ISHIKAWA DIAGRAM – FISH BONE ANALYSIS – PSS – OPD

Machine Method
Washing Machine Changing the bedsheet every 3 days

Fumigator Diet for outborn mothers NA

Gumboot No separate pediatric row at admission counter

Heavy duty gloves FPC not followed as per guidelines

Three bucket

System PSS <4

Separate counselling and
Insurance fund
Separate staff for musqan
FPC room
Department fund
Additional person at OPD for
Privacy screens in Level
No fund released for musqan
pediatric registration
Schedule and Checklist for

cleaning of toilets

Medium Money Manpower

 Gap analysis
S.No Gap statement Gap severity Action to be taken Prioritization Responsibility Time line Action taken
P – Possible - Facility level
I – Implementable - District level
C – Challenging - State level
K – Knock out
1. Inadequate information given Severe Staff at registration counter
to be instructed about
at registration counter
information to be provided I Facility 1 month
to patients admitted in
NICU using IEC
2. Behavior of the Hospital Moderate Training to be given to
Hospital worker to manage
worker at registration counter I Facility 1 month
the work load & talk to the
patient question politely.
3. Cleanliness Of Toilets Severe Supervisors to check and
monitor cleanliness daily I Facility 1 month
using checklist
4. Waiting time at registration Moderate To form a separate queue
counter for pediatric patients at C Facility 1 month
registration counter
5. Time spent on counseling and Moderate Proper counseling time to
intimation of lab results to be displayed and a separate
I Facility 1 month
attendors room with privacy for
counseling to be formed
6. Food provided at time Severe Diet requirement to be
intimated to the kitchen in I Facility 2 weeks
advance