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POWER OF SIX SIGMA IN HOSPITALS & HEALTHCARE MANAGEMENT DR. PRADEEP BHARDWAJ Medical Director POWER OF SIX SIGMA IN HOSPITALS & HEALTHCARE MANAGEMENT DR. PRADEEP BHARDWAJ Medical Director & CEO Six Sigma Star Healthcare, Delhi Six Sigma Accreditation Board www. drpradeepbhardwaj. in << 7 National Awards I 2 LIMCA Book Record Holder >> Visiting Faculty : IIM-Ahemdabad, IIM-L, ISB-Hyderabad, AIIMS, National Board of Exam, GIHM Delhi Listed under India’s TOP-10 Doctors (Hospital Management) Rajiv Gandhi Award – 2010 (First in Healthcare Management) Youth ICON Award – University of Delhi Rashtriya Ratan Award in Healthcare - 2009 Youngest Medical Superintendent in India -2005 (Limca Book) Padma Award- 2012 (Nominated by CM Delhi) Indian Achiever Award – UAE Govt. Shram Shri Award – 2012 Best Enterprise Award – Oxford, UK 1

Briefly About “Six Sigma Healthcare” Delhi 1. Rated No – 1 (Healthcare Management Company) Briefly About “Six Sigma Healthcare” Delhi 1. Rated No – 1 (Healthcare Management Company) by HBS. 2. Six Sigma Managing 278 + hospitals and successfully delivered over 1200 healthcare projects. (Hospital Planning/ O & M / Med. Education/ Quality) 3. Managing operation of more than 2600 bed across the India, having staff strength of 7500. 4. Managing 30 Post Graduate Hospitals/ Institute. 5. GIHM Offering 45 Doctorate/ PG/ Master Degree / Diploma in Healthcare 6. Offering one stop solution for all healthcare management (MM, July 2010) 7. Geographic footprint in 42 Cities of India. 8. 2 Monthly Magazines – Medgate Today & Six Sigma Health Express 9. High Altitude Medical Services at Any Time- Any Where – Any Height @ Amarnath Yatra - JK, Kailash Mansarover- China, Nepal Earthquake, UK Flood DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 2

Current Scenario of QUALITY in Healthcare QUALITY : BUSINESS OF OUTSOURCING If u can’t Current Scenario of QUALITY in Healthcare QUALITY : BUSINESS OF OUTSOURCING If u can’t do it yourself…. Outsource it to Consultants

Six Sigma - Global Acceptability • “Six Sigma aims for world-class performance” • Encourage Six Sigma - Global Acceptability • “Six Sigma aims for world-class performance” • Encourage and stimulate greater Accountability and Transparency • NO Constraint if you Implement Six Sigma DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 4

 CPD (Continue Professional Development) 1. 2. 3. 4. How you are DIFFERENT ? CPD (Continue Professional Development) 1. 2. 3. 4. How you are DIFFERENT ? What value addition you can do ? What is yours STRATEGY ? If “SYMBIOSIS Post Graduate” does not showcase the ‘Next Big Things. . then WHO will ? 5. Rules of the GAMES are going to CHANGE. . Be ENSURE, You change them. 6. If you Don’t GROW, the Competition will grow DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 5

INTRODUCTION • Patients are the foundation of our medical practice. • A Patient can INTRODUCTION • Patients are the foundation of our medical practice. • A Patient can survive without a Doctor but A Doctor cannot survive without a Patient. • Poor customer-service is a Worldwide problem. • Great customer-service is the Backbone to all successful businesses

 • Your first question is likely…. What is Six Sigma? • Your second • Your first question is likely…. What is Six Sigma? • Your second question is likely… Why Six Sigma? DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 8

DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI (www. drpradeepbhardwaj. in) 9 DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI (www. drpradeepbhardwaj. in) 9

Presentation Outline …. • • • • An Introduction …. What is Six Sigma Presentation Outline …. • • • • An Introduction …. What is Six Sigma ? International Accreditation. . Country wise JCI vs NABH vs Six Sigma What Six Sigma can do ? Most Popular Outcomes from Six Sigma How Six Sigma is Different ? Steps in Six Sigma. When to use it. Implementation Road Map. Education & Training in Six Sigma. Success Factor for Six Sigma Learning Institutes. Six Sigma online learning centre. DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 10

