"Hasta Luego"

Respected Colleagues,

I wish to take a moment of yours and inform you that I am leaving my position at Dr L H Hiranandani Hospital. Today (12th October 2010) is my last day at work.

I have enjoyed working for this company and I appreciate having had this wonderful opportunity to work with you all.

During these last five and a half years you all have provided me support, and through your encouragement and guidance I have been able to excel at the responsibilities offered to me and hope you continue to extend your cooperation to the current leadership teams and the succeeding manager.

 

With many of you, I have shared a unique camaraderie which I hope will continue in the years to come even though I shall not be here with the company.

 

Even though I will miss you all here I am looking forward to this new position as ‘Head Consultancy Services, HOSMAC India Pvt. LTD', that brings forth new challenges as it will involve me being involved in project nationally and internationally, and adds more diverse experience to start a new phase of my career.

I do wish you and Dr L H Hiranandani Hospital and the Hiranandani Family, every success in all it future endeavours.

 

You can be in touch with me by;
Email – akash.rajpal@gmail.com
Or call me on my existing mobile number

Or connect with me on linked in : http://in.linkedin.com/in/akashrajpal

Or connect with me on Facebook : http://www.facebook.com/akashrajpal

And you can visit my website and read my blogs on http://www.akashrajpal.com

 

This is not a goodbye, only “hasta luego” or “see you later”.

 

With best regards,

 

Dr Akash S Rajpal

Dated 12^th October 2010.

Sincerely,

Dr Akash S Rajpal,
AGM Operations,
Dr L H Hiranandani Hospital, Powai.
NABH Accredited Hospital.
ISO 9001:2000 Certified (DAR & NABCB accredited)
"IMC Ramkrishna Bajaj National Quality Award" Winning Hospital.

'Open request to the QCI, MCI and others - Quality in Healthcare-should be a subject in medical colleges'

Hi all,

I have been troubled with this thought lately to the fact that there are so many incidents where doctors are beaten up, hospitals broken down when a patient is lost or harm done.

The move now by government to take severe action against the miscreants and angry mobs who do such things is welcome, but the moot root cause is still unaddressed.

 

I feel there is a severe lack of communication, facts hidden and mostly may not be of malafide intention, but the doctors and health care authorities were never 'trained to handle such sensitive situations of handling end of care, or how to speak to a patient, and skeptic nature of not being transparent in sharing care plan completely, treatment, and progress in even critical most situations.

 

The patients are taken for granted by medical fraternity that they better adhere to the treatment advised and the patients entrust everything on doctors and sign consent forms even without reading the pros and cons. Doctors too many times do not explain the consent forms with the fear that the patient would get scared and would refuse the surgery, and loss of business thereof.

 

Typically a ambiance of assurance is provided and situations get out of hand when the outcomes do not meet expectations. The attributes are worsened in communication as doctors are trained mostly in public institutions where mostly poor are treated and there is no scope for good communication skills and no attempt is even made to be 'humble'. More so lack of quality in infrastructure & processes also play a major role as a gap here will lead to less than satisfactory treatment outcome and dissatisfied patients and relatives thereof. Such lack of processes and quality parameters also make the system more 'adhoc' and and then unavailability of desired quality and processes brings in irritability and ultimately carries forward negatively on the patient.

 

I feel a chapter or even a subject in quality/ NABH accreditation and communications should be introduced in medical schools and nursing colleges just like preventive and social medicine, and the budding doctors and nursing students should be trained on the health care accreditation standards, communication skills and even laws and policies and then should be evaluated like any other subject on the same. If this aspect comes to light, I am very confident that the future of Indian health care will be invincible and at international standards. Such teachings will create and ingrain concepts of 'quality' and 'processes' in the minds of these future medical practitioners and a sea change will be seen over a period of time in the working pattern of any health care institution be it public or private. the way we learn technicalities of medicine, diagnosis and treatment in medical schools, we would then learn the essential aspects of it very important and undeniable aspect of Quality.

 

We have excellent 'individuals' but do not have excellent 'quality driven mindsets' which need to change.

 

I openly request Quality Council of India (QCI) and MCI (Medical Council of India) and NBE and CPS and others including the National Health and family Welfare Ministry to sincerely give this a thought and implement the same ASAP.

