Master of Business Administration in Healthcare Services Semester 3 MH0052 – Hospital Organization, Operations and Planning (Book ID: B1213) Assignment Set- 1 Q.1 a. Explain zoning in the Operation Theatre complex. Introduction: The operation theater complex consists of operating rooms, pre-medication room, post-operative room, reception, surgeons room, nurses room, male/female changing rooms and other ancillary areas. The operation theater is high cost area to the hospital management; hence proper utilization of theaters is essential. The facility within the operating room requires presence of high-end equipment, sterile operating environment and good lighting and ventilation system. It is preferred to go in for grouping of operation theaters for effective utilization and overcome duplication of resources. Design considerations: The theater complex should be located on the first floor (ideal) in a vertical structure. It should be away from the main patient movement, close to surgical wards and post- operative rooms. The central sterile supplies department should have close access to the OT. It is preferred to have dum-waiters, (sterile and dirty) for movement of sterile and unsterile surgical items to and from the theater respectively.
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Master of Business Administration in Healthcare Services
Semester 3
MH0052 – Hospital Organization, Operations and Planning
(Book ID: B1213)
Assignment Set- 1
Q.1 a. Explain zoning in the Operation Theatre complex.
Introduction:
The operation theater complex consists of operating rooms, pre-medication room, post-operative room, reception, surgeons room, nurses room, male/female changing rooms and other ancillary areas. The operation theater is high cost area to the hospital management; hence proper utilization of theaters is essential. The facility within the operating room requires presence of high-end equipment, sterile operating environment and good lighting and ventilation system. It is preferred to go in for grouping of operation theaters for effective utilization and overcome duplication of resources.
Design considerations:
The theater complex should be located on the first floor (ideal) in a vertical structure. It should be away from the main patient movement, close to surgical wards and post-operative rooms. The central sterile supplies department should have close access to the OT. It is preferred to have dum-waiters, (sterile and dirty) for movement of sterile and unsterile surgical items to and from the theater respectively. There should be uni-directional flow of OT materials. In planning an operation theater the following criteria may be considered:
. List out the various functions in hospitals?
Zoning concept should be incorporated while considering the functional criteria. The design should follow the function and not vice-versa. The OT complex may be grouped into the following zones from inside-out:
1. Ultra clean zone: This area covers 1meter around the operating site.
2. Sterile zone: This area covers the operating room/suite; scrub room; gowning area; sterile linen area.
3. Clean zone: This includes drug stores; sterile store; staffroom; anesthetist room; reception; premedication room.
4. Protective zone: These are the areas through which patients are wheeled into the OT; personnel movement; lifts; reception; waiting area; change room, all form part of this zone.
5. Disposal zone: This is the outermost zone and comprises of the dirty corridor around the OT complex. Soiled linen and unsterile instruments are taken out of the operating room through the hatch, and then moved out of the OT complex through this corridor.
Q2. Classify hospitals.
There are different classifications of a hospital, based on objectives; size of hospital; system of medicine followed; level of care provided; nature of ownership and revenue generation.
1. Based on objectives the hospital may be classified as:
General hospital
Specialty hospital
Teaching and research institute
2. Based on the system of medicine followed:
Allopathy i.e. English medicine
Ayurveda
Homeopathy
Naturopathy
Unani
Multi system i.e. hospitals which follow combinations of various systems of medicine
3. Based on the size:
Small sized hospital i.e. bed capacity of about 100 beds
Medium sized hospital i.e. bed capacity ranging from 100-300 beds
Large sized hospital i.e. above 500 beds
4. Based on revenue generation:
Not- for- profit hospitals i.e. those run by voluntary organizations
Free hospitals i.e. where charges are not levied for services provided
For- profit hospitals
5. Based on the ownership:
Government /public hospitals
Semi- government hospitals
Voluntary/ Trust hospitals
Corporate hospitals
Private hospitals
Charitable hospitals
6. Based on location:
Village / Panchayat hospitals
Town hospitals
City/metro hospitals
7. Based on the level of care provided:
Primary care
Secondary care
Tertiary care
Q3. Kunnath enterprises is a construction company would like to open a new hospital at Yelahanka, Bangalore. They have got a team who constitute the hospital planning
a.Who are the team of experts who constitute the hospital planning?
The hospital planning team should ideally consist of the following members:
1. Hospital Administrator
The Administrator is the chairman of the planning team. He is mainly involved in putting up hospital requirements to his team in terms of, facilities for the hospital, design consideration, orientation of interrelated departments and service facilities. He also oversees and coordinates the various activities involved in planning.
2. Hospital Engineer
The engineer appointed to prepare the plan of the hospital should have previous experience in constructing hospitals. He works in close coordination with the administrator and the architect.
3. Hospital Architect
The hospital architect should have knowledge of the work flow involved in a hospital setup so as to suggest the design considerations of the hospital. The experience and expertise of the architect and the hospital engineer helps in planning a good hospital.
4. Financial Expert
The financial expert helps the administrator to study the feasibility of the project. He can advice on the funds required for the project and the sources available for the same. The estimates given by the finance expert helps in drawing up a smooth plan.
5. Health Statistician
The health statistician also contributes to the study of the feasibility of the project. He helps the team by providing vital information on the demographic picture of the region, disease related statistics, socio-economic condition of the people, all of which helps the administrator in deciding the type of facilities required and charges to be levied.
6. Representatives of government or local bodies
The representatives of the government or local bodies help in the coordination of the project. They form a link between the community and the hospital
7. Nursing Director/Superintendent
The nursing director can give valuable inputs to the project team, especially in ward planning.
8. Social scientist
The social scientist helps in identifying the felt needs and real need of the community. His suggestions during the planning process helps in fulfilling the communitys expectations of the project.
9. Consultant representative from user department
The success of everything planned in the hospital depends on whether it is user friendly. It is therefore necessary for the planning team to take into consideration the suggestions of the consultant representative from the user department. The design and functioning should be user friendly.
b.What are the steps followed in hospital planning?
The steps involved in preparing a project proposal for a hospital can be short listed as follows:
Conceptualization/ inception
This step involves the decision to build a hospital. The type of hospital to be built, location for the building, whether it should be a corporate, nonprofit voluntary or trust hospital should be decided at this stage. The target group which would benefit from this venture should also be considered.
Feasibility study/ Project report:
Extensive data is required while preparing the project report. It is as good as virtually visualizing the entire hospital. In depth technical knowledge is required to prepare this report. It estimates the viability of the project and explores the possibility of raising funds from investors, stake-holders, banks and other sources.
Project approval by appropriate authority:
After preparing the feasibility report, the same need to be submitted for sanction to the appropriate authority.
Site selection
The selection of site for the purpose of construction should be decided upon with utmost care. There should be exhaustive information of the selected plot of land. It should take into consideration transport modalities available for quick access to the hospital, environmental factors (wind, rain, sun, smoke, height of neighboring buildings), sources of water supply, electricity etc. There should be a good communication system operating in the locality (phone lines, pagers, mobiles, fax etc).
Preparation of Master Plan
Preparation of master plan is to establish circulation routes (both internal & external) on the site where various departments and buildings that make up the hospital can be established with no inconvenience caused. It can be written, sketched, or a model. It may include future plans, expansion of particular areas and identifying buildings for expansion.
Architects brief/Functional brief
An architects brief is the written expression of the functional need of the client, prepared in consultation with various professionals in the planning team. The contents of the functional brief includes a broad description of the project, schedule of accommodation, functional policies & procedures, staffing and equipment requirements, functional interrelationship among departments.
Preliminary drawings/Working drawings
This is the design stage in which the functional brief is converted into drawings. The hospital administrator has a consultants role to play at this stage, clarifying doubts which the engineers and architects may have.
Actual construction
This stage involves notifying tenders and calling for quotations. Selection of tender and award of contract are the steps that follow before starting the actual construction.
Equipment planning
This involves short listing the companies, selection of the models after discussion with those who use them, arranging for model demonstrations, negotiations and calling for quotations. Sometimes training sessions are arranged for equipment handling among the staff if required.
Staffing
This involves recruitment, selection and training for all grades and designations.
Commissioning of the hospital
This involves forming a commissioning team which includes heads of administration, nursing, finance, stores & purchase and human resources. This team begins coordinating, planning, staffing people and installing equipments for commissioning the hospital. The team is also concerned with developing an operational system and framing policies and procedures. The sequence of stages of commissioning the entire hospital is also decided by the commissioning team.
Shake-down period
The shake down period is the time taken from total commissioning of the hospital till satisfactory functioning of the hospital is achieved. This may prolong even to a few years. A well planned project will have a very short shake-down period.