Six Sigma in Healthcare Six Sigma can change the face of modern hospital & Six Sigma in Healthcare Six Sigma can change the face of modern hospital & healthcare delivery system. Corporatization and Competition in healthcare sector is forcing the organization to look for the new ways and mean for improving their process so that the quality of the products and services improve, dissatisfaction reduces and patient satisfaction increases. Hospitals involve highly qualified professionals dealing with the question of Life & Death. Hospital Administration is more complex than Administration of any other Business Institute / Organization. “GREAT CAREER Opportunities in Six Sigma Projects @ International Levels” DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 11

Healthcare become more complex, opportunities for error abound. the As Healthcare become more complex, Healthcare become more complex, opportunities for error abound. the As Healthcare become more complex, the opportunities for error abound. Most of the corporate hospitals functions at a three sigma to four sigma quality level and patient safety is usually described by medical mistakes. There is a need to breakdown the traditional boundaries that separate Physicians, Hospital Administration, Pharmacist, Technician, Nurses by shifting away from a culture of blame and working together to systematically design safer, more effective and efficient systems DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 12

What is Six Sigma? • Statistically-based process improvement methodology which aims to reduce defects What is Six Sigma? • Statistically-based process improvement methodology which aims to reduce defects to a rate of 3. 4 per million opportunities. • This reduction is achieved by identifying & eliminating variation in process. • Through defining “defects” the Six Sigma process focuses on customer requirements, and thus is very customer orientated. • Fundamental methodology of Six Sigma is based on “DMAIC” an acronym: Define, Measure, Analyze, Improve, & Control. • Six Sigma is not a quality management system, or quality certification system like ISO-9001. THE FOCUS ON DEFECTS IS SHIFTED FROM CHECKING PRODUCTS FOR DEFECTS TO IMPROVING THE PROCESS SO THAT DEFECTS DO NOT OCCUR. 13 •

Six Sigma Belt’s • Master Black Belt: Highest level of technical & organizational proficiency. Six Sigma Belt’s • Master Black Belt: Highest level of technical & organizational proficiency. These individuals provide technical leadership to the program, as well as provide most of the training. Because of this communications & teaching skills are as important as technical competence. • Black Belt: A technically minded individual with a strong background in college level mathematics & statistics. The Black Belt provides much of the quantitative analysis involved in the daily six sigma project. • Green Belt: Six Sigma project leader, capable of facilitating six sigma teams & projects from conception to completion. Training for green belts in much less than Black, with emphasis on project management, and quality control. These individuals are not employed full time on six sigma projects. DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 14

International Accreditation. . 1. 2. 3. 4. 5. 6. 7. 8. 9. India: National International Accreditation. . 1. 2. 3. 4. 5. 6. 7. 8. 9. India: National Accreditation Board for Hospitals & Healthcare Providers (NABH) USA: Joint Commission International United Kingdom: QHA Trent Accreditation Australia: Australian Council on Healthcare Standards International (ACHSI) New Zealand: Quality Health New Zealand (QHNZ), QHNZ quality standards are based on those used in Australia and Canada. QHNZ is accredited by the international umbrella organization, the International Society for Quality in Healthcare (ISQua). Canada - Accreditation Canada France - HAS (Haute Autorité de Santé) ISQua is the umbrella organization responsible for accrediting the Joint Commission International (JCI) accreditation scheme in the USA and Accreditation Canada, as well as accreditation organizations in the United Kingdom and Australia. UKAF ( United Kingdom Accreditation Forum) is responsible for accrediting accreditation schemes in the United Kingdom DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 15

JCI by FACTS • • • JCI Founded – 1951 821 Accreditation Done (Total) JCI by FACTS • • • JCI Founded – 1951 821 Accreditation Done (Total) 27 Accreditation in INDIA 15 Languages – JCI 5 th Std. 90 Country having JCI Accreditation DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 16

NABH vs JCI 1. NABH Accredited Hospital : 337 2. JCI Accredited Hospital in NABH vs JCI 1. NABH Accredited Hospital : 337 2. JCI Accredited Hospital in India : 027 DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 17

 • ON THE ONE HAND…. . Success is based on your PEOPLE • • ON THE ONE HAND…. . Success is based on your PEOPLE • ON THE OTHER HAND…. . Success is based on your PROCESSES DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 18

