figure F10 Point weight of parameters considered from Exposure Assessment, Organizational capabilities and Aggressiveness of the issue.

get builded up by the citizens as well.In the similar way, few ammends for mandating the activies and strict monitoring have been recommended. Every rcommendation has been given a point. Analysis - For better relevance and to link the recommendations & the city infrastructure capabilities, for now, all the recommendations have been considered as ideal situations. Simultaneously, the analysis parameters which were looked in the study previously were given point weights. The parameters

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are listed and their ratings are listed down in the figure F10. These parameters have been rated by comparing the statistics of the city to the state. After noting them down a gap between all the analized points has been noted down (i.e for example :7 - (the average of all parameters considered) = actual rating of the recommendations) Every recommendation has been mapped in such a manner &point weights have been derived. Refer annexures for detailed calculations. 83

Service Audit

Summary the city suitable process detailed

for a health status checkup for better monitoring systems and re-training the present frontline workers for efficient monitoring systems in the containment zones.

TESTING Good Practices * The staff was gentle, caring and very polite during the testing procedures. * The test centres were opened at promised time.

MONITORING Good Practices * The GHMC helpline number is functioning efficiently and is very helpful to find the testing centre for other information. * App to get telemedicine & other services during quarantine & in containment zones.

Recommendations - Constant updation of test centre inflow data on the arogya setu app to avoid overcrowding at test center could be implemented and Standardized testing procedures to formalize the analysis pan city could be beneficial.

Recommendations - Constant feedback system through the arogya setu app will help in constant updation of the management strategies. Zone/ area wise fine system for efficient monitoring of social distancing norms could be beneficial.

At the end of the analysis, learnings, good practices and recommendations for each analyzed previously have been out.

Figure F11 Service audit profile of the Rater parameters (Left side graph), actual recommendations point weights(right side graph) and the gap between recomendations and parameters (Orange graph at the center) with improved recommendations

On the service audit, the extreme left side has all the servqual responses and the points of each are mapped down to form a graph of the responses. On the right hand side are the recommendations for the parameters which had the most amount of 84

issues . The highest rated issue was taken and the gap for the recommendation as mapped and noted down in the orange graph in the Fig 11. So when analysed, the actual point weight of the recommendation and the gap point

weight can be clearly seen between the orange line (with the gap) and the grey graph (without the gap) mapped. The parameters with the most negative rating have been selected and recommendations have been given to them.

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QUARANTINE & SANITIZATION Good Practices * Containment of affected areas is strictly in place pan city. * Both private & government services provide easy & available sanitation practices at the citizens doorstep. Recommendations - Mandating doctor consultation during the quarantine period

For the mentioned points, parameters like manpower, finances and organizational capacity and structure of the departments could be the key driving fators which could not be explored during the course of the analysis.

Scope of improvements Other issues faced by the managing teams* Low availability of staff at all the stages of covid management. * Staff becoming more vulnerable while conducting the procedures. * Initially, low availability of PPE kits for all the frontline workers.

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INTRODUCTION TO CITY VIBHAV SINGHAL PG191102

Lucknow is the capital city of the state of Uttar Pradesh which is currently under the governance of CM Yogi Adityanath of Bhartiya Janta Party. The city is administered by Mayor Sanyukta Bhatia and the executive body head i.e. Municipal Commissioner is A.K. Dwivedi who looks after the basic facilities that are to be provided to the citizens. With reference to COVID 19 management, several different departments are looking after the services rendered in the city namely: • Chief Minister’s Office - To take an overview on the whole city’s COVID situation. Lucknow | Service Operations Management Studio 2020 I CEPT

• Chief Medical Officer’s (CMO) Office - To look after the medicalrelated needs of the city like the availability of beds for isolation and availability of testing kits and other medical equipments. • District Magistrate’s Office - To create a bridge between the state and the city level administrations • Lucknow Police Department - To maintain law and order and monitor the movement of all the citizens during lockdowns and around containment zones • Lucknow Municipal Corporation (LMC) - To look after the prevention strategies in the city against COVID 19. 87

About the city The district of Lucknow is spread in an area of 2528 sq. km (as shown in figure G1) with a population of around 46 lakhs with a near to 50:50 ratio of men and women population and a literacy rate of 77.29%. The district comes under one of the most densely populated ones with an average density of 1816 per sq. km in comparison to the state average of 830 per sq. km. As per Census 2011, the district caters to around 3.5 lakh (7.25% of the total population) of slum population which is one of the most vulnerable population to the pandemic The district’s adjoining boundaries contains: • Barabanki District on the east, • Unnao on the west, • Raebareli on the south and, • Sitapur and Hardoi districts on the north

order to tackle it, the district administration has to take serious measures to curb

Aggressiveness of the issue

Figure G1 Map of District of Lucknow Source : bharatmaps.gov.in

its effect. The first case of COVID 19 in Lucknow was registered on 8th March. Since then, the growth rate of the virus was under control until unlock 1.0 (as shown in figure G2). As the government announced the opening of offices and markets, the number of cases in the city increased drastically from 399 cases on 1st June to 63,515 on 1st November (COVID 19 India, 2020)

Chikankari and Plastic which has contributed to the overall migrant influx of 38 lakhs in Uttar Pradesh during the pandemic. All these factors have contributed to the exposure of the district to COVID 19, and in

The current active and recovered ratio s are 5.2% and 93.3% respectively which is better than the national ratio of 6.2% and 92.3% while the current fatality

Since the adjoining districts have inadequate medical infrastructure for COVID 19, so these districts are also dependent on Lucknow for the treatment of their citizens, which creates an additional burden on the administration to tackle the pandemic. Apart from this, the district also caters to various industries like Steel, Terracotta, 88

ratio is 1.4% which is almost at par with national ratio of 1.5%. Apart from that till 1st November around 8.02 lakhs tests

Organizational Capabilities have been done around the district. The Government of Uttar Pradesh created the COVID Management Plan to tackle the pandemic in different cities of the state. It comprises of different health infrastructure and support systems as follows: COVID Control Center COVID control center is a command center created to monitor the pandemic in the city and update data to help all the departments working towards containing it, and can get real time data to take effective actions. It is integrated with the District Surveillance Officer Portal (DSO Portal) for the real time data from all the test labs and quarantine centers. The COVID Control Center comprises of the following departments: • Chief Minister’s Office - To administer overall city information • Chief Medical Officer’s (CMO) Office – To administer city health department

information • District Magistrate’s Office – To administer management of COVID control centre • Lucknow Police Department – To administer city sanitisation and containment strategies • Lucknow Municipal Corporation (LMC) – To administer containment zone monitoring It contains a workforce of 100 people working in a shift of 2, making an average of 5000 calls everyday related to isolation checks and solving queries of the citizens. They also have a team of doctors from CMO’s office for advising the patients for quarantine. Test Labs To identify the COVID patients several test labs and collection centers have been established in the district to cater to the needs of its citizens and for the people from around the cities. There are 40 test labs to test the patient’s samples, 8 collection centers for the medical teams to deposit samples and 10 community health centers (CHC) which also acts as testing labs operated by the municipal corporation.