Hospital Planning
While planning on a hospital, the following points may be borne in mind:
Accessibility and Traffic
Architecture
Building Structure
Communication
Construction
Environment
Expenditures
Development
Town Planning, and last but not least
Flexibility
Newer technology and new trends in medicine, emerging concepts in building structure and requirements have made hospital being flexible all the more important and challenging.
Certain trends in Hospital Planning encompass the following points:
Rapidly changing needs and technologies
Changing regulations (by governments and insurers), with direct impact on hospital design.
Life-cycle costs determining changes in architecture and in construction methods
New standards for admission to inpatient wards: short stay (daycare); inpatient ward, up to 5 days; hotel stays at either moderate or more luxurious hotels (private patients); nursing home; home for the elderly (long stay)
More focus on preventive medicine
Patients with complex diseases and more than one disease (comorbidities) will determine more and more the functions of hospitals in the future
Hospitals have to be able to attract medical tourists
Hospitals must be acceptable to all cultures and religions
Many hospitals have to cope with the implementation of technical information and communication systems, including IT networks like HIS, RIS, PACS (Health Information System, Radiology Information System, Picture Archiring Communication System)
Changed room requirements (e.g. imaging PACS) due to new workflow procedures (filmless / paperless / wireless hospital)
The expectation of the patients / customers are rapidly increasing
Much more focus on OPD services, short patient stays, and daycare
The healing environment plants, water and natural daylight have a proven influence in the patients recovering process is playing a central role and also enhancing the concentration and well-being of the doctors, nurses and staff
Architecture as a company brand architecture must be updated and upgraded
Natural light and natural ventilation for most of the buildings, especially for the inpatient wards and workplaces
More emphasis on easy way-finding for elderly and disabled people
New meaning: the hospital is not a place for sickness and sick people but rather a place for health and recreation!
Consider the following during planning stages:
Primary structure: This includes the main structure with floors, columns and walls, should be built to have a 50-60 year lifespan.
Secondary structure: The secondary structure (in terms of the three main structural groups) has a life-span of 15-20 years. Examples of the secondary structure are:
Steam, ventilation, cooling, water of different qualities, gases, waste-water systems
Electrical lines of the most diverse types, and fire-extinguishing systems
IT net with fiber optic cables, pneumatic delivery, gas exit lines, all supply and disposal pipelines, elevators, heating, radio nets, etc. Since the kinds of installation and their capacities vary dramatically, an undefined, chaotic structure of installation routes and their junctions can be found in nearly all hospitals
Examples of increasingly frequent installations in hospitals are: air conditioning systems, electrical lines, and fire protection systems
Examples of reduced systems are: pneumatic delivery, heating systems, steam installations. In general, the installation system as a whole diminishes a hospitals flexibility and, even worse, makes necessary changes of units very expensive. Architects and engineers have to implement increased requirements for nearly all installation system groups, including installation, emergency energy supply, the fire alarm system, electrical and electronic installation, IT systems, etc.
In practice, the flexibility of hospitals should be measured by the organization of its installations. Among several solutions already tested are:
Substantially larger story heights, in order to be able to plan sufficient straight-line installation routes
Systematic junctions for crossing installation of different types (electrical installation, air-condition installations, gases)
All installations located above the main corridors, with short bypasses reaching the rooms
No bypassing of room units to reach other departments
Fire protection provided not directly oft the installation, but oft easily removable panel ceilings
Implementation of smart technologies with less consumption of space and easier maintenance, e.g. fog fire sprinklers, which eliminate water damage and operating problems
Tertiary structure: The tertiary structure (in terms of the three main structural groups) has a lifespan of approximately 10 - 15 years. The elements of this structure include:
All decoration and furnishings, wall panelling, paint colors, lighting, floor mats, etc.
All flooring, dry-wall construction, wood fittings
All furniture, and all sanitary equipment, such as basins
False ceilings, doors, and internal glass constructions
All installation system routes
Considering the primary, secondary and tertiary structure of a hospital:
Diversification of classesof hospital departments
Planning strategies should be respected at all times. Hospital planners have to distinguish among the following categories or classes:
- departments with many installations, like OT, ICU, nuclear medicine, ambulant surgery, emergency department and laboratories
- parts with fewer installations, like wards, which could be named hotel-areas
- departments like administrative offices and OPD consultation rooms with still less in the way of technical installations, medical equipment, training facilities, etc.
Keeping these classes in mind, the hospital might want to focus on the possibility of certain micro-extensions or changes of the interior within the same levelof the above-mentioned classes. Establishing a new high-tech treatment or diagnostic area in a class A high-tech department located in an area with the necessary level of blood and nerve system capacity, is easier than introducing an OR department in an administration area.
Q.4. Explain the various ward designs. Explain them with diagrams.
Size: The size of the wards depends on several factors. It can vary from as low as 10 beds to as high as 90 beds in a single ward. Some of the parameters influencing the design and layout of the wards are:
1. Severity of the patient condition The more the severity, smaller the ward. E.g.: ICU, CCU, T.B Sanatorium etc.
2. Category of the ward General wards has more number of beds than special room or deluxe wards.
Location: The location of the wards depends on the activities taking place, services rendered, movement of patients, relatives of patients, doctors, nurses, paramedical staff, visitors etc.
Example: It is desirable to have the surgical wards close to operation theater and post op; ante-natal wards close to labour theater; ICU close to the Accident & Emergency centre etc.
Ward Areas: the various areas that need to be included while designing the wards are:
Patient space: it includes: Multibed bays, patient rooms
Day space: serves as a space for reading, writing, watching TV, etc.
Patient relatives area
Visitors waiting area
Corridor space that would allow movement of man, machines and trolleys, stretchers, etc.
Ward Design
Nightingale Ward:
The nightingale ward is named after Florence Nightingale. This pattern came into existence after the Crimean war during the 19th century. Each ward has a total of 40 beds. Schematic picture of this plan is given below. This arrangement has the following advantages; 1) excellent cross-ventilation, 2) good lighting, 3) clear and unimpeded view of all patients.
Fig. 4.1: Nightingale Ward
The disadvantages are: 1) No privacy for the patients, 2) Lot of traffic (food cart, patient trolley, ward stock etc) moving through the patient care areas causing inconvenience and disturbance to patients admitted, 3) Nurses/ other staff fatigue factor, due to the distance to be covered for rendering services located in separate areas.
Variant Nightingale:
To overcome some of the disadvantages faced in the Nightingale pattern, a variant of the same was created. Even in this pattern there are 40 beds. The Variant Nightingale pattern is also called Cruciform Shape. The length of the ward is 26 meters. This concept gave rise to the evolution of having single bed room/double bed room wards. A sketch of this type of layout is illustrated below.
Fig. 4.2: Variant Nightingale Pattern
Advantages of this design is: 1) Privacy for patients 2) Reduction in noise levels 3) Reduced incidence of cross-infection 4) Attached toilets making it convenient for patient attenders/visitors 5) Flexibility in usage of wards among different departments. This pattern was not free of defects as it had a few disadvantages; 1) Reduced view from the nursing station 2) Patients found it difficult to communicate to nurses and doctors 3) Cost of construction, maintenance, overheads etc was more with high capital costs 4) Maintenance also was difficult as this pattern increased the floor area.
Rigs Design:
The Rigs pattern of ward was first designed in 1910 and implemented in Denmark. The length was reduced and width was increased as compared to the Nightingale pattern. A schematic representation of this layout is given below.
Fig. 4.3: Rigs Design
Some of the special features incorporated in this design are as follows:
1. There was a major shift in the earlier concept of spacing of beds.
2. Privacy in general wards was enhanced due to wall partition of 5 ft height.
3. The distance walked by the nurses for rendering service was reduced
4. Patient beds are arranged parallel to the main corridor, in order to reduce traffic disturbances in the ward
Some of the other patterns worth mentioning are:
Nuffields ward:
A lot of research was done on hospital design during 1950s. Nuffields study (1949-1955) deserves special mention. Based on the findings, an experimental ward was constructed. The design is represented below.
Fig. 4.4: Nuffields Ward
Race track design/deep plan:
This concept arose during 1950s in the United States. Also called double corridor system, this design has 36 beds with two nursing stations.
Fig. 4.5: Rack Track Design Harness type ward:
Also known as the crossed type, this design is known to have different types of rooms with single, double, four and even eight beds.
Fig. 4.6: Harness type Ward
Other ward types:
Courtyard ward:
This type of wards makes provisions for natural light and ventilation. This also helps in saving costs and hence contributes towards the hospitals economy.