The Six Sigma Accreditation Journey: GENERAL SUGGESTIONS • Senior management must be committed: without The Six Sigma Accreditation Journey: GENERAL SUGGESTIONS • Senior management must be committed: without top management support six sigma projects are doomed to failure. • Training the right people: People selected for a six sigma initiative should be motivated by compensation, rewards, recognition & promotion. • Selecting the right project: Initial six sigma projects should be focused on key problem areas with impact to critical aspects of business success. • Set a realistic timeframe for preparation, such as 3 -6 months • Allocation of resources: may include facility enhancement, Six Sigma training, recruitment of Qualified Manpower, and redesign of systems DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 19

LEADERSHIP SKILLS FOR SIX SIGMA 1. 2. Getting and Giving Information Understanding Team Needs LEADERSHIP SKILLS FOR SIX SIGMA 1. 2. Getting and Giving Information Understanding Team Needs and Characteristics 3. Understanding Team Resources (SWOT) 4. Controlling the Team 5. Counseling 6. Setting the Example 7. Representing the Team 8. Problem-Solving 9. Evaluation 10. Sharing Leadership 11. Manager of Learning

DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 21 DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 21

SIX SIGMA ACCREDITATION - NEW • • • • Powerful Quality Tool – Low SIX SIGMA ACCREDITATION - NEW • • • • Powerful Quality Tool – Low Cost Investment Higher Patient & Staff Satisfaction World class Recognition Benchmark of Quality Healthcare Service Eliminate the ‘I don’t know’ DMAIC - Methodology Reduce overtime, Employee Turnover & Error Improve Health Services & Accuracy Make sound data driven decisions Six Sigma Impact Bottom Line Improvement Opportunity to serve organization with power & status Matter of Great Pride for the Staff, patient & Management A better ambiance for innovation & creativity is observed. Error free process NO chance of medication mistakes. DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 22

SIX SIGMA COURSES DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 23 SIX SIGMA COURSES DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 23

DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 24 DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 24

TRAININGS & CERTIFICATIONS If you want to make yourself more valuable and attractive to TRAININGS & CERTIFICATIONS If you want to make yourself more valuable and attractive to employers then get training and certification • Option I – Certification as Six Sigma Green Belt • Option II – Certification as Six Sigma Black Belt DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 25 25

National Record: Six Sigma Accreditation of SIR GANGARAM HOSPITAL, New Delhi Link - http: National Record: Six Sigma Accreditation of SIR GANGARAM HOSPITAL, New Delhi Link - http: //ijcpbookofmedicalrecords. com/Gangaram_Hospital. aspx About IJCP- IJCP BOOK OF MEDICAL RECORDS The IJCP Group was founded in 1990 by Padmashri and Dr B C Roy National Awardee Dr KK Aggarwal and was the pioneer of medical journalism in India. ‘The Indian Journal of Clinical Practice’ which was launched by Dr S D Sharma, former Vice President of India. Today, IJCP reaching over 200, 000 doctors per month and working with over 60 pharmaceutical companies in a year. IJCP Book of Medical Records is the only accreditation body in India to document and publish exclusivity authenticated health and medical records. The records cover the firsts or the maximum in the medical and health field. The records are in the form of claims as authenticated by the sender as on the day of approval. The records can be used as part of a personal bio data or institution's achievements. IJCP -Recent Records. Gangaram Hospital, Delhi (750 Bedded) is awarded top quality accreditation – SIX SIGMA Heart Care Foundation of India: The Only NGO to have three national commemorative postal stamps Largest Health camp attendance in a day organized by an NGO Only DMA President to have received both Padmashri and Dr B C Roy National award Dr K K Aggarwal, First Indian to have chapters in first text book of Color Doppler Echocardiography Clot Dissolving Therapy in India Dr K K Aggarwal first Indian to have chapters in first text book in contrast echo 1 st Pacemaker Bank in India 1 st Public Conference of Heart Care Foundation of India 1 st National Echo Cardiography Institute in India In Press Interviewing Dr Naresh Trehan 1 st Color Doppler Echo Free Checkup Camp in India DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 26

MOST POPULAR OUTCOMES FROM SIX SIGMA 1. 2. 3. 4. 5. 6. 7. 8. MOST POPULAR OUTCOMES FROM SIX SIGMA 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. International Hallmark of Quality Excellence Higher satisfaction (Patient/ Staff) FEW COMPLAINTS. IMPROVED PROCESSES INCREASED ACCURACY. REDUCED WAIT TIME & VARIATION. SAFER & MORE EFFICIENT EMERGENCY SERVICES. FEWER MEDICAL ERRORS & DEFECT. Increase service orientation. Eliminate the ' I don't know' factor. Certification by External Agency Matter of Great Pride DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 27