Apart from that, the CHC’s also provide the parking facility for the ambulances which are used to carry COVID patients from their residents to the nearest COVID facility. Rapid Response Team Rapid Response Team is a team comprising of Asha workers, teachers and Anganwadi staff nurses whose work starts during contact tracing where all the people who were in contact with the patient needs to be identified and quarantined to prevent further spread of the virus. Currently there are 600 teams across 110 wards that are working in the district, where the number of teams varies from 20-60 as per the population of that ward. Municipal Corporation The Municipal Corporation is working towards sanitisation and creation of Containment Zones. All the services provided by them are free of cost. They also take help from the police department for the monitoring of the containment zones, which usually contains 200-300 houses.

Figure G2 Outbreak Timeline in the District of Lucknow Lucknow | Service Operations Management Studio 2020 I CEPT

Lucknow | Service Operations Management Studio 2020 I CEPT

Service Concept As the Government of India announced full lockdown in the country from 22nd March till 31st May, the Government of Uttar Pradesh and Lucknow took various measures to tackle this outbreak.

Figure G3 Service Concept 90

Process Analysis To analyse the process of COVID management in Lucknow various tools of process analysis were used where first a process flow (Annexure G1) was created to establish a proper understand-

ing of the flow. Below are the tools used in the process analysis after the process flow was created to provide a better understanding of the whole process. Process Identification After a brief study of the mind map, the process identification worksheet was created in which four major processes were identified mainly Identification, Confirmation, Treatment and Prevention. As the process names were created, there trigger events were also created which causes the process to start, mainly person getting the symptoms, suspect getting their testing done, then the confirmation of a positive case and finally patient getting into quarantine.

Figure G4 Process Identification Worksheet Lucknow | Service Operations Management Studio 2020 I CEPT

Process Profile Worksheet The process profile worksheet is used to further analyse the key measures and risk of services associated with the process identified. Firstly, the process profile for identification (Annexure G2) focuses on identifying the COVID patients in the city with various service risks like being careless with the symptoms, technical issue with the call and unavailability of the doctor, with their key control as getting proper consultation and being responsible after having the symptoms.

tion checks and unhygienic quarantine facility with key control as trained staff, data backup, reconfirmation of data entered and record of all the quarantine facilities. Lastly, the process profile for prevention (Figure G5) focuses on preventing further

spread of virus in the city with various service risks inability of trace contacts, create and monitor containment zones and unsystematic sanitisation, with key control as trained staff, sufficient PPE kits, and proper data to create containment zones and doing the sanitisation.

Secondly, the process profile for confirmation (Annexure G3) focuses on testing and confirming the COVID patients in the city with various service risks mishandling of suspects sample, test sample not analyzed properly and untrained medical staff, with their key control as following proper SOP for conducting the testing, maintaining equipment and highly qualified teams. Thirdly, the process profile for treatment (Annexure G4) focuses on treating the COVID patients in the city with various service risks incorrect patient information, data loss, miscommunication with the quarantine facility, inconsistent isola-

Figure G5 Process Profile Worksheet - Prevention

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Swimlane The swimlane helps in analyzing the process flow and the people responsible for doing them in a given time-frame. The swimlane provides a detailed analysis

of all the process happening in Lucknow from the start, mainly, getting in contact with a COVID 19 patient to getting test done and then finally into quarantine for further recovery. It includes all the

major stakeholders like suspect/patient, personal doctor, test labs, COVID Control Center, Lucknow Municipal Corporation and Rapid Response Team who are involved in executing those processes.

RACI The RACI chart (figure G7) helps in understanding the people responsible, accountable, consulted and informed during a given process. It is a process analysis tool which helps us establish people who are responsible and accountable for doing the work and also people who needs to be consulted and the one that are to be informed about every details or progress made. SERVQUAL TOOLS The process analysis helped identify certain

Figure G6 Swimlane

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issues in the overall management of tackling COVID 19 in the city. Issues like ambulance response time, COVID Control Center response and Sanitisation workers are some of the major setbacks which the city is facing while managing the whole situation. So, to further understand them, a survey was done in 7 containment zones and 3 slums comprising of total 20 citizens, were surveyed who were either patient’s or close relative to a patient. Taking into consideration the impact of

COVID on different age groups, hence, the survey included citizens from all the age group, i.e. from below 30 till above 50. The Survey questions were based on five factors namely Reliability, Assurance, Tangible, Empathy and Responsiveness, which collectively known as RATER. 1. Ambulance Response Ambulance Response, as understood in the swim lane also, the overall responsiveness is identified as an issue which needs to be resolved, and as shown in the graph

Figure G7 RACI Chart

Lucknow | Service Operations Management Studio 2020 I CEPT

below (figure G8), it is highlighted as a problem under responsiveness as well, as there are problems of high waiting period before the ambulance arrives, delay in assigning of ambulance by the COVID Control Center and lack of proper complaint resolution system to report this issue. 2. COVID Control Center Response COVID Control Center is the most im-

Fiigure G8 - P-E Analysis for Individual Parameter for Ambulance Response

Figure G9 - P-E Composite Analysis for Ambulance Response 94

portant department in the district which looks after the COVID management. With a workforce of 100 people, the Control center faces the issue of empathy and assurance as the staff are not able to resolve the queries that the citizens are asking making the control center unapproachable and insensitive towards them. 3. Sanitisation Workers Response Sanitisation process as shown in the graph

Figure G10 - P-E Analysis for Individual Parameter - CCC Staff

Figure G11 - P-E Composite Analysis for CCC Staff

below (figure G12) are also facing the same problem like the ambulance staff, regarding responsiveness i.e. high waiting time for them to arrive at the patients house. Apart from that they are also identified to be unapproachable as they fail to reduce panic among people during the sanitisation drive. While for the good part they are perceived to be wearing proper equipment while doing the process.