Q5. Write short notes on:
i. ICU (Intensive care unit)
Introduction
The intensive care unit is the first step in progressive patient care. Patients admitted to these beds are in critical condition and are unable to communicate but may be salvaged. These patients generally require life support and constant monitoring. Intensive care units are areas
of high cost and hence smaller hospitals/nursing homes do not have an ICU. The Indian Medical Association has recommended that any hospital with bed strength of 200 and more should have an ICU. Few other associations/boards recommend an ICU setting in all hospitals which should account for approximately 2 % of the commissioned beds.
Objectives:
After going through this section you will be able to:
Explain the concept of location and layout of intensive care unit
Draw the infrastructure required for setting up an ICU
Describe the general policies and procedures followed in ICU
Definition
An intensive care unit is a place where critical patients are admitted, who cannot communicate but can be salvaged, requiring advanced life support and constant monitoring
Location and Layout:
The Intensive care Unit (ICU) also known as High Dependency Unit (HDU) should have close access to the Accident & Emergency wards, Operation Theater, post-op wards and medical/surgical wards. Ideally it should be centrally located close to Central sterile supplies department (CSSD), labs and diagnostics etc.
The number of beds in an ICU should be 6-8 beds with 1-2 isolation beds. To be more cost effective an ICU with less than 4 beds is not viable alternatively an ICU with more than 16 beds will suffer in terms of delivering quality care to critically ill patients. It is indicated that in tertiary care centers there should be separate ICUs for Neurosciences, Cardiology, Burns, Post-op, Pediatrics, Neonatology and Pediatric Surgery.
The arrangement of beds can be in the form of a semicircle with, nursing station at the centre for complete patient view. Another design pattern may be a circular design with ancillary services in the middle and separation of patients, department wise into two halves.
There should be a step down unit or an intermediate care unit with less number of staff and equipments. There should be a proper signage for easy access to patients relatives, friends and movement of severely ill patients.
Infrastructural Facilities
The infrastructural facilities should, at design stage itself ensure good view for observation from the nursing counter. It is advisable to have a semi-circular bed arrangement, however a rigid partition is not recommended.
Few recommendations worth considering in setting up an ICU care facility are:
1. Marble or terrazzo tiles are advisable for flooring / wall as it can be easily cleaned.
2. Corners should be rounded off to prevent infection.
3. Space requirements of 150Sq. feet/ bed should be sufficient for rapid movement of patients, equipment, health personnel.
4. It is preferred that all ICUs be located on the same floor, especially in case of vertical layout hospitals.
5. The operation theater and ICU are best identified on the first floor in a vertical setting with a ramp leading to the ground floor.
6. There should be a wash basin near every bed to minimize cross infection.
7. Auxillary facilities like doctors rest rooms, nurses rest rooms, store room, dirty linen room etc should be planned taking the work-flow into consideration.
8. One or two beds can be ear marked as isolation beds for infected patients. Dialysis facility should be available at ICU so that Dialysis machine can be wheeled in for patients requiring dialysis support.
9. The internal environment of ICU should have a temperature of 22o - 24oC and 60% humidity. (For NICU a temp. of 26-28o C or higher)
10. The ICU should be well ventilated with air changes of 14-16 per hour.
11. The beds should be specially designed with all position maneuvers possible, slots for X-ray cassette positioning; fixing IV stands etc.
12. Every bed should have a nurse call-bell facility.
13. The electrical requirements for the ICU should be at minimum 5-6 sockets for plugging in electronically operated life saving gadgets.6KV strength of current would be sufficient in these sockets.
14. There should be central lines of suction/medical oxygen/air with proper backup.
15. Lighting requirement of 100lux in patient care areas; concealed type lighting; pedestal lamps for procedures. Soothing color for the wall is preferred.
Medical Equipment requirements
The minimum medical equipments to be housed in an ICU should be cardiac monitors; pulse-oxymeter; defibrillators; ventilators; infusion pumps; syringe pumps; portable suction apparatus. Portable X-ray and ABG analyzing machine should be available in the ICU setting. All medical equipments should be maintained, calibrated and checked for proper functioning on a day-to-day basis especially in the OT, ICU and accident emergency services.
Staffing
In modern ICU management, intensive care unit is viewed as a specialized department, the role of an intensivist in post-operative and critical care management has been emphasized. The staffing requirement for the unit should have an anesthetist; intensivist/ pulmonologist; critical care specialist; respiratory therapist and nursing staff and hospital auxiliary.
The nurse requirement is based on the number of nursing hours provided in the ICU which is usually 10-18 hours and the number of beds. It is advisable to have multi-tasking for the nurses, having them to work in other areas if ICU occupancy is low. Alternatively the ICU staff may be rotated to create a bank of nurses having ICU expertise.
Policies and procedures
To avoid confusion in the working pattern, responsibilities/protocols should be agreed by the staff working in the ICU set-up. It is suggested to have standard operating procedure in place to simplify the working pattern. Once the patient is shifted to intensive unit, it is best to hand over the responsibilities to the ICU in-charge after having enumerated the treatment details of the earlier physician. The intensive care unit should have policies for the following:
Admission policy
The admission policy should clearly state the mode of admission, whether the patient is received directly into ICU or via casualty. Protocols for the patients received due to poisoning; burns; head injury; septicemia etc should be in written format and all staff working there should be aware of the same.
Patient receiving in ICU
There should be a written protocol for receiving critical/ unconscious patients in ICU, policy for handover of any valuables/yellow metal, documents on the patient at the time of admission to patients relative with proper documentation.
Training and development:
There should be written policies on training and development for new comers as also those already employed, in knowing the latest update in ICU treatment and patient care.
Discharge policy
Like the admission policy, movement of patient out of the ICU should be stated. Protocols for discharge against medical advice; discharge at request; death in ICU; patients improving in ICU (progressive patient care) etc should be stated and must be aware of the same.
Visitors policy
One of the common problems faced by administrators is, restricting the visitors in ICU. This requires formulating visiting hours for ICU along with restricting the number of visitors visiting the patient in order to prevent cross infection.
Maintenance policy
There should be a maintenance policy for all the equipments housed in the ICU including the central lines, electric lines, medical equipments etc. Daily checking for the functioning of life saving equipments is mandatory, and calls for serious legal implications if maintenance of these equipments is neglected.
Infection control in ICU
The infection control measures adopted in the ICU should be in line with the hospital infection control manual. There should be written procedures for patient handling, clothing for medical personnel handling the patient, hand washing policy, periodicity of fumigation, sterilization technique etc.
ii) Nuclear Medicine
Introduction
Radiology services in a hospital are very vital, especially in the present day practice of modern medicine where investigative procedure forms the key to diagnosis. Also radiology & Radio diagnosis is one such important department in the hospital that contributes directly to patient care. The term radiology covers i) Radio-diagnosis ii) Radiotherapy iii) Nuclear medicine iv) Interventional Radiology.
With the rapid growth seen in radiology each of the above has become a specialized field in itself. The wonder gadgets of Nuclear medicine imaging department are the Radionuclide scanning (gamma camera) & radioimmunoassay counters. Such a department exists only in specialized centers having buildings, constructed to their requirement with highly trained staff having experience in cancer therapy & surgery.
The radiologist uses his apparatus to emit radiation, which passes through the subject & emerges to imprint shadows in a film. The consultant in Nuclear medicine department makes the patient emit his own radiation by making him radioactive or rather part of him. This is done by administration of radioactive compounds, which are selectively taken up by certain organs or tissues. He then uses a GAMMA RAY CAMERA to detect this radioactivity & to make pictures of its distribution. In other words, the radionuclide usage includes radioimmunoassay methods (purely in vitro), wet studies such as absorption studies, excretion tests & hematological tests (partially in vivo & in vitro), imaging studies (in vivo), Therapeutic applications (thyroid & blood diseases).
In radioisotope units or nuclear medicine services, short-lived isotopes are used diagnostically as tracers to locate lesions & tumors. Long-lived isotopes are used therapeutically.
Now a days the older term X-ray is being replaced by the term Imaging due to the evolution of expensive & sophisticated equipment like CT-Scan, MRI & Radionuclide scanning.
However the economy of scale does not permit these facilities to be available in smaller hospitals.
SPECT Gamma Camera Room
The room has the SPECT (Single Photon Emission Computer Tomography) or gamma camera. The cost of the equipment is nearly 80-85 lakhs. It has a calibrator, the counter & a separate workstation with a computer. The technicians in the presence of the consultant operate the machine. The staff nurse assists in all the procedures.
The various studies done with the SPECT gamma camera are:
1. Gastric reflux studies.
2. Whole body scans.
3. Bone scans.
4. Renal scans.
5. Thyroid scans
Bone scans, renograms, cardiac and thyroid scans are the commonly done procedures.