MOST POPULAR OUTCOMES FROM SIX SIGMA. . Cont. . • • • DR. PRADEEP MOST POPULAR OUTCOMES FROM SIX SIGMA. . Cont. . • • • DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI Generates sustained success Sets performance goal for everyone Enhances value for customers Accelerates rate of improvement Promotes learning across boundaries Executes strategic change Systemizes the processes Adds great value in Medical Tourism International Recognition 28

Six Sigma Hospitals 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Six Sigma Hospitals 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Max Healthcare Long Island Jewish, New York Stanford Medical Center, CA Northwestern Memorial, IL M. D. Anderson, Texas Virtua Health System, NZ Charleston Area Medical Center, WV Boston Medical Center, MA Yale New Haven Medical Center, CT Verdugo Hills Hospital, CA Johns Hopkins Hospital, MD Good Samaritan Hospital, Ohio Sir Gangaram Hospital, Delhi, India Fortis Hospital DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 29

SIX SIGMA COMPANIES Hospitals: Gangaram, Max, Apollo, PD Hinduja, Fortis, Rainbow, Amrita Pharma: Pfizer, SIX SIGMA COMPANIES Hospitals: Gangaram, Max, Apollo, PD Hinduja, Fortis, Rainbow, Amrita Pharma: Pfizer, Baxter, Johnson & Johnson Hospitality: ITC Hotels, GRT Hotels, Taj. Hotels Manufacturing: Motorolla, GE, Wipro, Nestle, Samtel, Samsung Banking: HDFC, HSBC, BOA, American Express Telecom: Airtel, Vodafone, Siemens, Tata, IT: Wipro, Satyam, Acenture, Infosys, TCS, Birlasoft Companies in almost all sectors have a Six Sigma success story DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 30

Sigma Defects Per Million Level Opportunities 1 690, 000 Rate of Improvement 2 308, Sigma Defects Per Million Level Opportunities 1 690, 000 Rate of Improvement 2 308, 000 2 times 3 66, 800 5 times 4 6, 210 11 times 5 230 27 times 6 3. 4 68 times DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 31

Six Sigma Project Methodology Project Phases Define Measure Ø Identify, evaluate Ø Collect data Six Sigma Project Methodology Project Phases Define Measure Ø Identify, evaluate Ø Collect data on size of the and selected projects for problem, improvement Ø identify key Ø Set goals customer Ø Form teams. requirements, Ø Determine key product and process characteristic. DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI Analyze Ø Analyze data, establish and confirm the “ vital few “ determinants of the performance. Ø Validate hypothesis Improve Control Ø Improvement Ø Establish strategy standards to Ø Develop ideas to maintain remove root process; causes Ø Design the Ø Design and carry controls, out experiments, implement and Ø Optimize the monitor. process. Ø Evaluate Ø Final solutions financial impact of the project 32