Figure G12 - P-E Analysis for Individual Parameter sanitisation workers

Figure G13 - P-E Composite Analysis for sanitisation workers

Lucknow | Service Operations Management Studio 2020 I CEPT

FMEA TOOL The Failure Mode and Effect Analysis is a tool for analyzing the root cause of every potential failure for any function using three unique factors namely its severity, occurrence and its delectability. On the basis of these three factors a risk priority number (RPN) is calculated which tells the how acceptable the risk is, and accordingly recommended actions are given to lower the existing RPN. In the following study, a two way approach was taken where first, FMEA analysis is done by rating the issues on the basis of its severity, occurrence and delectability (Figure G14 ), and after that a city constraint analysis is done to identify the real life applicability of the recommendations provided. 1. Ambulance Response Under Ambulance Response, for the

three potential failures identified, following are the root causes recognized inadequate number of ambulance, lack of responsibility held and lack of data to assign ambulance on time (Annexure G5). After analyzing this, various recommendations were proposed like an integrated ambulance system which would help in assigning the ambulance on time and also keep a check on their availability. Apart from that one major recommendation was the PPP model with the private hospitals ot increase the number of ambulances in the city. 2. COVID Control Center Response Under COVID Control Response, for the two potential failures identified, following are the root causes recognized improper training of the staff to resolve queries and also lack of empa-

Figure G14 - FMEA Rating Lucknow | Service Operations Management Studio 2020 I CEPT

thy and approachability towards the citizens by the staff (Annexure G6). After analyzing this, one major recommendation was proposed which was to create a training regime and train them at various aspects like empathy and assurance 3. Sanitisation Response Under Sanitisation Response, for the two potential failures identified, following are the root causes recognized inadequate number of workers, lack of proper channel to communicate inter department for timely arrival of information and incompetent workers. (Annexure G7) After analyzing this, various recommendations were proposed like an time bound sanitisation service which would mandate the municipal corporation to provide the services to its citizens in limited period in order to curb the effects of COVID 19 in the city. Finally, these recommendations were analyzed using the constraints decided to come up to the actual improvement happened in the city. This whole analysis is then summarized in the audit profile by comparing the area of improvements and their suitable recommendations.(Annexure G8) 95

Service Audit Profile Service Audit Profile is a tool used to compare the existing scenario with the recommendations given, to analyse how much the system has improved.

After an elaborate study of the existing scenario of COVID Management in the city of Lucknow, using various tools and a survey various good practices and area of improvements were identified which can be used by other cities while improving their management city in the pandemic.

CHANGE IN BUSINESS LANDSCAPE OF THE CITY

The Integrated COVID Control Center, which comprises of all the major departments which works in the city to curb the effect of COVID 19 is a good learning one can take from the city. It provides with one help line number for all the queries around the city, and person can ask for assistance from any department through the Control Center. Also, one call sanitisation system in the city as it guarantees of the service to be done within 12 hours of the call made. This service provides with assurance among the citizens that the government is helping in fighting the pandemic efficiently.

From September to November, the UP government and Lucknow Administration has taken various steps like Virtual Intensive Care Unit (v-ICU) where a battery of experts sits on one end to review case summary of a patient in need of treatment miles away. After the case is discussed, the advice is implemented by the team of doctors at the patient’s end. Initially, this technology was implemented in the two main Medical institutions of Lucknow i.e. KGMC and SGPGI.

On the other hand, the city is also facing problems like lack of data availability on any public portal despite the fact that there is a track of all the data, making the system not transparent for its citizens.

Apart from that, ‘SANITISATION ON ONE CALL SERVICE’ launched in the first week of September, so now when a person tests COVID-19 positive in Lucknow, there will be sanitization in their area by placing just one call on the help line number 0522-2307770) In this way the government has been evolv- Figure G16 - COVID Changing dynamic ing through the process and taking various Source: https://www.ippf.org/covid19 measures to fight the COVID 19 pandemic.

Figure G15 - Audit Profile 96

As the city is evolving with the pandemic the administration is also working towards tackling the pandemic through new ways which can help them fight it efficiently.

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City Learnings

List of Figures Vadodara Figure A1: Organogram of VMC 12 Figure A2: Exposure assessment charts 12 Figure A3: COVID outbreak timeline 13 Figure A4: Charts showing the statistics of COVID related parameters 13 Figure A5: Active Cases Trend 14 Figure A6: Healthcare details shown on website 14 Figure A7: Tested vs Positive graph 15 Figure A8: Micro Containment Strategy 15 Figure A9: RT PCR report & Antigen Test report 16 Figure A10: SWIMLANE chart 17 Figure A11: Location of patients 19 Figure A12: Cumulative RATER Analysis 19 Figure A13: Occupational aspects of patients 19 Figure A14: Cumulative RATER analysis of all 4 process 19 Figure A15: Individual process RATER analysis 20 Figure A16: Individual process RATER analysis 20 Figure A17: Service Audit Profile Graph 22 Gandhinagar Figure B1: Gandhinagar Figure B2: Organogram Figure B3: Age wise population Figure B4: Confirmed vs Recovery ratio Figure B5: Analysis of containment zone Figure B6: Land use pattern at Gandhinagar Figure B7: SWIMLANE Figure B8: Tests per million Figure B11: Home quarantine RATER Figure B12: Sanitization RATER Figure B11: Surveillance cont. RATER Figure B12: Surveillance PAN city RATER Figure B13: Audit profile

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26 26 27 27 28 28 30 31 32 32 32 32 33

Pathanamthitta Figure C1: Pathanamthitta District Revenue Division 36 Figure C2: Administrative Divisions Pathanamthitta 36 Figure C3: Administrative Framework Pathanamthitta 36 Figure C4: Pathanamthitta District Business Profile 37 Figure C5: District boundary neighborhood context 37 Figure C6: Cumulative Analysis of COVID 19 cases as on 31.10.2020 38 Figure C7: Date Wise Quarantined as on 31.10.2020 38 Figure C8: Case trend as on 31.10.2020 38 Figure C9: Kudumbasree Organization Framework39 Figure C10: District Police Station Organogram 39 Figure C11: Enforcement actions taken by police department during COVID 39 Figure C12: District Volunteering Staff Activities 40 Figure C13: Psychological Support Treatment 40 Figure C14: Service-wise survey result of RATER 44 Figure C15: Calculation of new audit profile ranks 45 Figure C16: Service audit profile showing issues and its recommendation based improvement 46 Ahmedabad Figure D1: Zone, City Administration Classification50 Figure D2: Organogram of AMC’s Health Dept 50 Figure D3: Exposure Assessment Vulnerable Population of Ahmedabad City 51 Figure D4: Covid timeline in the Ahmedabad City Lock down 52 Figure D5 : Testing Patterns of Covid in Ahmeabad52 Figure D6: Covid time line in the Ahmedabad City

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Unlock 53 Figure D7 : Confirmed Cases Ahmedabad and India Peak Point 53 Figure D8 : Covid process rough mind map 55 Figure 9: Rapid Test center and Treatment 55 Figure D10: Containment and monitoring 55 Figure D11: RACI Chart for covid process analysis 53 Figure 12: Swimlane for Covid Identification, Confirmation, Treatment and Prevention 58 Figure D13 : Cumulative RATER for each process 58 Figure D14: Individual RATER for testing process 59 Figure D15: Individual RATER for treatment 59 Figure D16: Individual RATER for monitoring 59 Figure D17: Individual RATER for sanitization 60 Figure D18: Service Audit Profile 61 Delhi Figure E1: Delhi District Division 66 Figure E2: Major stakeholders involved in COVID Management 66 Figure E3: COVID spread in Delhi 67 Figure E4: : India’s Largest COVID Care Centre 67 Figure E5: Delhi Fights Corona Poster 68 Figure E6: Sanitization being done by DJB 68 Figure E7: Drive Thru and Test Centre 70 Figure E8: RACI Chart 71 Figure E9: Swimlane Diagram 71 Figure E10: Reliability 72 Figure E11: Assurance 72 Figure E12: Tangible 72 Figure E13: Empathy 72 Figure E14: Responsiveness 72 Figure E15: Testing RATER 72 Figure E16: Service Audit Profile 73