Other Equipments
The other equipments in the nuclear medicine department include:
Mini gamma counter
Radio-iodine uptake machine
Giger Muller (GM) counters
Spectrometer
The radiation dose though not high, should not exceed the lethal permissible dose of 5 mCu. For the same purpose there are radiation dose monitors in the department, and the staff should be trained to check it periodically. These are:
Gun monitor
Survey monitor
Area monitor
The staff in the nuclear medicine department is provided with dosimeters, which they should put on the aprons while doing any procedure in the rooms. It is sent to BARC - Mumbai, for regular check-up of the dose every 3 months. If there is any radiation detected in the discs, then the employee should be given leave immediately, till his blood counts come back to normal levels.
There should be fume hoods in the department which are lead chambers where the personnel of the department load the isotope into the syringes. The radiation, which gets emitted, is sent into the atmosphere through this.
Procurement of Radioisotopes:
The radioactive isotopes used in the procedures of Nuclear Medicine department are: Radioactive I131, Mo99, and Radioactive P32 . These isotopes may be procured from different companies like Amerytiun & they should be approved by BARC, Mumbai. Normally the isotopes are procured depending on the available stocks.
The In-charge of the Nuclear Medicine department should take up the responsibility to keep a check on the stocks & indents. The material is indented almost every 2-3 weeks depending on the workload. About 10 mCu of radioactive material at a time would be ideal with an average workload. The material is transported in a cardboard box. In the box the isotope is stored in proper insulated boxes, i.e. the isotope is in a glass vial which is placed in a lead box, which in turn is covered by thermocol.
Preparation of isotope
The preparation of the isotope is done, by taking it out of the box (SALINATION APPRATUS), where Molybdenum turns into Technetium, loading the isotope into a syringe (wearing gloves) behind the fume hood, it is placed in a lead container till it is administered to the patient. The isotope is injected and then the patient is scanned for the movement of the isotope. The scanning of the patient should be done ONLY in the presence of the doctor.
Isolation room
The Nuclear Medicine department has an isolation room. Here the patients who receive I 131 (iodine 131) therapies are isolated till the patient emits radiation in lesser doses within permissible limits. The Patients relatives are allowed to meet the patient only to give food. The healthcare personnel attend to the patients call whenever required.
The patient who come for receiving therapy should be given fresh linen (male patient: one pajama and one shirt; female patient: one gown and one skirt). The waste products generated from the isolated patient ward (i.e. food & general waste) is put in a plastic bucket for a week, before being disposed off with the hospital general waste.
The isolation room should have a separate toilet to be used only by the patient (as the patients urine & stool also emit radiation). The drain from the toilet is connected to a separate tank (here the radioactive material in the tank gets decayed and left for nearly a week). After safety level of the radioactivity is reached it is drained into the general sewage line. The principle adopted here is dilution and overflow method.
Nuclear Waste Disposal Policy
The waste generated during diagnostic and therapeutic procedures on patients with radioisotopes are disposed in the following way:
All linen used for the patient (i.e. bed and body linen) are stored separately in plastic containers with lead lining in a separate room for a period of ten half-lives of the isotope used. After this, the radiation emitted from the contaminated linen is deemed harmless and processed in the routine method.
Waste generated like cotton gauze and glove, contaminated with radioactive isotopes are stored in lead containers for a period of ten half lives of the isotope in a separate room before they are disposed of according to routine waste disposal policy.
Q6. Write short notes on
a. ABC-Analysis
Economics of materials control is a matter of self-preservation in todays competitive environment. Since material control is a matter of rupee control, stringent control must be placed on higher value items.
Paretos law:
According to this law, The significant items in a given group normally constitute a small portion of the total items in the group and the majority of the items in the total will, in aggregate be of minor significance.
Principle
A small number of items represent a large percentage of the cost value. Conversely, large percentage of the items represents only a small portion of the cost value. The procedure adopted to determine varying levels of control is called ABC-analysis.
Procedure
The list of all items in the store & the current annual consumption of each item (in Rupees) are taken down from the records available in the Stores / Purchase dept. The items in the list are then re-arranged in the descending order of annual consumption cost (highest to lowest)
An analysis of this list will show that:
The first 10% of the items account for approx.70-75% of the annual consumption cost. These are categorized as A items.
The next 20% of the items account for approx. 20-30% of the annual consumption cost. These are categorized as B items
The remaining 70% of the items account for only 10-15% of the annual consumption cost. These are categorized as C items
Control
Low value items require low investment cost even to increase the level of safety stock. Hence large quantities can be purchased & because of higher stock the physical inventory can be lengthened. Conversely high value items require higher investment cost. Safety stock should be as low as possible and economical purchases should be made, close controls of these items should be ensured. Without ABC-analysis the ordering policy may be to order all items once in 3 months, in which case the stock position may become chaotic.
Other Classifications
VED Analysis (Vital, Essential, Desirable)
HML Analysis (High cost, Medium cost, Low cost)
FSN Analysis (Fast, Slow, Nonmoving)
SDE Analysis (Scarce in market, Difficult to procure, Easy to procure)
b. Economic Order Quantity (EOQ)
Definition
It is that quantity at which, the cost of ordering the requirements of an item and the inventory carrying costs are nearly equal i.e. when the sum of the two costs is the lowest. In other words, it seeks to strike a balance between purchase costs and the cost of holding inventory.
Advantages of EOQ
1. Helps in finding appropriate levels of holding inventories.
2. Facilitates the function of ordering sequence and the quantities so as to minimize the total material costs.
In order to understand EOQ method two important costs must be considered and analyzed.
Ordering Cost
In most cases, ordering cost is hidden under overheads. Ordering costs include many variables and are not easily measurable.
They include salaries / wages of the involved personnel
Postal / Telephone / Telex and similar bills
Advertisements
Stationeries
Entertaining Vendors / Suppliers
Travel by Stores Personnel (staff)
In general the ordering cost per order may vary between Rs.15 to Rs.40, which is quite acceptable.
Inventory Carrying Cost
It is obvious that holding excess inventories will result in an increase in the cost of storage, space, maintenance, electricity, insurance and other holding charges along with money tied up in holding it. However there are tangible and intangible costs and problems in carrying too little inventory.
Some inventory carrying costs are as follows.
Cost of storage / Insurance
Salary / Wages of stores personnel
Stationary forms / Paper work
- Loss of interest on money deadlocked in inventory
- Deterioration and Obsolescence
- Losses due to pilferage
Inventory carrying cost is expressed as a percentage of the average investment in inventory. The total inventory carrying cost may range from 1% - 5% of the total inventory cost of a health organization.
EOQ Formula
TC = RP + (RC / Q) + (QH / 2)
Where,
TC=Total cost
R= Annual demand(units)
P= Purchase cost of an item
C=Ordering cost per order
H= Holding cost per unit per year
Q= Lot size or order quqntity(units)
Factors Influencing Order Quantities
Lead time
It is the period that elapses between placing an order and receiving the supplies in stores.
Administrative lead time: Time required for preparing purchase requisitions, obtaining quotations, initiating purchase order etc. It also includes checking and inspection of materials on arrival, recording and sending the material to the appropriate stores.
Delivery lead time: It is the time taken by the supplier in getting the materials ready, transport of materials from his warehouse and actual delivery to the user organization.
Minimum Stock Holding
The guiding principle is that high value items should have a very low stock (since orders are closely followed up). Low value items can have high quantum of minimum stock. Medium value items fall in between. Shelf life affects the minimum stock holding of an item to a great extent.
Safe Buffer Stock
This is the quantity of stock that is set aside as insurance against variation of demand and procurement period for unforeseen reasons and to avoid stock out.
Reordering Systems
Reordering Point: The reordering level is equal to the minimum stock plus requirement during lead time.
It is given by the formula B = RL / 12, where B = Reordering point;
R = Annual demand (units); L = Lead Time (months)
Cyclic System: In this system the physical position is reviewed at fixed intervals. Orders are placed depending on the stock in hand and rate of consumption, i.e. ordering interval is fixed but the quantity ordered varies each time. Ideal for A value items and high value B items.
Two-Bin System: In this case sufficient stock to meet consumption before placing of the next order is held in one bin and the other bin contains stock sufficient to meet probable consumption during the period of replenishment. Here, the order quantity is fixed but the frequency of the order varies. Fixed order quantity is suitable for C items and low value items.
Master of Business Administration in Healthcare Services
Semester 3
MH0052 – Hospital Organization, Operations and Planning
(Book ID: B1213)
Assignment Set- 2
Q1. Explain in detail about Hospital pharmacy.
Introduction
The Hospital Pharmacy is the drug dispensing centre in the hospital. Purchase of drugs and maintaining the right inventory is an important function of the chief pharmacist. Nearly 20% of the hospital budget is spent on medicines. Availability of the right drug, at the right time and right place is the key to a hospitals existence. The pharmacy should be properly organized and the department should be under a professionally competent pharmacist.