Sincerely,
Dr Akash Rajpal

Disclaimer:
Contents of this e-mail and any files transmitted along with it may contain confidential and privileged information and are for the sole use of the addressee indicated in this mail. If you are not the indicated addressee or have received this communication in error, kindly notify the sender by reply e-mail immediately and destroy this e-mail and any attachments permanently.

Disciplinary action for quality non compliance - whether harmful?

In health care where accreditation compliance and quality is essential, how much can punitive action help in bringing things in place? I mean if staff are not complying to what you want, whether disciplinary action will help the cause? Say for example if needle stick injuries are on the rise, and the staff is careless or even otherwise, would giving a scolding help? as the same may be under reported due to fear of punitive action.

 

I personally feel that generating awareness and importance of compliance is most essential and punitive action should be reserved for the rare occasions for repetitive carelessness by one individual.

 

Reporting of incidents and compliance deviations should be encouraged without fear or penalty to achieve the most out of accreditation's or quality initiatives.

 

Sincerely,
Dr Akash Rajpal

Disclaimer:
Contents of this e-mail and any files transmitted along with it may contain confidential and privileged information and are for the sole use of the addressee indicated in this mail. If you are not the indicated addressee or have received this communication in error, kindly notify the sender by reply e-mail immediately and destroy this e-mail and any attachments permanently.

RE: Comments

Please find the responses against each query.

 

• How can we implement NABH works in old (structural problem )hospital ? we provide services based on FMS chapter but not satisfactory due to the lack of fund h w can we rectify that problem ?

        

 

The fundamental for any organisation be it accredited or not is to have a 'safe and secure' working environment which meets necessary regulatory requirements and that is the essence of FMS chapter.        

 

If you feel this fundamental aspect is there and there are certain interpretations related aspects which you need to clarify kindly send in few examples of your bottlenecks and I shall try and respond to it.

 

In case the basic fundamental aspect is not adhered to as stated above, then the same should be addressed immediately as it should have been done in the first place itself and the costs now must be felt therefore.

 

 

• Sir, we wish to open up a hospital with NABH norms. Where can I get details of norms?

 

You should visit the website of NABH section of the Quality Council of India on http://www.qcin.org/nabh

You are advised to purchase the NABH standards (large/small hospital as appropriate) along with the guidebook for interpretation purpose.

You may also contact the NABH secretariat at adnabh@qcin.org for further details.

 

 

• I am a pursuing my masters in hospital management. I wana do my desertation on gap analysis between "NABH STANDARD AND BIO-MEDICAL WASTE MANAGEMENT FOLLOWED BY A HOSPITAL".So can you please help me in this aspect and told me how to proceed.

 

You would have refer to relevant sections in the NABH standards and also refer to the guidebook for appropriate interpretation. You may request the same from the hospital management. You may also purchase on your own from the NABH secretariat. Please refer to my earlier response on the same.

 

You would have to refer to the organisations SOPs on the said subject and compare it to the requirements of NABH. Mind you that BIO WASTE needs to follow appropriate regulations as per the pollution control board and you would need to access the licence and terms which the hospital would have and also kindly refer to the National guidelines on hospital waste management Rules ( http://envfor.nic.in/legis/hsm/biomed.html )

 

Published by Govt. of India, under Section 6 & 25 of Environmental Protection Act 1986 on 20/7/98 and appeared in official gazette of India on 27/7/98.

Deals with the generation/handling/treatment/disposal of Bio Medical Waste.

These rules apply to all persons who generate, collect, receive, store, transport, treat, dispose or handle bio-medical waste in any form.

 

 

• Requirements of an ICU of a NABH accredited hospital in India.

 

You may kindly refer to You may also refer to the Indian Journal of Critical Care Medicine, issue dated June 2010.

It has a very good article on Indicators for Intensive Care areas. You may refer to international standards design books , CDC or WHO websitez or refer to http://www.isccm.org (Indian Society of Critical Care Medicine) which has good knowledge base for the same. 

You can refer to references like the IPHS (http://mohfw.nic.in/nrhm/Documents/IPHS%20for%20201%20to%20300%20bedded%20with%20Comments%20of%20Sub-group.doc) or even a good management / design book/resource/hire a reputed hospital design consultant. Methods of manpower planning, criteria used and references cited (as referred above) would be appreciated by the assessor.