List of Figures & Tables Hyderabad Figure F1: Timeline showing the Telangana’s COVID state as and on 1st September 76 Figure F2: City statistics as & on September 1st 77 Figure F3: Containment zones in Hyderabad 77 Figure F4: Present service concept of COVID management in Hyderabad 78 Figure F5: COVID Management process through Swimlane 80 Figure F6: RACI mapping 80 Figure F7: Survey sample details 81 Figure F8: Area wise details of samples collected 81 Figure F9: Statics of all the point weight results received from the survey questionnaire. Individual and compiled rating of all the questions and parameters of RATER considered. 82 Figure F10: Point weight of parameters considered from Exposure Assessment, Organizational capabilities and Aggressiveness of the issue 83 Figure F11: Service audit profile of the Rater parameters (Left side graph), actual recommendations point weights(right side graph) and the gap between recomendations and parameters (Orange graph at the center) with improved recommendations 84 Lucknow Figure G1: Map of District of Lucknow 88 Figure G2: Outbreak Timeline 88 Figure G3: Service Concept 90 Figure G4: Proces Identification Worksheet 90 Figure G5: Process Profile Worksheet Prevention 91 Figure G6: Swimlane 92 Figure G7: RACI Chart 93 Figure G8: P-E Analysis for Individual Parameter for Ambulance Response 94 100

Annexures

Figure G9: P-E Composite Analysis for Ambulance Response 94 Figure G10: P-E Analysis for Individual Parameter - CCC Staff 94 Figure G11:P-E Composite Analysis for CCC Staff 94 Figure G12: P-E Analysis for Individual Parameter - sanitisation workers 94 Figure G13: P-E Composite Analysis for sanitisation workers 94 Figure G14: FMEA Rating 95 Figure G15: Audit Profile 96 Figure G16: COVID Changing dynamic 97

Vadodara Table A1: Case Study analysis Table A2: RACI chart Table A3: Sanitization FMEA calculations Gandhinagar Table B1: Bed occupancy Table B2: Details of testing Table B3: Manpower at fire department Table B4: Service concept Table B5: RACI

16 18 21

ANNEXURE A1 – Mind Map

28 29 29 30 31

Pathanamthitta Table C1: Types of testing and procedure 40 Table C2: Types of treatment centers and infrastructure 40 Table C3: Types of quarantine centers 40 Table C4: Service Concept Pathanamthitta District41 Table C5: Process Identification 42 Table C6: RACI Chart 43 Table C7: Swimlane 43 Delhi Table E1: Healthcare Infrastructure Table E2: Available beds and Ventilators Table E3: Process Flow

67 68 70

Hyderabad Table F1: Healthcare Infrastructure in Hyderabad for COVID19 78 Table F2: Bed Status in Government & Private Hospitals as and on 14th September 2020 78 Table F3: Process identification and responsible body of all processes 79

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ANNEXURE A2 – Process Profile Sheets Identification

PROCESS NAME – NUMBER

Process of identifying symptomatic patients

PROCESS OWNER VMC Health dept/UPHC/Private clinic/hospital DESCRIPTION

TRIGGERS Person falling sick Suspecting the potential patients Calling helpline number/screening while surveying, Consulting doctor, taking ADDITIONAL EVENTS medication INPUTS – ITEMS AND SOURCES Consulting doctor - Patient/Screening - VMC OUTPUTS – ITEMS AND CUSTOMERS Potential patients list – Health staff PROCESS UNITS PROCESS UNIT OWNERS Calling helpline number ICCC (VMC) Screening households Medical officer (UPHC) Consultation Doctor Taking appropriate medicines Patient SERVICE OBJECTIVE(S) SERVICE RISKS Missed covering area, incorrect survey details, people Reach every household, provide accurate consultation not responding and detect the symptomatic patients Miscommunication within staff, improper consultation KEY CONTROLS MEASURE OF SUCCESS Monitoring of surveying staff Maximum households covered and staff performing the Awareness among people assigned duty, timely identification of symptomatic Standard survey procedure patients Internal communication within staff EVENT BEGINNING EVENT ENDING

PROCESS NAME – NUMBER

PROCESS OWNER Treatment Authorized labs/hospitals, UPHC, Mobile vans DESCRIPTION Process of providing appropriate treatment facility to the patient TRIGGERS EVENT BEGINNING Patient testing positive for COVID19 EVENT ENDING Patient reaching destination for treatment ADDITIONAL EVENTS Checking of home condition, checking severity of the infection, consultation, booking of facility INPUTS – ITEMS AND SOURCES Positive report of Patient – Authorized labs/UPHC OUTPUTS – ITEMS AND CUSTOMERS Quarantine period - Patient PROCESS UNITS PROCESS UNIT OWNERS Checking favourable conditions at patient’s home UPHC (field team) Checking infection percentage UPHC (field team) Recommendation of quarantine facility Medical officer Booking of facility Quarantine centre/hospitals Monitoring of health condition ICCC SERVICE OBJECTIVE(S) SERVICE RISKS Miscommunication about availability of quarantine facility To recommend patient appropriate quarantine facility as per Inefficient communication from the centre the health condition of the patient & favourable environment Lack of monitoring on health Delayed delivery of medicines KEY CONTROLS MEASURE OF SUCCESS Regular updating of status about facility to all medical entities Systematic booking process at facility centre Maximum number of test results generated Introduction of technology to ease the process of health Timely and accurate delivery of report monitoring Increased manpower & proper distribution as per critical areas

102

PROCESS OWNER Authorized labs/hospitals, UPHC, Mobile vans DESCRIPTION Process of testing the patient and sharing the details with concerned dept TRIGGERS EVENT BEGINNING Valid COVID19 symptoms of the patients EVENT ENDING Accurate test results Recommended testing of the patient, taking basic details, sharing of the test count and ADDITIONAL EVENTS result with concerned dept INPUTS – ITEMS AND SOURCES Visit lab for test - Patient OUTPUTS – ITEMS AND CUSTOMERS Positive test result – Health dept PROCESS UNITS PROCESS UNIT OWNERS Test recommendations Doctor Collection of samples Labs/Hospitals/UPHC/Mobile vans Recording basic patients details Labs/Hospitals/UPHC Sharing of data with other depts Labs/Hospitals/UPHC SERVICE OBJECTIVE(S) SERVICE RISKS Improper diagnosis Delay in reporting To diagnose the COVID19 virus in the patient and keep Lack of testing kits track of positive cases Faulty testing kits/equipment Lack of coordination KEY CONTROLS MEASURE OF SUCCESS Use of advance technology to produce accurate results Standard reporting procedures Maximum number of test results generated Calculated distribution of testing kits Timely and accurate delivery of report Proper storage & check on testing kits Professional & trained staff Confirmation