Objectives
After going through this section you will be able to:
List the functions of the pharmacy
Explain the importance of hospital formulary
Describe on the activities of PTC
List the design considerations of the pharmacy
Explain the legal implications in running the hospital pharmacy.
Objectives of a Pharmacy:
Some of the objectives of the hospital pharmacy can be highlighted as:
Purchasing, storing and dispensing the drugs
Ensuring the potency of the drugs at the time of purchase and storage
Dispensing prescriptions to inpatients and outpatients,
Ensuring Quality control of the preparations made to be used in dispensing
Maintaining information regarding cost, quality and source of supply
Ensuring adherence to the laws, rules and acts applicable to hospital pharmacy
Promotion in the economy of use of medicines
To monitor the adherence by all concerned to hospital formulary
Importance of Hospital Formulary:
With advancement in science and technology, newer drug preparations have come into the markets in a highly competitive scenario. Most drug formulations have been shown to be ineffective and few of them even dangerous. It is necessary to identify the harmful drugs and eliminate them in the market. Only those preparations which meet the criteria of sound therapeutics; good benefit-to- risk ratio and cost effective should be selected for use. A hospital formulary serves 3 main purposes, promotion of rational therapeutics; prevention of duplication, confusion etc; promotes economy to both the hospitals and the patient.
Drug therapeutic Committee
For efficient functioning of the pharmacy, it is necessary that the users of the service and its providers along with the top management meet together and have a committee to discuss on any decisions to be taken and any protocols to be formulated for the pharmacy.
The optimum composition of the committee will depend on the size and type of a hospital. For a general hospital of about 500 beds the committee composition will be at a minimum, Medical Superintendent who is the chairperson; one representative from the administration; Heads of departments (Medicine, Surgery, Pediatrics, Obstetrics & Gynecology); consultants from various specialties; Nursing Superintendent; the Chief pharmacist who is also the secretary and one pharmacist.
The frequency with which the committee should meet is a policy decision of the individual healthcare organizations.
Location
The hospital pharmacy serves both inpatients and outpatients. Availing the pharmacy services is the last activity of any patient who visits the OPD on outpatient basis; hence it is preferred to have the pharmacy services close to the exit of the OPD block. Unlike other clinical departments this service should be located in regular patient movement areas, so that there is easy access to patients, ward staff and also the suppliers of medicines. The location and layout of the pharmacy should be submitted to the Drug Control authorities for sanctioning the plan. In large hospitals there may be separate outpatient and inpatient pharmacy; there may also be multiple pharmacy outlets in the hospital, depending on need and structure of the hospital.
Physical facilities
The walls of the pharmacy should be thick, to prevent any theft from breaking into the pharmacy. Narcotic drugs should be stored under lock and key.
The size of the pharmacy depends on the size of the hospital, type of hospital and location of the hospital.
Following will be the space requirements for an average size hospital:
Three dispensing counters and one cash counter
Two store rooms including standard and refrigerated stores i.e. cold room
Room for compounding and production if PMW is available
Small library
Office room i.e. for record keeping, filing cabinets, bin cards, registers etc.
Adequate circulation space
Equipments and Infrastructure:
These include, refrigerators; shelves; filing cabinets; equipments for preparation of fluids and mixtures; furniture
Storage facility:
It is important to ensure that appropriate storage facilities are made available. Fixed location racks with adjustable shelves offers suitable storage facility. If inside surface of the shelves are painted in light colour, a better light reflection is obtained for clear identification of the marking on stocks. The temperature in the cold room should be between 2-8oC and that of cool room should be between 8-20oC. There should be a thermograph or a digital thermometer to monitor the temperature continuously.
Legal implications:
There are many legislations and regulations concerning the pharmacy. It is necessary that the pharmacy follows all the rules and regulations. In order to run the pharmacy, the approval from the drug controller is necessary. Details of staffing, qualification and experience are sought along with the layout plan before issuing the license. The license is valid for a period of 5 years. Separate license from central exercise department should be obtained for procuring, storing and issue of narcotics.
Q2. Mr Manoj Kumar has been recruited as material manager in Kethams health care located in HAL, Bangalore. He has found that there is a huge wastage of drugs and money in the hospital. He wants to stop this wastage. He called for a meeting and discussed the same with his colleagues and sub ordinates, they took some decision for solving the issue. As per the discussions they found out that the staffs need some training in managing drugs and there are some common causes for these problems
A.What are the common causes of wasting drugs and money?
Common causes of wasting drugs and money
1. A non-optimal use of drugs results in waste. We find cases where a number of drugs are administered on one patient when he/she requires an optimal dose. This results in waste and in addition to the side-effects, we also find non-availability of drugs for the needy patients.
2. Some of the doctors develop a craze for using expensive drugs when we find low-cost drugs equally effective. This draws our attention on brand loyalty resulting in waste and an increase in Medicare costs.
3. Just to try it or Trial and Error Method has been found common. A large number of drugs though not necessary for the patients are used by the doctors. This in addition to an increase in the cost of treatment also generates side-effects. It is really amazing that some of the doctors just to get commission from the dispensaries adopt such a practice which results in the waste of drugs, vis--vis over medication.
4. Disproportionate dose also results in a waste. We also find cases where the doctors administer a larger dose of drugs when even smaller dose would have been equally effective.
5. Providing drugs to those patients who dont use them and throw it away. Or, the patients not serious about the treatment avoid using the drugs regularly, resulting in waste of drugs.
6. Over supply also results in waste. We also find cases where just to get commission, the over supply of drugs is practiced and we have no option but to throw them because of the expiry date.
7. Inadequate provisions for preserving the expensive and sensitive drugs also result in waste. This is due to the fact that proper refrigeration or preservation facilities are not available. Vaccines in a majority of the cases are no longer effective and we throw them.
8. Mismanagement of drugs is also found to be due to improper steps such as exposing drugs to sunlight or heat.
9. A non-optimal supply by the stores also results in waste. Giving out too many drugs from stores to Departments at one time results in wastage, theft and misuse.
The aforesaid reasons generate huge financial losses and in addition also increase the cost of treatment. Hence there is need for a scientific management of drugs so that cases of waste are checked and financial losses to the hospitals are regulated. It is the prime responsibility of a material/stores/hospital manager to take due care of drugs so that the increasing cases of waste are checked.
B.Do you think is it necessary to educate or train the staff and patients in the use of
drugs?
We have studied that one of the main causes of wastage of drugs in hospitals is negligence, ignorance of the employees connected with purchase, storing and usage of drugs in hospitals. Particularly the latter category is often involved in wastage. For example, often nurses or other attendants do not care about the minimum use of drugs. Hence educating staff in hospitals becomes important function in material or drug management. It becomes a part of the internal control measure of hospitals.
This can be done in the following ways:
1. Put one or more copies of a simple book on pharmacology in the library.
2. Make notes on the common drugs used, explaining their uses and side effects. Give copies of these notes to all staff.
3. Set out the correct doses of common drugs on wall boards in the hospital.
4. Hold staff meetings to discuss causes of wastage.
5. Inform all staff about cost of various drugs.
6. Make presentations; hold lectures by specialists explaining about the various drugs .
7. Optimizing the use of life saving drugs. Some steps that can be taken in this regard are:
a) The materials and stores manager should be advised to keep stock of life saving drugs.
b) A list of vital or life saving drugs should be prepared
c) These drugs should placed on a separate shelf.
d) This shelf should be checked frequently by a responsible employee of the hospital.
e) These drugs should be put in A category while doing ABC Analysis
f) Ordering these should be done when stock level reaches 50% (half of the drugs are issued)
C.What are the steps for educating the staff and patients in managing drugs?
To be more specific, in the Indian Society where we find the rate of literacy low, it is the prime responsibility of a hospital manager to educate the patients in the right way so that the increasing cases of over-medication are checked. It is really amazing that in the Indian society, a majority of us believe that taking more drugs and expensive drugs would solve our problems but instead of getting relief from the medicines, we face the problem of side-effects and invite a number of serious health problems. This makes it essential that we educate and the masses and the patients with creative slogans and messages so that they come to know about the side-effects of wrong or over-medication. It is against this background that we talk about improving the promotional measures or revolutionizing the process of healthcare communications.
The following steps are effective in educating the patients:
1. Narrating the Facts: At the very outset, it is the responsibility of doctors attending on the patients to explain to their attendants. Write on the prescription the required dose of medicines to be used by them. Let them know about the side-effects of excess dose and over-medication. It is essential because in a number of cases we find patients and attendants believing in the principle of taking excess dose of medicines.