 

 

Sincerely,

Dr Akash Rajpal

 

---

From: Ashwini Ranade [mailto:ashwini.ranade@completewellbeing.com]
Sent: 20 August 2010 10:14
To: Dr.Akash S Rajpal; 'Akash Rajpal'
Subject: Comments

Dear Dr Akash,

 

Here are some more comments on your NABH article.

 

Can you please answer them and send it to me.

 

• How can we implement NABH works in old (structural problem )hospital ? we provide services based on FMS chapter but not satisfactory due to the lack of fund h w can we rectify that problem ?

 

• Sir, we wish to open up a hospital with NABH norms. Where can I get details of norms?

 

• I am a pursuing my masters in hospital management. I wana do my desertation on gap analysis between "NABH STANDARD AND BIO-MEDICAL WASTE MANAGEMENT FOLLOWED BY A HOSPITAL".So can you please help me in this aspect and told me how to proceed.

 

• Requirements of an ICU of a NABH accredited hospital in India.

 

 

Stay Well
Ashwini

 

Hospital Administrator - a funny incident

Hi folks,
Just to sway away from the serious blog routine, I would like to share a
small piece of conversation I had with a old colleague some time back.
A old physician colleague from my previous organization called me up the
other day and congratulated me on my 'vibrant' administrative career.
He recollected our earlier days when we used to see patients and how I
had shown interest in becoming an administrator and that I finally did
my post graduation in hospital administration etc.
He expressed his desire to become a administrator too just like me and
wanted some career advice.
I asked him, why he wanted to become a administrator and what drives him
to take such a decision.
He replied :
When ever he goes to the management for a resolution on certain
problems, they always are 'busy in meetings' & that he wants to change
this scenario once he becomes an administrator.
I just wished him luck & said goodbye.
I have not heard from him in a while and I hope he manages to change the
administrative 'scenario'.

Sincerely,

Dr Akash Rajpal.

RE: Query

Dear Madam,

 

Please find my response to your queries as mentioned below:

 

Is there any guide lines for installation , maintenance and cleaning of Chimneys used in kitchen?  (A)
Is it required to list out the Nonformulary drugs that can be purchased locally? (B)

Is it mandatory for Ophthalmic services to have triaging area? (C)

How to carry out validation and authentication of HMIS? (D)

 

A.

You may refer CWA (CEN Workshop Agreement) 15596 OR NSF standards for kitchen equipment standards.

 

http://docs.google.com/viewer?a=v&q=cache:-6RQYQRClKsJ:nsf.org/business/newsroom/pdf/CWA_Flyer.pdf+CWA+%28CEN+Workshop+Agreement%29+15596&hl=en&gl=in&pid=bl&srcid=ADGEEShgC-rICCxexZujCD7qLZkndKFpO7llfuJRFZAO5Vxo1dPsqMDobhlRoznqVppnmnWcIyjMC0sewz6DqoMYRExToKVXS0dOzq5EpsEAP2OLHBdYm-t5TygU-NavMMFQh3cU19Rz&sig=AHIEtbTkBGIEE2ny00QrtrgDgh-_OVpNVg

 

http://www.nsf.org/business/food_equipment/standards.asp?program=FoodEqu

 

B.

If you list out the non formulary drug for local purchase, it as well be part of the formulary. The standard requirement(MOM2D) means that there is a process to acquire medicines not in your formulary. WHich may include recent FDA approvals which the doctor may want to try etc. The formulary basically indicates whether you have tied up with vendors to procure the drugs in formulary and that you a system in place to update the list(requests from doctors for new brands, deletion of drugs on adverse reactions etc). You may put a protocol in place on approach of local purchase which may be different for different items (vendor/chemist/etc). You may say Unlisted antibiotics should be procured from vendor X, and unlisted vaccines from Vendor Y. Idea is not to have too many local purchase. It would indicate a non robust system of making your formulary, and that it is not in check. ROL, Lead times, discipline in prescription from managements decided brands etc, is the key.

 

C. Opthalmic traiging depends on the protocols set by your Opthalmologists. If you have a high volume Opthal centre, it would be prudent to have one to segregate the patients as per triaging to reduce patient waiting time. Its a common practice to have triaging today in Opthalmology. Refraction, pressurechecks etc are done (mandatory initial evalaution) prior to seeing the consultant. The consultant then can further refer the patient to a higher specialist and thus save unnecessary referrals.