PROCESS NAME – NUMBER

PROCESS OWNER Authorized labs/hospitals, UPHC, Mobile vans DESCRIPTION Process of conducting prevention activities at contact places of patient TRIGGERS EVENT BEGINNING Patient testing positive for COVID19 EVENT ENDING Sensitization in the neighbourhood ADDITIONAL EVENTS Sanitization, Contact tracing, Monitoring, Updating on website INPUTS – ITEMS AND SOURCES Positive report of Patient – Authorized labs/UPHC OUTPUTS – ITEMS AND CUSTOMERS Sensitization and precautions - Neighbourhood PROCESS UNITS PROCESS UNIT OWNERS Sanitization (interiors & exteriors) Fire dept (team of 3) Collecting immediate contact details Health dept Tracing the immediate contacts ICCC/Police dept Monitoring health of other house members ICCC Sticking posters for awareness Health dept Micro containment categorization Police dept/ICCC SERVICE OBJECTIVE(S) SERVICE RISKS Patient not sharing accurate immediate contact details Inadequate data collection by team To identify the immediate contact persons of the patient and monitor Absence of tracing & monitoring their health, also conduct prevention activities around the patient’s Improper sanitization home (sanitizing & sensitizing the neighbourhood) Insufficient monitoring of violators in containment areas Lack of awareness in surrounding KEY CONTROLS MEASURE OF SUCCESS Knowledge sharing among the citizens Strict monitoring on the teams Technological interventions for tracing Early detection of suspects and breaking chain of community Sanitization as per SOP transmission Proper planning and distribution of workforce Neighbourhood awareness Prevention

PROCESS NAME – NUMBER

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ANNEXURE A3 – FMEA Assessment Parameters S

Point weight

Degree of EVERITY Adverse effect on the patient without any warning

Adverse effect on the patient with any warning

Very high dissatisfaction of the patient due to loss of function

High dissatisfaction of patient without complete loss of function

Significant problem faced by the patient

Patient not satisfied with performance of the service

Patient not satisfied with few aspects of service

Exposure Assessment

Ability to detect

DETECTION

Point weight

Nearly Impossible

<50%

> 30000

> 40

> 60

20000 – 30000

35 - 40

50 – 60

15000 – 20000

30 – 35

40 – 50

10000 – 15000

25 – 30

35 – 40

5000 – 10000

20 – 25

30 – 35

4000 – 5000

15 – 20

25 – 30

3000 – 4000

10 – 15

20 – 25

< 10

< 20

certainty

Very Little

50%

Negligible

60%

Very Low

70%

Low

80%

Population density (per sq.km.)

Point weight

Population growth (%)

Point weight

Vulnerable pop. (%)

Point weight

Average

85%

Medium High

90%

Patient experience displeasure

High

95%

Patient experience slight displeasure

Very High

99%

Effect on patient not in notice/insignificant

< 30

Almost Certain

100%

2.5 – 3

30 – 40

7–8

2 – 2.5

40 – 50

6–7

1.5 – 2

50 – 60

5–6

1 – 1.5

60 – 70

4–5

0.5 – 1

70 – 80

3–4

0.25 – 0.5

80 – 90

2–3

< 0.25

> 90

OCCURRENCE Almost certain

Frequency Testing

Frequency

(days)

(time)

(hrs)

Contact Tracing

Sanitization

7 days

(time)

Monitoring

Monthly

Point weight

2000 – 3000

Aggressiveness of Pandemic Fatality Rate (%)

Point weight

Recovery Rate (%)

Point weight

Affected pop. (%)

Point weight

Very often

5 days

Weekly

Often

3 days

Once in 5 days

Moderately often

2 days

Once in 3 days

Average

24 hrs

Once Daily

< 30,000

< 0.5

> 2,00,000

30,000 – 40,000

0.5

1,00,000 – 2,00,000

40,000 – 50,000

70,000 – 1,00,000

50,000 – 75,000

60,000 – 70,000

Organizational Capabilities Testing (per million)

Point weight

Gov. Hospitals (per 1L pop.)

Point weight

UPHC (population)

Point weight

Seldom

12 hrs

Twice daily

Very seldom

6 hrs

Thrice daily

Slight

4 hrs

3 hrs

75,000 – 1,00,000

50,000 – 60,000

1,00,000 – 1,50,000

40,000 – 50,000

1,50,00 – 2,00,000

30,000 – 40,000

> 2,00,00

< 40,000

Very slight

1:30

1 hrs

2 hrs

Almost impossible

Within 1 hr

2 hrs

Hourly

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ANNEXURE A4 – FMEA Function

Potential failure mode

Improper detail verification

Inappropriate screening of patients

Testing in UPHC

Potential effects of failure

Inaccurate data sharing

Severity of health condition will be unknown

Function S

Potential cause of failure

Lack of proper training to staff

Improper consultatio n/ diagnosis

No monitoring by higher ups for required data

Inadequate services from the doctors

104

None

Daily update from test centres

RPN

Recommended Actions

VMC Health dept

Checking on equipment by the team as per OEM recommendation

Medical Association

Periodic training to the staff

Assigning patient as per capacity

Population/infection rate based staff allocation

Incentives for work done

Break from work

Basic testing equipment as per standard protocols

None

252

Training for handling the equipment

320

Division of patients based on rate of infection in area & population density

Division of patients based on rate of infection in area & population density Appreciation of work & relaxation from duties periodically

Request application to higher officials for need of any equipment

Parameter

Periodic training to staff

216

No trained staff

None

RPN

Data report submission in specific format & should be 100% filled up

280

VMC – Health dept

Absence of additional benefits

Standardized data verification sheet

Regular calibration

324

None

Action to be taken

Medical Association

No proper equipment

Resp. & Target

Regular training sessions as per checklist/protocols

Protocols for maintenance & breakdown needs to be mandated

Inadequate facilities in the labs

Failure Mode:

Current process controls

Overload on doctors Inadequate services from the staff & doctors

384

Appreciation of work & relaxation from duties periodically

160

Every lab should have standardized & capacity based equipment

VMC – Health dept

Medical Association

VMC Health dept

Validation of training If score ,70% reappear for training

Influence %

Factors

EA {(Density + Growth + Vul.)/3} (100%) OC {(Gov lab + UPHC lab)/2} (75%) AP {(Fatality +Recovery +Affected )/3} (50%)