2. Explaining Facts in Catalogue: In the hospital libraries, we find catalogues detailing the list of medicines. It is quite important that a hospital manager with the consultation of doctors explain the dose and duration to be followed by the patients. The facts should be mentioned in the catalogue and all the doctors should be made available the literature regarding the same so that they remember the details and explain the same to the patients while writing the prescriptions.
3. Displaying Signposts: For educating the patients and attendants, it is also pertinent that some of the selected medicines often prescribed by the doctors should be mentioned in the signposts detailing the dose and duration besides the side-effects. At different important places of the hospitals where patients and attendants assemble in a large number, the display of signposts would be instrumental in informing and informing them. Since the hospital managers are supposed to know about creativity in messages and slogans, the task of sensitizing the patients and attendants in a right fashion would be found easier.
4. Information Packaging: In addition, the pharmaceutical industry also bears the responsibility of informing and sensing the patients and attendants with the help of detailed information regarding the dose, duration and the side effects. If the patients and attendants come to know about the details, there would be less scope for taking the excess dose.
Pre packaging drugs for outpatients also helps in avoiding misuse. Pre packaging means that a full course of treatment with instructions is put in a small envelope or paper before the out patient session. This has several benefits.
a) The patient is correctly told about the course of treatment
b) It saves the time of the doctor as he need not explain in detail
c) It saves the patients as he need not wait in a queue
d) There is no abuse or misuse of drugs.
5. Social advertising to be promoted: Besides this, the media, pharmaceutical industry, health department, social organization, and leading hospitals bear the responsibility of promoting social advertising. This would let the patients and attendants know about the side-effects and over-medication due to the excess dose of medicines. This is necessary since the masses are illiterate and they dont know about the harmful effects of taking excess dose and over-medication.
6. Explaining the use of Drugs: It is pertinent that we explain to the patients the right way of using the medicines. Each drug has a particular effect in a particular condition and therefore a drug taken by an individual will not help another. It should be made clear to them that the optimal dose of medicines plays an important role. If it is too little, the effects are very slow and if it is too high, the reactions and side-effects cant be avoided. The dose for children is different. It should be clarified that regularity or continuity in treatment plays an effective role because it helps in maintaining the required dose of medicines in the body. We find treatment as a course and the patients need to complete the full course. If the course remains incomplete, the possibilities of relapse resulting in an even more dangerous condition cant be ruled out. The place for drugs should be out of the reach of small children who may use it and the effects may be very dangerous.
7. Explaining the Importance of Life-saving Drugs: While sensing the patients, it is also significant that we explain to them the importance of life-saving drugs. In a few cases, we
find the condition of patients so acute that immediate use of drugs is essential since a delay in the use of drugs may result in irreparable loss.
In the true-sense, drug management is a major problem requiring due attention of almost all the segments. The staff, doctors, the patients, the media, the social organizations, the Red Cross societies need to understand the importance of use of drugs or medicines to get the positive effects and remove the side-effects.
Q3. Write short notes on
a. Hospital Engineering services
Introduction
The hospital engineering services play a key role in providing support to the clinical services. As the hospital functions as a system the importance of these support departments cannot be ignored. It may be recalled that the efficiency of patient care is directly related to the efficiency of the engineering services. The engineering services include the following departments, civil department; electrical department; plumbing and sanitation department; Biomedical engineering department.
Objectives
After going through this section you will be able to:
List the functions of the engineering services in the hospital
Explain the organization structure
Describe the various type of maintenance
The functions of the engineering department can be enumerated as:
1. To create/ innovate methods for energy conservation opportunities.
2. Building renovation and maintenance.
3. Involved in selecting cost-sensitive equipments.
4. To decrease maintenance costs and minimize downtime for all equipments.
5. Create an environment safety program.
6. Proper management of medical gas systems.
7. Maintenance of ventilation system, temperature, humidity and lighting in appropriate areas.
8. These departments should aim at increasing operational efficiency while optimizing patient care.
9. Proper space management and allocation.
10. Proper water purification and distribution within the hospital premises.
Organizational structure:
The organizational structure of the engineering and maintenance departments can be schematically described in a chart format.
Hospital engineering departments Vs Productivity:
Since the engineering departments are responsible for the maintenance of hospital equipments, as well as for the performance or co-ordination of contractors involved with renovation and changes, the department has a significant impact on the productivity of the institution. Productivity directly affects the department by, frequent equipment breakdown; time taken to renovate the facilities. Thus the effectiveness with which this department maintains equipment and facilities has a direct impact on patient satisfaction and productivity.
Preventive maintenance systems:
The best way to minimize engineering and maintenance department costs and to ensure minimum equipment and facility down time is to maintain and operate effective preventive maintenance system. The different types of preventive maintenance are:
Break-down maintenance:
This can be defined as a maintenance contract which starts after a machine has broken down. This system has no advantages; however the disadvantages can be summarized as, the services comes to a stand still due to sudden disruption of the machine; Idle time of the machine in such cases is not predictable; the staff working in such setup are under-utilized; incurs huge expenditure for the organization.
Preventive maintenance:
This type of maintenance helps in reduction or minimizes the chances of complete break down. It can be defined as routine action taken in a planned manner. Master maintenance programs can be planned by giving details of spares required; staff required and facilitates spare purchase at minimum cost well in advance. In short it helps in preparedness before the break down. Ideally about 10% of the equipment cost can be allocated to preventive maintenance in the annual budget. Some of the benefits due to adoption of such a program is, yields profitable results much more than expenditure involved; helps conserve the machine
with increased life of the equipment; better spare parts control; less reserves required; helps to identify cause for the break down; reduces inventory. Preventive maintenance can be undertaken monthly; quarterly; half yearly or annually.
Corrective maintenance:
This type of maintenance aims at redesigning or correcting a component that has been failing frequently so as to overcome the problem of the equipment breaking down frequently.
Predictive maintenance:
This type involves inspection or monitoring of the conditions of the equipment used for critical care, failure of which can lead to death of the patient. An item qualifies to be critical if malfunctioning of the equipment adversely affects quality of service; functioning of the equipment is vital for patient care; failure of which will stop services in the hospital; equipments where capital investment is high.
b. Laundry services
Laundry services within the hospital forms an essential support service. Most hospitals run their own Power/Mechanical Laundry. Of late most of the smaller hospitals & nursing homes have outsourced laundry services. This has several advantages in terms of economy of the building & operation. In some places several hospitals make use of a single laundry, which is centrally located. Normally 200 beds and above must have a mechanical laundry.
The location of the laundry within the hospital (if present) is very useful for control of infection. One of the principles observed in the setting up of laundry facility is that, dirty and clean linen should be kept separate. Severely infected linen in the ward should be disinfected first & then put in metal containers with lid. The linen should then be moved to the laundry.
One essential structure that needs to be looked into at the time of commissioning a laundry is the boiler house. It is ideal for the boiler to be constructed close to laundry, as steam is made use of in drying the linen. Depending on the type of fuel required, appropriate facilities for its delivery, storage & handling of boiler need to be provided.
Most hospital laundries serve more than one hospital, such large well designed and efficiently run, group laundries have almost without exception resulted in marked savings in running costs. The possibilities of centralization of laundry services in groups or within a group should be considered when a new laundry is planned.
The advantages of having a power laundry are many fold. They are,
Regular washing helps to increase life span of linen.
The quality of linen washing can be properly monitored.
Regular supply of linen can be ensured with prompt delivery service.
In locations where there is continuous heavy rains, mechanical laundry helps in easy handling of washing and drying the linen.
Disadvantages of the mechanical laundry
Although there are several advantages in having a self run mechanical laundry it has its own disadvantages. They are,
The location should be suitable and investment on land is a prerequisite.
Appropriate equipments for washing, drying and ironing the linen need to be procured which would require a high investment.
The mechanical laundry should be adequately staffed depending on its functioning.
The staff salaries and emoluments paid will build up the expenses.
Maintenance of the equipment will be an additional burden on the institution which needs to look into mechanical failures as well.
Location of hospital laundry
The power laundry is best located in the basement of the hospital if the building has a vertical structure. Another added advantage is space utilization will be best and noise of a laundry will not disturb especially the patient care areas of the hospital. If the hospital is spread over a large area then it would be better to locate the laundry away from ward blocks and patient care areas.
Design and Space requirement
The design of the building and layout should be complete, physical separation of the soiled linen area from the remaining area. If a barrier is used, it must have glazed viewing panels at working level and should extend to roof height. About 10 sq. feet per bed can be taken as a thumb rule. For a 500 to 600 bed hospital approx. 6000 sq. feet area would be required. The wash areas should be physically divided to provide dirty and clean sections; with the use of end-loading washing machines.