 

D. HMS validation- You can check inventory stock levels in HMS against physical stocks, shelf tallying with system location etc. Check the login/security aspects-whether authorized personnel are only accessing patient records as stipulated in hospital SOP, check billing accuracy of posted services and total, Census reports - whether it tallies with actual, timely generation/computing of data, unique patient identification number-whether it is generated, whether owner of the process-who entered data can be traced back etc. It all depends on what the deliverables are as per hospitals scope.

Sincerely,

Dr Akash S Rajpal,

 

---

From: messages-noreply@bounce.linkedin.com [mailto:messages-noreply@bounce.linkedin.com] On Behalf Of Sarmila Periyasamy
Sent: 19 July 2010 01:20
To: Dr.Akash S Rajpal
Subject: Query

LinkedIn Sarmila Periyasamy has sent you a message. Date: 7/19/2010 Subject: Query Dear Sir, I am Sarmila,NABH Consultant, I have some queries regarding implementation.Please clarify my queries How to carry out validation and authentication of HMIS? Is there any guide lines for installation , maintenance and cleaning of Chimneys used in kitchen? Is it required to list out the Nonformulary drugs that can be purchased locally? Is it mandatory for Ophthalmic services to have triaging area? View/reply to this message Don't want to receive e-mail notifications? Adjust your message settings. © 2010, LinkedIn Corporation

RE: NABH query on ICU design / Infection control

Please see my reply below.

 

Sincerely,

Dr Akash S Rajpal,

 

---

From: Ashwini Ranade [mailto:ashwini.ranade@completewellbeing.com]
Sent: 18 June 2010 12:00
To: Dr.Akash S Rajpal; 'Akash Rajpal'
Subject: NABH query

Dear Dr Akash,

 

Kindly answer the below queries on NABH.

 

 

1. I'm doing my project work on NABH with Apollo hosp. I'm said to make unit binders so far. Can you guide me how to proceed further?  ; Kindly eloborate 

 

2. I’m doing my internship on NABH. Can you provide me basic guideline how to make a project report.  : You may do a gap analysis on standard requirement and evidence seen. I wonder how long you would be doing your internship. Standard internships are for one to three months. In that it will be difficult to do a complete gap analysis. You may choose few departments or chapters from NABH to make the report/case study. For interpretation of standards you would have to refer to the NABH guidebook. 

 

3. respected sir/madam
i would like to know what are the standards which are to be maintained according to NABH while handling patient in ICU. basically to control nosocomial infections since i am from non-medical background i would request you to please guide me just regarding hand washing procedure, proper waste disposal technique, wen to use gloves, how to enter in icu i.e. dress-up. 

You may refer to international standards design books , CDC or WHO websitez or refer to http://www.isccm.org (Indian Society of Critical Care Medicine) which has good knowledge base for the same. 

 

Stay Well
Ashwini

 

NABH queries & responses - 2

RESPONSE TO AN EMAIL QUERY ON NABH STANDARDS RELATED TO QUALIFICATIONS OF NURSES.
(All are requested to post the queries via this blog for a larger sharing of knowledge)


Sir,

NABH says you need to comply to statutory requirements. So the qualifications will be as per states/regions requirement. If you have anything out of norm you should have evidence in writing from the local authority that its allowed.
Normally nurses registered with state nursing council are required. Also check NMMCs (your local hospital registration authority) guidelines of registration which mentions this.You should also refer to the Bombay Nursing home acts (http://www.maha-arogya.gov.in/actsrules/nursing/BombayNursingHome.pdf) page 8-point 8 & page 5-point 15 for better understanding. Depending on region/accessibility various liberties are provided by state keeping in mind difficulty in availability of medical staff. For example a recent gazette of GOI allows certain AUYSH practitioners to practice allopathy.
 
Bottom line: NABH does not specify specific qualifications.
You can also refer to NABH standard HRM11 to outline a policy which state which qualified staff will do what at what course of treatment. This way you could have a optimised mix of qualified staff doing certain aspects of plan of care and non qualified staff doing certain aspects keeping in mind criticality of care.

I would compile Internet links to various acts concerning health care ASAP which could benefit the fraternity at large.