Potential failure mode

Potential effects of failure

Service provided only to RTPCR tested patients & not to Antigen tested patient

No trust on government due to inequity

Sanitization

[{(6+6+3)/3} + {(5+2)/2}*0.75 + {(4+6+7)/3}*0.5]/3

= 3.5

Service Operations Management Studio 2020 I CEPT University

More private players in the market

Potential cause of failure

Providing free service to all is not profitable to government

Less staff to cover all the patients

Delay in list circulation Delivery timing is not immediate

Failure Mode:

7-3.5 = 3.5

Chances to spread virus is high

Service provided only to RTPCR tested patients & not to Antigen tested patient

Current process controls

Other agencies are permitted to conduct activity as per protocols

Training gov teachers for capacity building

Monitoring by the health department

RPN

630

504

280

7 Unavailable staff

This service should be provided with minimal charge to all the patients despite of test type (subsidized) Collaboration of government with private players

Service Operation Management Studio 2020 I CEPT University

None

420

Recommended Actions This service should be provided with minimal charge to all the patients despite of test type(subsidized)

Collaboration of government with private players

Patients list need to be circulated within 1 hr of result

Ratio of staff to patient needs to be maintained

Resp. & Target

VMC fire dept

VMC

Testing labs

HR dept in Fire dept /VMC

Action to be taken

RPN

List of positive tested patients get the service within 24hrs

Minimal charge (70 gov : 30 patient) should be implied to all to avail the service

Private players are involved with the team with specific share in service

Area wise teams are formed & work is divided

Labs inform directly to area wise team for immediate response

Recruitment in team as per population density

Scope of work defined for every staff

Monitoring on the staff for their work done

OC {Testing} (100%) EA {(Density + Growth + Vul)/3} (75%) [{6} + {(6+6+3)/3}*0.75]/2 = 4.9

7-4.9 = 2.1

105

Function

Potential failure mode

Patient not sharing details

Potential effects of failure Immediate contacts wont be reachable

Potential cause of failure Concerns for security of privacy details Lack of relevant info

Contract Tracing

No tracing of immediate contacts of the patient

Suspects cannot be detected at early stage

Contacts not responding

Ignorance by the dept. Proper isolation measures not shared with the contacts

106

Contacts may spread virus to others if they are infected

Measures are not fully known by the staff

Current process controls

Awareness campaigns

None Trying various means to avail info

None

Measures shared through public media platforms

RPN

288

648

192

384

105

Recommended Actions

Assurance of safety of data shared

SOP to be followed which needs to be informed to the patients

Resp. & Target

VMC Health dept, UPHC

ICCC – Health team

Daily reporting to concerned officials Using digital technology to overcome gaps of human error

Action to be taken

RPN

Function

Permission letter to be duly signed by the patient Importance of sharing contact details should be explained Formatted sheet/form to be circulated with the patient & contacts to be filled fully within given time

Standard message of measures is circulated to all contacts for a period Team needs to be set up to follow up with all the contacts

Potential failure mode

No daily check up of home quarantine patients

Cross verification of data with gov. documents Staff has to upload the verified form on a common portal

State health dept

Service Operations Management Studio 2020 I CEPT University

Monitoring of patient

Ineffective communication to understand the needs

Analysis of health condition

Potential effects of failure Violation of rules by patient Condition might get worse if not kept a tab Improper analysis of health condition

Needs of patient not met

Cause severity or death if not consulted accurately

Potential cause of failure

Current process controls

Protocols not followed by the staff

Ignorance of the staff

Patient are asked to call the helpline

Inappropriate assignment of doctors

Team is formed with experts for consultation

Gaps in internal communication in the dept.

None

RPN

Recommended Actions

900

Using digital technology to overcome gaps of human error

Communication error

Upgrading the digital network

Untrained staff

Training provided once before job assigned

392

VMC Health dept - ICCC VMC – HR dept

Action to be taken

Through an app patient can daily update their health status & if required they will be called

RPN

175

Separate setup of call entre with team of experts for home isolation patients

SETU & Health dept

Helpline no circulated among patients & daily call to tab the needs

432

Feedback should be taken after every call so that gaps could be known

VMC

Feedback form should be filled by the patient after consultation

189

Using different ways of communicating with the patient

ICCC

288

Regular training sessions as per checklist/protocols

VMC – Health Dept

Service Operation Management Studio 2020 I CEPT University

Resp. & Target

Daily call has to be done to know the health status Medical officer or junior doctors to be assigned for physical examination of patient once in 3 days Periodic training to staff Validation of training If score ,70% reappear for training

107

ANNEXURE B1 - Mind Map

108

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ANNEXURE B2 – Process Profile Sheet

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ANNEXURE B3 – FMEA

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114

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ANNEXURE C1 – Mind Map

ANNEXURE C2 – Identification Process Profile Worksheet

ANNEXURE C3 – Confirmation Process Profile Worksheet

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ANNEXURE C4 – Treatment Process Profile Worksheet

ANNEXURE C6 – Parameters for FMEA

ANNEXURE C5 – Prevention Process Profile Worksheet

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ANNEXURE C7 - FMEA

ANNEXURE C8 - Parameters for Assessment

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ANNEXURE D1 – Ahmedabad Covid Model

Annexure D2: Service concept for covid

Annexure D3: Process profile worksheet for Covid Identification PROCESS NAME – NUMBER

PROCESS OWNER Ahmedabad Municipal Corporation (AMC) DESCRIPTION Individual makes an inquiry anout his symptoms on the helpline number or goes to get tested TRIGGERS EVENT BEGINNING Individual calls AMC or goes for testing EVENT ENDING Individual is aviced to get medical help or fills tesing survey form at the test center Information is availed by surfing the internet and calling the helpline, individual describes his symptoms or individual gives his ADDITIONAL EVENTS demographic details, progression of his symptoms and if they have the Arogya Setu App INPUTS – ITEMS AND SOURCES Showing symptoms - Individual/suspected patient OUTPUTS – ITEMS AND PATIENTS Call the Ahmedabad Municipal Corporation at the state Helpline number 104 or goes for Rapid test / Rt-PCR PROCESS UNITS PROCESS UNIT OWNERS Data on the symptoms Precautioneray measures Technical Support Team at the AMC Helpline number Testing team Rapid Test/ RT-PCR Test survey Form SERVICE OBJECTIVE(S) SERVICE RISKS Lack of trust on the information operator and health system To communicate accurately and effectively with the citizens about the pamdemic Number is busy, switched off or disconnected effect, impact and importance of getting tested Delay in testing due to unavailability of survey forms Insufficient medical teams/kits available for testing KEY CONTROLS MEASURE OF SUCCESS Maximum number of individuals using the helpline or lab/medical team service Easy and people user friendly interface Maximum calls answered by the AMC/ or Max survey forms filled at testing Efficient communication and on-point advice by the AMC Support team centers Systematic and precautionary measures at the testing centers Positive feedback on the helpline system (4+ Rating) Covid Identification