The reception should be located in the dirty linen section; sorting and classifying section will not normally be separated physically from the dirty section of the wash area. On the clean side is the calendering, drying and pressing sections which should be a distinct area, not physically separated from each other or from the clean side of the wash area. It is not necessary to provide unloading dock or ramp. Soiled linen can be manually unloaded or by using an overhead mono rail system.
At the entrance external canopies should be provided over reception and dispatch areas. Adequate space for easy maneuver of linen transport vehicles is required for easy loading and unloading of linen.
Flooring
The floor finishes in the productive area should withstand wear and tear, easily cleaned and of non-slip type. In case of washing area, the flooring should be of non slip type even when the floor is wet.
Physical facilities
The physical facilities required in setting up a mechanical laundry can be broadly classified under
Basic accommodation
These areas include, productive area (comprising of reception, sorting and classifying, washing area, calendering, drying and pressing, assembling, packing and dispatch areas); Staff toilets; changing rooms; barrier rooms; dining room; rest room; office; store room (for storing washing material); electrical switch room; calorifier and plant room; cleaners room and space for header tank. During planning the facilities, circulation space for the above mentioned areas should be considered.
Additional accommodation
The additional areas would include the following; fowl sluice room; main linen stores; repair room for linen; water softening plant room; engineering stores and dry clean room.
The productive area of the laundry should have a clear floor area free of structural support. This will avoid obstruction in the work flow and restrictions in location of the plant, both in the initial stage and when replacement is necessary. The laundry as a major heat user should be sited near the boiler plant. It should have easy access to the main service records.
Basic structural design should be such as to allow extension if necessary. The need if any will be for lateral extension of the productive area. A building of light construction having a clear head room of 14 feet is suitable for the main working area. The room should be designed to minimize surfaces, which are prone to dust collection.
Drainage system should be designed to deal with the effluents from all machines without the risk of floor flooding. The effluent is usually assumed to be about 2-3 times the rate of flow of the cold water supplied to the machines. When the machine sumps have to cope with a heavy flush of effluents due to simultaneous discharge, the higher flow rate (i.e. 3 times) should be taken into consideration while designing. The effluent from the laundry may be run into any existing hospital drainage system, it is therefore important that in the case of a new or enlarged laundry, the total capacity of the drainage system should be carefully considered.
The formation of a certain amount of lint during washing is unavoidable and this is discharged with the effluent. In order to avoid the possibility of the lint and other wastes matter clogging the drains, a sump, complete with strainer between the discharge from the wash area and the drains, should be provided. The strainer should be designed to have convenient access and easy removal of waste matter
Q4. Explain Hospital committee in detail.
. Introduction
One of the most ubiquitous and controversial devices of organization is the committee. The committee is group of persons to whom, as a group, some responsibility is assigned. Committees are so essential to the present day mode of functioning that they have become institutionalized in the structure of most organizations. Various types of committees function in government, educational, religious institutions and business industries.
Advantages of having committees: To foster shared decision making and participative style of management which are vital for employee motivation, commitment and achievement of objectives. Committees facilitate better communication, team building, and inter-departmental co-operation. Since the decision taken is viewed from various angles anda consensus emerges, the final decision taken is likely to be more rational and objective. Many executives dread taking decision on sensitive matters not endorsed by the committee, reason being of the committees relative anonymous entity. Certain committees are set up as statutory bodies to prevent centralization of power, autocracy, and corruption.
Disadvantages of Committees: High cost in terms of time and money Compromise and watering down of decisions Indecision Forcing the decisions
Factors which affect the effectiveness of committee are:Purpose and scope:Has it been carefully spelt out and defined? Unless this is done, the members may not know whether they are responsible for a decision, a recommendation or just an inconclusive discussion for the benefit of the chairman
Need and SizeIs the committee the best solution for accomplishing the defined purpose? or would a meeting with a few subordinates in one session would do? Is the size of the committee appropriate? Is it too large or too small? What should be the adequate number?
Frequency of meetingA committee should meet as often as needed to fulfill its obligation. Some committees may be required to meet very often in the initial period, with the frequency of meetings tapering as time passes. For example, the drugs and therapeutic committee will require to meet almost every week when it is considering preparation of the hospital formulary. Once the formulary is prepared, once in a month review meeting may be sufficient. For any committee, it is better to meet at fixed intervals/ days, (example: The first Monday of each month at 4 pm). This helps the members to avoid conflict with other engagements.
Committee membersThe members nominated to the committee must be representative of the interest they are intended to serve. Has he got the capacity to work in the group and does he relate well with his peers? Does he have the ability to look at the underlying causes of the problem? Does he think critically? Can he look past his vested interest and examine all sides of the issue?It should be remembered that, not every one has the temperament, analytical ability and capacity for objectively working with others.
Subject matterCan the subject matter be handled in group discussions? Has the agenda been prepared and circulated? The way the subject matter is presented is important.
The committee ChairmanThe success of the committee will depend on the ability of the chairman. He sets the tone for the meeting. When the subject matter is open to contention, he leads the discussion so that members are not forced into a position. His skill, is in integrating committee deliberation. Integration of ideas, as contrasted with compromise, builds a point of view.
Minutes and ConclusionIt is necessary to prepare minutes of the committee meetings, circulate them in a draft form for correction and issue the final copy after approval of the committee. Conclusion and recommendations to be provided for follow-up.
Hospital Committees
Management / Administrative CommitteeThis committee is a high level committee that includes all the key executives. This committee essentially includes the senior management executives who monitor and oversee the day-to- day affairs of the hospital. The following people may be part of this committee:1. CEO2. Hospital Administrator3. Medical Superintendent4. Nursing Superintendent5. Assistant administrator6. CFO7. Personnel / HR ChiefThe management committee preferably meets at least once a week on a set time and day of the week. The management Committee meets for the following purposes: To update and assist CEO of the day- to- functions of the respective departments To provide a platform for the executives to meet and discuss their problems and arrive at possible solutions To keep the colleagues of the problems in a particular area / department To review major changes in procedures, rules, regulations, etc. To advice CEO on policy decisions To prepare or assist in preparing annual hospital report, budgets, etc.
Medical Staff executive committee: The executive committee acts on behalf of the medical staff, coordinating their activities. The chairman of this committee generally reports to the board of trustees on matters of extension of policy. He may be required to report to or consult with the chief administrator on day-to-day matters depending on organizational pattern. The medical committee is the highest technical committee in a hospital. They are responsible for laying down policies on code of medical practice. The members of the Medical Committee include the following:1. Medical Direction / Superintendent2. Hospital Administrator3. Nursing Superintendent4. Quality Assurance Officer5. Heads of Medical departments6. Deans / principals of medical and nursing colleges (if it is a teaching institution)This Committee preferably meets once a month on set date and time.The Medical Committee is responsible for the following functions: Ensure high standard of medical care Consider means of improving effectiveness and efficiency in the medical practice, thereby reducing costs To recommend changes in the organization structure, rules and regulations regarding medical practice To receive reports from technical committees
Quality Assurance Committee:This committees primary purpose is to coordinate, monitor and review quality assurance activities in the hospital. Members of this committee includes:
CEO Chief of quality assurance department Medical and nursing superintendent Heads of all the departments Chief Pharmacist Medical record officer
Medical records committee:The committee overviews the entire record keeping functions of the medical record department. The committee also approves introduction or deletion of various forms and their design. This committee usually consists of the following members:1. Medical superintendent2. Medical records officer3. Quality assurance officer4. Nursing superintendent / head5. Heads of departments6. Statistical health information officerIt usually meets once in every 2 or 3 months. The functions of the medical records committee may be summarized as below: To ensure medical records for timely completion To ensure adequateness of medical records To review the correctness and completeness of medical records To take decisions on retention policy, medico legal cases, etc. To review plans and programs of the medical records department
Infection control committee: It studies prevalence of hospital infection, detect reasons for the same and continuing education of hospital personnel in minimizing the hospital infection. Members of this committee include:1. Head of clinical microbiology department2. Infection control doctor3. Infection control nurse4. Medical and nursing superintendent5. Quality assurance officer6. Heads of medical departmentsThe Infection control committee preferably meets once a month. The functions of the infection control committee are outlined as follows: To incorporate measures to reduce infection in the hospital premises To supervise the functioning of the infection control team To make infection control policies and rules To train and educate staff on infection control measures To supervise and ensure on safe infection practices in the hospitalOther Committees in the hospital are listed below:
Joint staff committee: This includes medical as well as administrative staff. This committee meets for joint deliberation when such a need arises
Medical audit committee: The medical audit committee carries out retrospective medical audit or a full scale quality assurance review.
Utilization review committee: The task of utilization review committee is to review utilization of hospital resources, facilities, and suggest measures for their maximum utilization.
.Tissue committee: The tissue committee reviews reports of tissues removed in surgery, in order to detect whether tissues are unnecessarily removed without sufficient justification. This committee is supplementary to the hospital audit or quality assurance committees.