Six Sigma DMAIC Improvement Process Road Map Define Activities • Identify Problem • Validate Six Sigma DMAIC Improvement Process Road Map Define Activities • Identify Problem • Validate Problem Statement • Gather Voice of the Customer & Business • Develop CCR’s & CBR’s • Validate Goal Statement • Validate Business Case • Validate Project Scope • Select and Launch Team • Develop Project Tools Schedule • Project Charter • Complete Define Gate • Project Selection Tools • PIP Management Process • Value Stream Map • Various Financial Analysis • Effective Meeting Skills • Stakeholder Analysis • Communication Plan • SIPOC Map • High-Level Process Map • Project Management Tools Measure Analyze • Appropriately Map Process • Identify Potential Root • Identify Key Input, Process and Causes Output Metrics • Reduce List of Potential • Develop Operational Root Causes Definitions • Confirm Root Cause to • Develop Data Collection Plan Output Relationship • Validate Measurement System • Estimate Impact of Root • Collect Baseline Data Causes on Key Outputs • Determine Process • Prioritize Root Causes Performance/Capability • Complete Analyze Gate • Complete Measure Gate Improve • Develop Potential Solutions • Develop Evaluation Criteria • Select Best Solutions • Develop ‘To-Be’ Process Map(s) • Develop Pilot Plan • Pilot Solution • Develop Full Scale Implementation Plan • Complete Improve Gate Identify and Implement Quick Improvements with Kaizen • Process Mapping • Process Cycle Efficiency • Little’s Law • Operational Definitions • Data Collection Plan • Statistical Sampling • Measurement System Analysis • TPM • Generic Pull • Setup Reduction • Control Charts • Histograms • Constraint Identification • Process Capability • Value Analysis • Process Constraint ID • Takt Time Analysis • Cause and Effect Analysis • FMEA • Hypothesis Tests • Correlation Analysis • Simple and Multiple Regression • ANOVA • Components of Variation • Conquering Product and Process Complexity • Queuing Theory Kaizen, 5 S, NVA Analysis, Generic Pull Systems, Four Step Rapid Setup Method • Brainstorming • Replenishment Pull/Kanban • Stocking Strategy • Process Flow Improvement • Process Balancing • Analytical Batch Sizing • Total Productive Maintenance • Design of Experiments (DOE) • Solution Selection Matrix • ‘To-Be’ Process Mapping Control • Implement Mistake Proofing • Develop SOP’s, Training Plan and Process Controls • Implement Solution and Ongoing Process Measurements • Identify Project Replication Opportunities • Complete Control Gate • Transition Project to Process Owner • Control Charts & SPC • Standard Operating Procedures (SOP’s) • Training Plan • Communication Plan • Implementation Plan • Process Control Plans • Visual Process Control Tools • Project Replication • Project Commissioning • Team Feedback Session 33

Real World Examples Organization Project Outcome Achievement Charleston Area Medical Center Supply chain for Real World Examples Organization Project Outcome Achievement Charleston Area Medical Center Supply chain for surgical supplies Lower inventory, Improved supplier relations Saved: $163, 410 immediately $841, 540 future Commonwealth Health Corporation Radiology Decreased time between dictation $800, 000 savings, 25% and signature, Improved wait better throughput and times and staff scheduling eliminated 14 positions Froedtert Memorial ICU lab times Lutheran Hospital Reduced turnaround times Cut turnaround times from 52 to 23 minutes Mount Carmel Hospital Medicare+ Choice Redefined coding working. Plan reimbursement aged Medicare recipients Wellmark Inc. Physician addition to managed care network Scottsdale Healthcare Over crowded ED Improved transfer time from ED to inpatient hospital bed Profit $857, 000 Reduced time for adding Savings: $3 million physicians to medical plan per year Profits: $600, 000 34

Six Principles for Quality Improvement Principle : 1 DR. PRADEEP BHARDWAJ @ SIX SIGMA Six Principles for Quality Improvement Principle : 1 DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 35

Think and Plan Principle : 2 DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI Think and Plan Principle : 2 DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 36

Principle : 3 DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 37 Principle : 3 DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 37

Bring in Technology Principle : 4 DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI Bring in Technology Principle : 4 DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 38

Principle 5 Remain focused and not get distracted DR. PRADEEP BHARDWAJ @ SIX SIGMA Principle 5 Remain focused and not get distracted DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 39

REFERENCES • http: //www. isixsigma. com • http: //www. sixsigmaonline. org/index. html • http: REFERENCES • http: //www. isixsigma. com • http: //www. sixsigmaonline. org/index. html • http: //www. businessballs. com/sixsigma. htm • http: //www. ge. com/en/companyinfo/quality/whatis. htm • http: //www. slideshare. net/Sixsigmacentral/10 -six-sigmappt • http: //mypptsearch. allpopular. info/searchppt/six+sigma+ppt/ DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 40

JAI HIND…Thank you Good Luck…, The Journey ahead is going to be CHALLENGING, EXCITING JAI HIND…Thank you Good Luck…, The Journey ahead is going to be CHALLENGING, EXCITING & REWARDING. DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 41

Feel Free to Share your Query • DR. PRADEEP BHARDWAJ, Mob- 98 188 68 Feel Free to Share your Query • DR. PRADEEP BHARDWAJ, Mob- 98 188 68 727 • E. Mail – pradeepkb [email protected] com • WEB – www. drpradeepbhardwaj. in www. sixsigmahealth. org DR. PRADEEP BHARDWAJ @ SIX SIGMA HEALTHCARE, DELHI 42