122

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Service Operation Management Studio 2020 I CEPT University

Annexure D4: Process profile worksheet for Covid Confirmation PROCESS NAME – NUMBER Covid Confirmation

PROCESS OWNER Testing center DESCRIPTION

Conducting Covid test TRIGGERS Individual comes to get tested at the test centre Test center does the test Nose swab sample is given for testing, mask and gloves, sanitized and systematic testing INPUTS – ITEMS AND SOURCES Nose swab sample – Patient/suspected patient OUTPUTS – ITEMS AND PATIENTS Test report – Medical Officer or Lab Technician PROCESS UNITS PROCESS UNIT OWNERS Nose swab sample Processing the swab sample and the report Testing team (i.e. Medical Officer of rapid testing team or Lab Technician) Put the patient in isolation in isolation units SERVICE OBJECTIVE(S) SERVICE RISKS Unaffordable testing To appropriately test the patients in a systematic manner with all Faulty testing precautionary measures followed to create a safe and assured testing Delay in testing experience No sanitized or systematic testing Misplaced or replaced test samples KEY CONTROLS MEASURE OF SUCCESS Adequate PPE kit Maximum number of patients successfully tested and detected Lab equipment Maintenance Maximum positive feedback received from the patients (4+ Rating) Hygiene and disinfectant Maximum positive feedback received on the efficient testing process (4+ Systematic testing Rating) Increase in designated testing centers EVENT BEGINNING EVENT ENDING ADDITIONAL EVENTS

123

Annexure D5: Process profile worksheet for Covid Treatment

Treatment

PROCESS NAME – NUMBER

Patient is put in 14 days home quarantine

AMC Doctor DESCRIPTION

PROCESS OWNER

TRIGGERS Patient isolated in a room for 14 days Symptoms recovered / Patient admitted Daily montioring of oxygen levels, pulse, BP, temperature and diet and patient maintains a daily covid chart, medicines ADDITIONAL EVENTS refilled every 3 days INPUTS – ITEMS AND SOURCES Self monitoring and daily updates – Patient who is in home quarantine OUTPUTS – ITEMS AND PATIENTS Individual is allowed to come out of home isolation and self monitor once the symptoms fade – AMC Doctor PROCESS UNITS PROCESS UNIT OWNERS EVENT BEGINNING EVENT ENDING

Keep the doctor updated about the progress daily through Covid chart Medicines refilled every 3 days Inform the AMC officials once 14 days quarantine is over SERVICE OBJECTIVE(S) To isolate patients at home and keep them under doctors monitoring their health while also following self monitoring practices for a safe and speedy recovery KEY CONTROLS Take safety measures to ensure mental and physical health remains stable Follow self isolation accurately Take precautionary measures (Wear protective gear if interaction is very necessary)

AMC doctor AMC SERVICE RISKS Family, relatives and neighbors are at risk of contracting the virus Patient get’s frustration Mental health is affected MEASURE OF SUCCESS Maximum number of patients successfully overcoming getting symptoms Maximum positive feedback received from the patients about the doctors and home quarantine (4+ Rating)

Annexure D6: Process profile worksheet for Covid Prevention PROCESS NAME – NUMBER

PROCESS OWNER Police and Fire Department DESCRIPTION To stamp people who are under home quarantine and demark the containment zone lines and monitor the society and do mist sanitization TRIGGERS EVENT BEGINNING Police personnel get the stamp and containment zone demarkation tape and Fire presonnel get sanitization equipment EVENT ENDING Police and Fire dept personnel complete monitoring and sanitization processes protocols Hand is stamped, gate/floor is sealed, society is containment notice tagged, police personnel put on monitoring, mist ADDITIONAL EVENTS sanitization processes every 3 days INPUTS – ITEMS AND SOURCES Get the stamp and containment tape – Police Dept. and getting equipment for sanitization – Fire Dept. OUTPUTS – ITEMS AND PATIENTS Hand is stamped and home is demarcated and sanitized- Home Quarantined patients PROCESS UNITS PROCESS UNIT OWNERS Patient’s demographic details Stamps, containment zone notice and demarcation tape Police personnel Monitoring Fire Dept. Personnel Mist Sanitization SERVICE OBJECTIVE(S) SERVICE RISKS Peaople can find loopholes to scrub it off their hands To ensure the patients remain in home isolation and can be identified, Difficulty to maintain an accurate track, low on manpower, equipment and contained and monitored as well as other persons remain in safe and sanitized resources environment Home not demarcated, Society not monitored, Society and area not sanitized KEY CONTROLS MEASURE OF SUCCESS Skin safe stamp ink, Maximum number of home quarentine patients stamped Ensure the police stays on monitoring duty (Inventory and Manpower Maximum number of areas demacated as containment zones monitoring) Maximum number of homes sanitized throughly Systematic sanitization procedures Maximum number of areas monitored during quarantine Regular follow ups by the HO officials to see if the protocal is maintained Prevention

Annexure D7: FMEA for Covid Testing Process

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Annexure D8: FMEA threat scoring criteria for Covid Testing Process Annexure D9: FMEA action scoring criteria for Covid Testing Pro-

Annexure D10: FMEA for Covid Treatment Process

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Annexure D11: FMEA threat scoring criteria for Covid Treatment Process

Annexure D12: FMEA action scoring criteria for Covid Treatment

Annexure D15: FMEA action scoring criteria for Covid Monitoring Process

Annexure D16: FMEA for Covid Sanitization Process

Annexure D13: FMEA for Covid Monitoring Process

126

Annexure D14: FMEA threat scoring criteria for Covid Monitoring Process

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Annexure D17: FMEA threat scoring criteria for Covid Sanitization Process

Annexure D18: FMEA action scoring criteria for Covid Sanitization Process SCORING CRITERIA FOR ACTION SEVERITY (S)

128

Sanitization potential effects of failure

Descriptive scale of possible threat

The potential threat effects

Following the sanitization schedule as per the SOP manual

The SOP manual should cover sanitization checks and rules so that the spread of the virus is limited

Almost nil

Preventive sanitization measures

The sanitization should be done to limit the spread of virus in areas where there are suspected cases as well

Very little

Up gradation of staff salary check sheet

If the staff salary is upgraded for following the sanitization rules then they will be motivated to do so

Little

Identify your assets and give a data-heavy proposal with different package levels

To get more sponsors and donors the HR and management team will have to give a data-heavy insight and proposal stating the benefits for both the parties

Average

Fund management

If there is inadequate management to monitor and supervise the ongoing procedures then additional staff and incentives are needed

Little

Maintenance of rented equipment’s and replacement of current defective gears

If there is a shortage of equipment's, then more equipment should be rented and maintained and the defective equipment should be repaired or sold off

Very little

Training staff for more coverage and informing staff of the incentives

The staff should be trained on faster sanitization techniques and informed of the monetary benefits of more coverage