Pharmaco-therapeutic committee
OT/ICU users committee
Purchase committee
Condemnation committee
Q5. Explain planning, staffing and workflow on CSSD
central sterile supply department (CSSD).
Ensuring a high standard of sterilization and disinfection to minimize the incidence of hospital infection has been a priority for clinicians as well as hospital administrators. In the past, sterilization of syringes and other items of routine use in wards and operation theatres were done by boiling or in low pressure steam sterilizers. However, the advantages of centralization of all sterile supplies through one unit have been realized by all hospitals for ensuring sterilization safety and quality control.
Adequate disinfection of the environment and provision of properly sterilized materials for all diagnostic and treatment procedures is a necessity. Sterilization of instruments and consumables is more effective when carried out in a separate unit, the central sterile supply department (CSSD).
The Central Sterile Supply Department (CSSD) is now an accepted feature of hospital planning. With this new concept, nursing time is saved; sterilization processes has been more effectively controlled; aseptic techniques are safer and can be standardized throughout the hospital. These factors contribute to the reduction in the incidence of hospital infection.
The scope of sterile supply services has changed considerably ever since they have been operational. They have taken over a greater variety of materials for processing; disposables now replace some of the items which were once the main source of work in central sterile supply departments. Since the days of Lister, we have been striving to improve aseptic techniques and sterilization efficiency and to reduce the possibilities of infections during surgical procedures.
A Sterile Services Department (SSD) is vital for an effective Infection Control programme. Using its expertise and knowledge of sterilization and disinfection to ensure high standards of cleanliness. An SSD always results in long-term savings. Most hospitals in developed countries have an SSD to deal with hospital and community services and a Theatre Sterile Services Unit (TSSU) to deal within the operation theatres and associated departments. Hospitals in developing countries do not often have the funds to run duplicate units and have a single department, covering all areas. This is perfectly acceptable if the service is satisfactory.
The use of CSSD reduces the problem of over-heating of the operating suite within, due to the sterilization equipment. Nowadays the sterilizers within the OT are small, high-speed, automatic autoclaves designed to sterilize the surgeons' instruments only. These are however, a source of heat, and special measures must be taken in the design of the building and its ventilation to make sure that this heat is effectively removed, else it may cause serious discomfort to the staff and interfere with the functioning of the ventilation system.
While major hospitals regard a central sterile-supply department as essential, it may be easy to organize a sterilization unit in a small hospital. However, it is essential to ensure that all
instruments, dressings, and equipments that come in contact with patients' tissues are sterile. It is also necessary to ensure that, after use, contaminated utensils are rendered safe for handling. The old method of boiling instruments in water or soaking them in disinfectant are not reliable, particularly where there is a high risk of Hepatitis and HIV infection. Such a practice should be discouraged. Steam under pressure is required for sterilization. This can be achieved by use of a simple pressure cooker or a table top autoclave in large hospitals. There are some places in the hospital (e.g. operating theatre, delivery suite, emergency room) where sterilization facilities are constantly needed, and these may require their own equipment. A few sterilization equipments could be well centralized, with staff having access to it as the need arises. In due course, such a central area might be developed into a central sterile-supply unit. Special staff should be designated and trained to maintain all the sterilization equipment in the hospital.
Hospital administrators today recognize the CSSD as one of the most important service departments in the hospital. However no uniformity exists among hospitals in defining the functions of the department; providing adequate facilities with modern equipment; applying specialized techniques like method study; careful in selecting and training the staff etc. An in-depth study, research and development of these services will add to the means of controlling cost, providing quality in supplies and equipment, and promoting the most effective utilization of personnel and materials.
Sterilization is a process that is intended to kill all types of micro-organisms including spores. The process must be validated by appropriate physical, chemical and biological tests and monitored regularly during routine operation, to ensure that the intended conditions for sterilization are achieved throughout the load in the sterilizer and are maintained for adequate time.
Function and Scope of CSSD
1. Receipt of used CSSD sets from the user departments.
2. Cleaning, washing and packing of the CSSD sets
3. Sterilizing the CSSD sets using Autoclaves or Ethylene Oxide machine.
4. Issue of the sterile CSSD sets to user departments.
5. Providing training to CSSD assistants.
6. Processing and sterilization of Rubber Gloves.
Staffing:
The staffing pattern in a tertiary care centre for the CSSD should be as follows:
One In-charge, CSSD
One CSSD trained technician
One staff nurse
CSSD Assistants
General Duty Workers
Housekeeping staff/cleaners
Once in a week, the housekeeping staff carries out the floor cleaning of the department using the floor scrubbing machine.
Location:
The Central Sterile Supply Department should ideally be located in the basement or on the ground floor, with the operation theater complex located right above this department. There should be a sterile access and an unsterile access between the OT and CSSD.
Physical Facilities
CSSD should have a separate receipt and issue area; sterile supplies are kept separate from unsterile supplies. Its entrance should be provided with automatic closing doors. Flooring can be of mosaic or tiles. Dadooing of side walls should be up to one meter. There should be air-conditioning facility in sterile store area. Fire extinguishers should be made available in the department. Rest room/change room facilities, separate for male and female staff should be available. Two toilets and a bathroom provided separately for ladies and gents should be adequate.
Zoning Concept:
The department is designed so that the workflow is unidirectional and flows from the unsterile to sterile zone, which is very important in a central sterile supply department. The department should have its own storeroom to maintain the necessary stock of materials for the working of the department.
Dumbwaiters:
Dumbwaiters connecting to OT, one for sterile equipments and another for unsterile equipments should be available. The unsterile (receiving) dumbwaiter may be located at the entrance of CSSD and likewise the other can be located in the sterile store area. This facilitates the easy transport of various equipment sets between the two departments.
Glove Room:
The Glove washing machine, Glove dryer and Glove powdering machine are located in the glove room.
Solution Preparation Room:
This room contains the water distillation plant and steel tank which stores the distilled water. A soaking sink should be located in the room. Tap water is used for distillation plant.
CSSD Preparation Room:
It is the main area where the sets are prepared and autoclaved. It should have facilities to prepare the sets and store them before autoclaving. Three wooden tables with wooden racks to keep the instruments should be adequate. These are used to pack the sets. In addition to this stainless steel tables may be provided, which are used for assembling the sets.
Sterile storeroom should be located adjacent to the preparation room. The entrance to this area is restricted. Dumbwaiter supplying sterile supplies to OT is located in this area. Air-conditioning should be provided within the sterile storeroom with recommended air changes of ten/hour. Temperature of 25-26C, with 65-70% humidity is ideal.
Issue Counter
Issue counter should be located in the sterile zone.
Supervisors room
Supervisors room can be placed centrally and provided with glass partition on all the four sides, facing the preparation room, issue counter and receipt counter. This helps the supervisor to monitor the department activities. An intercom facility should be provided for the supervisor.
Equipment
Equipments in the department are as follows:
Autoclaves; Trolley loading; Trolley transfer; Instrument wash machine; Glove washer; Glove drier; Glove powdered; Distilled water plant; Wooden Packing tables; Stainless steel tables; Steel racks; Sealing machine; Gas sterilizer; Needle flush device; Air compressor; Vacuum cleaner; Ultrasonic cleaner.
Q6. Write in note on functioning of reverse osmosis (RO) plant.
Water Treatment Plant
The haemodialysis unit shall have an overhead tank (approx 5000liters) on the terrace/high elevation, to provide water to the water treatment plant. A pump is fitted to draw water from the overhead tank. The water drawn is sent to:
1. Activated charcoal filter, which helps in removing chlorine. The water then goes to the softener.
2. Softener: This is a salt solution containing Na2+ions. Here Ca2+ and Mg2+ present in water are exchanged for Na+ ions. Once the softener is devoid of Na+ ion, it is regenerated by treating with salt water.
3. From softeners, the water passes to up-flow filter, where heavy particles are removed. Then the water enters RO machine.
4. Reverse Osmosis (RO) All the other impurities are removed so that, the water purity becomes 99%. From here water is stored in tanks, having 500 liters capacity (2-3 nos.), interconnected with each other. The water is made to recycle by using a pump so that, no microorganisms grow. This pump should have UPS backup for continuous power supply.
5. Treated water is sent to the machine through a PVC pipe at 20-30 psi. Each machine is provided with separate connections. Before entering the machine it is again purified and utilized.
Note - For each dialysis 120 liters of water is required.
The maintenance and hygiene of dialysis water treatment should consider disinfection, filter, resin change, biofilm synthesis destruction and quality control (chemical and microbiological purity). The water treatment plant should be assembled in series which includes water pretreatment, water purification system, water storage and distribution system.
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