Sincerely,
Dr Akash S Rajpal

Disclaimer:
Contents of this e-mail and any files transmitted along with it may contain confidential and privileged information and are for the sole use of the addressee indicated in this mail. If you are not the indicated addressee or have received this communication in error, kindly notify the sender by reply e-mail immediately and destroy this e-mail and any attachments permanently.
--------------------------------

On Thu, May 6, 2010 at 9:39 PM, ramani brahma wrote:

Does NABH Specify any minimum qualifications for nursing staff/lab technicians and X- ray technicians? Thanks regards Dr. Ramani

NABH queries & responses

I refer to a email where this gentleman enquired whether NABH prescribes
standards for staffing (quantity).
My response is mentioned below with a copy of the email.
I hope the same would help any concerned on the said aspect of HR
planning.

Best wishes,
Dr Akash S Rajpal.
--------------------------------------------------
Sir,

Kindly refer to the below mentioned NABH standard.
NABH does not lay down staffing quantity specifications and it is upto
the organisation to decide what is suitable.
What NABH would look at would be the efficacy of operations and human
resource planning. If you are able to comply to various standards
related to patient records effectively even with one staff they would
appreciate it, and if you cant even with 10 staff then a non compliance
would be made depending on the severity of the problem. Therefore it is
important to assess how much staff is required to carry out the assigned
tasks in specified shifts by way of HR planning followed by continuous
monitoring for efficiency of staffing & errors for improvement &
training needs.

HRM.1: The organization has a documented system of human resource
planning
A.The organization maintains an adequate number and mix of staff to meet
the care, treatment and service needs of the patient

Sincerely,

Dr Akash S Rajpal,
-----Original Message-----
From: Alex Roy
Sent: 04 May 2010 07:02
To: Dr.Akash S Rajpal
Subject: NABH Standards

Dear Sir,

I just have one question about the NABH Standards.

According to NABH standards, is there any specific number of staff
(strength of staff) in a medical record department for a 1000 bedded
hospital.

I would be thankfull at your response.

Have A Blessed Day
Carol Peter

Mission & its influence on staff performance.

The challenge we administrators always face is to retain the
satisfaction levels of our customers - the patients.
All would agree, that while its very difficult to attract new patients,
its so easy to loose them.
A major reason for the same is often the lack of good communication by
various categories of personnel including the front office, Nursing and
even the doctors.

So how to counter this problem?
I think the most essential element missing in various training sessions
or the approach by various staff while handling patients is that the
mission statement of the organization is never on the conscious level of
any staff's mind.
Actually a training session to orient staff on importance of Mission
statement and how each and every staff including the housekeeping
personnel can contribute in achieving the Mission Statement, is hardly
conducted.

I remember, during our audits, one of the housekeeping boys was
interviewed by an external auditor to assess if he was aware about the
Mission statement. The auditor hardly expected a positive reply.
The Housekeeping not only explained the interpretation in the local
language about the Mission Statement, but further explained (when asked)
how he contributed to achieve the same.
He confidently replied that his good cleaning practices of the toilets
and other floor areas would create good impression of the hospital,
would impress upon the users including doctors and patients and thus
influence the patients and doctors to like the hospital.
It would be an understatement that the external auditors were surprised
to hear that response.

The ingraining of mission statement I feel is the most essential
component of training, and should be "made to understand" for better
delivery of services.

In my next blog as a continuation to the introduction of this blog, I
would write about certain areas which can be looked into for better
customer satisfaction.


Sincerely,

Dr Akash S Rajpal,
AGM Operations,
Dr L H Hiranandani Hospital, Powai.
NABH Accredited Hospital.
ISO 9001:2000 Certified (DAR & NABCB accredited)
"IMC Ramkrishna Bajaj National Quality Award" Winning Hospital.

Insurance Claims Process - The future?

What started off as a query from Arijit M - Insurance Professional -
Manager Claims (National Level) at Reliance General Ins Co. Ltd on
Linked-in with the topic 'How can we use the mobile technology in Claims
servicing, Health top, renewals, premium quote' actually made me think
of a possible ideal future of the claims processing process between the
service provider & the back office of TPA/insurance.

Except for premium alerts, notices, and status update of the claim
stage, mobile technology is of not much use as a large amount of work is
done with interaction with personnel from provider and payer.

So how can technology & IT help in faster claims processing, the biggest
grouse of every stake holder including the provider, payer, and the
claimant (patient)?

I feel a web based service instead can be used for live claim
processing, input of data and attachment of scanned medical records by
the service provider for faster processing. Digital signatures can be
used to authenticate the files.