Harmless

ANNEXURE E1

ANNEXURE E3

ANNEXURE E2

ANNEXURE E4

SCORING CRITERIA FOR THREAT OCCURRENCE (O) Point Weight 2

Occurrence Very seldom

Every week

Every 6 months

Every week

Every quarterly

Slight Very seldom

SCORING CRITERIA FOR THREAT DETECTION (D) Detectability

Probability

Point Weight

Very high

0.999

Medium high

0.98

High

0.99

Medium high

0.98

Very high

0.999

SCORING CRITERIA FOR RISK ASSESSMENT RPN (Risk Priority Number)

Point Weight 4

Slight Very slight

Frequency estimation Every quarterly

Risk Assessment

≤ 40

Tolerable risk

40 < RPN ≤ 100

Controlled risk

RPN > 100

Unacceptable risk

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ANNEXURE E5

130

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ANNEXURE E6

ANNEXURE E7

ANNEXURE E8

ANNEXURE E9

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ANNEXURE F1 – Identification Process Profile Worksheet

132

ANNEXURE F2 – Confirmation Process Profile Worksheet

Service Operations Management Studio 2020 I CEPT University

ANNEXURE F3 – Treatment Process Profile Worksheet

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ANNEXURE F4 – Prevention Process Profile Worksheet

133

Annexure F5 - Evaluation criteria for FMEA

Annexure F7 - FMEA for Quarantine & Sanitation Process

RPR = Severity * Occurance * detection

Annexure F6 - FMEA for Testing Process

Annexure F8 - FMEA - Recommended RPN calculations

* As all the recommendations are considered to be as ideal & suitable situation for the issues, highest rating of 7 is considered as a point weight for each for further analysis *

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Annexure F9 - FMEA for Monitoring Process

136

Annexure F10 - FMEA and parameters gap analysis calcu-

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ANNEXURE G1 - Procees Flow - Mindmap

138

ANNEXURE G2 - Process Profile Worksheet - Identification

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ANNEXURE G3 - Process Profile Worksheet - Confirmation

140

ANNEXURE G4 - Process Profile Worksheet - Treatment

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Annexure G6 - FMEA - COVID Control Center Response

Annexure G5 - FMEA - Ambulance Response

142

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Annexure G7 - FMEA - Sanitisation Workers Response

144

Annexure G8 - City Constraint Analysis

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Bibliography

Hyderabad

Pathanamthitta

1. Census, O. (2011). Pathanamthitta District : Census 2011-2020 data - Corona Virus | Covid 19 Data. Retrieved September 01, 2020, from Census 2011: https://www.census2011.co.in/census/district/282-pathanamthitta.html 2. Kerala Government . (2020). Kerala: COVID-19 Battle. (C-DIT, Ed.) Retrieved September 01, 2020, from GOK Dashboard: https://dashboard.kerala.gov.in/index.php 3. Kerala Local Government, G. o. (2020). Covid - 19. (I. K. Mission, Ed.) Retrieved September 01, 2020, from Local Self Government of Kerala: https://lsgkerala.gov.in/ml/covid-19 4. Kerala State IT Mission, & NIC Kerala. (2020). Jagratha Dashboards. (N. I. Kerala, Ed.) Retrieved September 01, 2020, from Covid-19 Jagratha: https://covid19jagratha.kerala.nic.in/ 5. Kudumbashree, D. o. (2020). Kudumbashree. Retrieved September 01, 2020, from Kudumbashree State Poverty Eradication Mission (SPEM) of the Government of Kerala: http://www.kudumbashree.org/ 6. Pathanamthitta, D. A. (2020). About the district. Retrieved September 01, 2020, from Pathanamthitta District: https://pathanamthitta. nic.in/about-district/ 7. Police, J. (2017). Janamaithri Community Policing Project of Kerala Police. Retrieved September 01, 2020, from Janamaithri Policing: http://janamaithripolicing.org/ 8. Police, S. (2020). Janamaithri Suraksha. (S. State Police Computer Centre, & District Police Computer Cell, Pathanamthitta. , Eds.) Retrieved September 01, 2020, from Pathanamthitta District Police: https://pathanamthitta.keralapolice.gov.in/pathanamthitta-police/innovative-initiatives/janamaithri-suraksha 9. Services, D. o. (2020). Daily Bulletin. Retrieved September 01, 2020, from Directorate of Health Services, Government of Kerala: https:// dhs.kerala.gov.in/ 10. State Planning Board, T. K. (2019, January ). Economic Review 2018. Retrieved September 01, 2020, from Invest Kerala: http://invest. kerala.gov.in/wp-content/uploads/2019/02/Economic-Review-2018.pdf

1. Census. (2011). https://www.census2011.co.in/census/district/122-hyderabad.html. Retrieved September 2020, from Hyderabad District : Census 2011: https://www.census2011.co.in/census/district/122-hyderabad.html 2. Hyderabad Corporation. (2014). http://hyderabad-india-online.com/2009/12/ghmc-zones-circles-and-wards/. Retrieved August 2020, from GHMC – Zones, Circles and Wards: http://hyderabad-india-online.com/2009/12/ghmc-zones-circles-and-wards/ 3. India, G. o. (2020, September). https://www.covid19india.org/state/TG. (G. o. India, Editor) Retrieved September 2020, from Covid India Telangana State: https://www.covid19india.org/state/TG 4. Telangana Tourism, C. D. (2016). https://telanganatourism.gov.in/partials/about/31-districts-of-telangana.html, @2016. Retrieved August 2020, from 33 Districs of Telangana: https://telanganatourism.gov.in/partials/about/31-districts-of-telangana.html 5. Telangana, G. (2020, September). https://covid19.telangana.gov.in/health-facilities/. Retrieved September 2020, from Health facilities in Telangana: https://covid19.telangana.gov.in/health-facilities/ 6. Telangana, G. (2020, April 13th). Operational Guidelines for day to day management of Containment zones. Hyderabad: Municipal Administration & Urban Development Department. Retrieved September 2020, from Operational Guidelines: https://covid19.telangana.gov.in/wp-content/uploads/2020/04/Cirucular-Memo-3654-Operational-Guidelines-for-day-to-day-management-of-Containment-Zones-13-04-2020.pdf

Delhi

1. Department of Information & Publicity. (2020, September 16). Containment Zones. Retrieved September 2020, from Delhi Fights Corona: https://delhifightscorona.in/ 2. DELHI. (2020, September 16). Retrieved September 2020, from COVID19 INDIA: https://www.covid19india.org/ 3. Ministry of Home Affairs. (2011). Tables and Statements. Retrieved August 2020, from Census India: https://censusindia.gov.in/2011-provresults/data_files/delhi/3_PDFC-Paper-1-tables_60_81.pdf 146

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Service Operations Management Studio 2020- Covid 19 Management

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