A network among all TPA/insurance back offices can prevent duplication
of claims for which original documents are sought from patients (which I
feel is waste of paper and time) on lines of CIBIL rating for loan
processing.

There were thoughts whether an integrated system which captures real
time data information like condition of the patient, proposed/final line
of treatment, day to day billing will bring about faster turn around
times in claim processing?

But then how will this real time capture of EMR bring in value and
expedite the claims process?

The medical treatment is not always as per the proposed line of care.

In India still the consultants have a 'problem' of data entry when it
comes to using computers (it's still better than the US where clinical
EMR penetration is very low).

Capturing of EMR (Forget real time) cannot happen until the application
and data entry is standardised across all insurance network hospitals.

Standardisation even if willing (by hospitals) will be a problem because
various software's would have various programming intricacies built in
to their existing software's which would make the modification &
integration difficult and leading to unnecessary cost overloads.

So what is the possible ideal future for the claims processing?
I could only think of this: I would propose an online simple web based
claim process form where all necessary claim related fields are filled,
and scanned copies of medical records are attached by the service
provider. But this should not follow a sending of hard copy as that
would mean duplication.

A CIBIL (Credit Information Bureau (India) Limited) like network would
prevent duplicate submissions where all claim processing back offices of
TPA/Insurance can log in & check the insurance history of patients akin
to the loan/credit history of the borrower. Patients can log in and see
how they fare & make appropriate amendments.

Sincerely,

Dr Akash S Rajpal,
AGM Operations,
Dr L H Hiranandani Hospital, Powai.
NABH Accredited Hospital.
ISO 9001:2000 Certified (DAR & NABCB accredited)
"IMC Ramkrishna Bajaj National Quality Award" Winning Hospital.

Active Versus Proactive Operations

All of us hospital administrators have to face customer/patient complaints almost on a daily basis.

In best of our abilities the operational planning is done to ensure that the customer leaves the premises satisfied, however that’s a wishful thinking.

I am yet to design a plan which delivers 100% customer satisfaction.

However I have already moved on to the aspect of 'proactive' operational planning as opposed to the 'active' coordination which we do normally to ensure the time oriented end result.

 

To cite an example:

 

1. Discharge Process:

Almost every hospital has a similar discharge process:

Doctors write the discharge note, which follows a series of events (which if patient comes to know of he would probably no feel dissatisfied).

After the discharge note is written, the discharge summary is prepared, unused medicines are returned, additional prescriptions are indented, missing reports are collated, billing service postings are validated and so on.

 

Any bottleneck above would be 'actively' corrected by persuasion & interdepartmental coordination.

 

However as almost every discharge request would accumulate for the day in a concentrated manner, the resources deployed always seem to be deficient in numbers as well as efficiency.

 

Our recent approach (I am sure other likeminded people may have already embarked on the same) has been (or striving to be) 'proactive' as follows:

 

'Predict' the discharges for the next day.

Ensure all necessary reports/return of medicines/indent of new medicines are made in advance.

Billing is almost ready.

Discharge summary is already prepared, except minor changes if may be required.

All necessary interdepartmental coordination & 'persuasion' now can happen any time of the day or middle of the night as and when the human resources available and not bogged down by 'peak' volume demands.

 

This would lead to a 'quick' discharge of the patient the next day.

Yes, there would be exceptions, change of orders, change of decision by doctor even patient, but a majority would be covered in the predictive proactive preparation and better customer satisfaction.

Sincerely,

Dr Akash S Rajpal,
AGM Operations,
Dr L H Hiranandani Hospital, Powai.
NABH Accredited Hospital.
ISO 9001:2000 Certified (DAR & NABCB accredited)
"IMC Ramkrishna Bajaj National Quality Award" Winning Hospital.

Sharing knowledge

Dear all,
Starting today I would try and interact with all desirous of sharing knowledge specifically pertaining to the domain of healthcare & quality.
There have been many queries on NABH, ISO, and Malcolm Baldrige from the hospital management trainees, and peers which I have been replying to, but this will make the interaction archived for the benefit of all who came in late.
I would post from time to time my thoughts on problems related to hospital operations, quality and so can you vice a versa.
I hope this blog opens up a great knowledge pool for every one to dive in.

Best Wishes,
Dr Akash S Rajpal